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Title: Practical podiatry
Author: Alfred Joseph
E. K. Burnett
Reuben H. Gross
Editor: Maurice J. Lewi
Release date: July 29, 2026 [eBook #79224]
Language: English
Original publication: New York: The First Institute of Podiatry, 1918
Other information and formats: www.gutenberg.org/ebooks/79224
Credits: deaurider and the Online Distributed Proofreading Team at https://www.pgdp.net (This file was produced from images generously made available by The Internet Archive)
*** START OF THE PROJECT GUTENBERG EBOOK PRACTICAL PODIATRY ***
PRACTICAL PODIATRY
BY
ALFRED JOSEPH
_Senior Professor of Podiatry, The First Institute of Podiatry;
Ex-President, Nat’l. Ass’n. Chiropodists; Editor, Pedic Items._
E. K. BURNETT
_Professor of Clinical Podiatry, The First Institute of Podiatry;
Vice-President, Nat’l. Ass’n. Chiropodists; Editor, The Podiatrist._
REUBEN H. GROSS
_Professor of Didactic Podiatry and Registrar, The First Institute of
Podiatry; Associate Editor, Pedic Items._
EDITED BY
MAURICE J. LEWI, M.D.
_President, The First Institute of Podiatry; Ex-Secretary, N. Y.
State Board of Medical Examiners; formerly Professor of Medical
Jurisprudence, Albany Law School; Ex-President, Albany Co. Medical
Society; formerly Instructor, Albany Medical College; Member, American
Medical Association; Member, N. Y. State Medical Society; Member N. Y.
Co. Medical Society, etc._
PUBLISHED BY
THE FIRST INSTITUTE OF PODIATRY
213-215-217 WEST 125TH STREET
NEW YORK
COPYRIGHT, MAURICE J. LEWI, 1918
THE WILLIAM G. HEWITT PRESS
BROOKLYN, N. Y.
TO THE MEMORY OF
GEORGE ERFF
AND
ELLIOTT W. JOHNSON,
builders of the foundation upon which
the edifice of modern podiatry is
reared, this book is reverently and
appreciatively dedicated.
The beauties of contour of the human foot, coupled with its strength
to perform the functions for which it was created, caused the ancient
Greeks to glorify it in song and in art. Medically and surgically
it has always been a negligible factor in the world of science,
notwithstanding the burdens which it is made to bear and in spite
of the interference with locomotion and with general health which
this non-care has occasioned for all centuries since creation. Our
propaganda recognizes the importance of this part of the anatomy and is
causing the race to realize the need for foot care in health and for
scientific foot treatment in disease.
CONTENTS
FOREWORD ix
I THE RECENT HISTORY OF PODIATRY 1
II THE SKIN 11
III ASEPSIS AND ANTISEPSIS 19
IV STERILIZATION 39
V THE CARE OF THE FOOT 46
VI DRESSINGS AND BANDAGING 60
VII INSTRUMENTS 78
VIII SHIELDS AND SHIELDING 96
IX LOCAL ANESTHESIA 143
X HELOMA 149
XI CALLOSITAS 182
XII VERRUCA 185
XIII CALLOUSED NAIL GROOVE 205
XIV ONYCHOCRYPTOSIS OR INGROWN TOE NAIL 210
XV DISEASES OF THE NAILS 237
XVI FISSURES, BLISTERS, AND BURNS 248
XVII BURSITIS 263
XVIII CHIMATLON 283
XIX DISEASES OF THE SWEAT GLANDS 297
XX ULCERS 306
XXI CUTANEOUS MANIFESTATIONS OF SUPER-ACIDITY 329
XXII VOCATIONAL FOOT DISORDERS 339
XXIII LOCOMOTION AS AN AID IN DIAGNOSIS 343
XXIV MISCELLANEOUS FOOT LESIONS 357
XXV X-RAYS IN PODIATRY 385
XXVI THE PODIATRIST’S OFFICE 405
GLOSSARY 411
INDEX 433
FOREWORD
This volume has been compiled by men who started out in life as
chiropodists. They have lived to see the genesis of podiatry from the
trade which was theirs, and each of them has taken active part in the
efforts which marked the transition from the old to the new order
of things. The period of evolution has been extremely brief. Five
short years have sufficed to transform the corn-cutters’ trade to the
podiatrists’ profession.
One of the programmed features of the educational development of
podiatry was the creation of a scientific literature bearing upon
the practice of this branch of medicine. The earliest manifestation
along the lines of this progress was the production of “The Text Book
of Chiropody.” This ponderous tome (1183 pages) contained matter
pertaining to the teaching of medical and other scientific subjects
that led up to the study of chiropody and to practical chiropody
itself. The chapters on this latter topic were the first attempts of a
scientific nature to collect material relating to podiatry practice.
In consequence, the articles were few and their contents were meagre.
Nevertheless this pioneer attempt to array chiropodical facts and
methods of treating foot lesions proved efficacious in stimulating
members of the chiropody profession to the higher educational needs,
and all over the english speaking globe this literature was hungrily
masticated and digested by individual practitioners and by chiropody
societies.
Bright and intelligent members of the profession utilized the material
thus furnished them by practically applying suggested treatments and
methods. Aspiring to augment their own knowledge and to add to this
literature, they wrote up their experiences and, from time to time,
their matured deductions were given publicity through the columns
of “The Pedic Items” and “The Podiatrist.” The instructors on the
faculties of the various chiropody teaching institutions, utilized
these chapters in their pedagogic work, and medical practitioners
turned to them to gain their first concrete knowledge of the subjects
which they treated. These initial chapters thus filled an acute want
and so proved their worth.
In this volume, a more serious task has been undertaken. Each article
will be found to have been prepared with a view to presenting the
subject matter in its entirety, in scientific order and with accuracy.
There has been no guessing as to cause and effect. Empiricism finds
no place in these pages. The medical and surgical viewpoint is
continuously in evidence and “Practical Podiatry” thus becomes the
first medical work of its kind ever published, a sad commentary on the
negligence of medical teachers and medical practitioners who have thus
permitted non-medical graduates to compile the first facts relating to
an important branch of medicine. The erstwhile tabooed “corn-cutter”
thus becomes a leader in a collateral branch of medicine, and medical
practitioners are compelled to glean their knowledge of this subject
from laymen, who, without their material, moral or monied support--yes,
often in spite of obstacles which medical practitioners have placed
in their way--have succeeded in clearly and scientifically portraying
features of essential medical practice which are to aid materially in
creating a better species of the genus homo, and in relieving the woes
of our race. Podiatrists may well feel a pride in this achievement
and medical practitioners would do well to take home the lesson of
indifference which this incident discloses.
Podiatry has not alone enriched the scholastic literature of medicine,
but has also augmented the language of science. New terms have had to
be coined to properly designate conditions, diseases and instruments.
In order that these may be understood by the readers of this volume,
their purport is given in the general glossary which will be found
in the book. The etymologic construction of these new words is not
explained because their origin will be readily apparent from their
definitions.
“Surgery with special reference to Podiatry” was the first volume of
this series to be published. In presenting “Practical Podiatry” to the
profession and to the public, the second rung in the ladder of podiatry
literature has been created and within two years it is hoped that the
“System of Podiatry,” of which both of the above volumes are a part,
will have been completed.
Thus will be constituted a library for practitioners and students of
podiatry which it is hoped will ever prove creditable to its sponsors,
profitable to the profession and helpful to humankind.
M. J. L.
CHAPTER I
THE RECENT HISTORY OF PODIATRY
The first steps in the movement for the enactment of a law governing
the practice of chiropody in the United States were made in the state
of New York, when, in 1895 C. S. Levy, H. Levy, L. B. Rosenberg, H.
Mayer, E. Werther and M. M. Marks met at the residence of C. S. Levy
to discuss this matter. As a result of this meeting, a bill drafted by
Maurice Marks, a well known New York lawyer, was subsequently presented
to the New York State legislature. John B. Stanchfield, leader of the
assembly, spoke at length on the question of “feet” and amid mirth and
laughter (the question was considered somewhat of a joke), the bill was
passed by the lower house. Shortly thereafter, the senate took similar
action on the bill, whereupon Governor Morton promptly signed it.
In accordance with the provisions of the law, the Pedic Society of the
State of New York was organized on the 3rd of June, 1895, and R. H.
Westervelt was elected president, George Erff, treasurer and Louise
Hartogensis, secretary. Wm. D. Gaige, Jonas M. Heimerdinger and L. B.
Rosenberg were selected as the first board of examiners.
R. H. Westervelt served as president of the society for a period of two
years, when he was succeeded by Elliott W. Johnson, who acted as chief
executive officer for fifteen years. George Erff was the next president
and he in turn was succeeded by Alfred Joseph, J. P. Solomon and Ernest
Graff.
The affairs of the society improved with each succeeding year, and
much of the credit of its success should go to Maurice M. Marks, who
acted as attorney for the society, and in addition, assisted wherever
he could.
BIRTH OF “THE PEDIC ITEMS”
“The Pedic Items,” which has done so much to advance the calling of
podiatry, is the child of Alfred Joseph. In 1906 he outlined a plan
to the members of the Pedic Society of the State of New York, whereby
a journal could be created and conducted profitably. On January 1st,
1907, a leaflet called the “Pedic Society Items” was sent to the
members. On April 1st, 1907, a four page paper was published, and after
that Alfred Joseph was offered the position of editor. The “Items”
appeared every four months for the first few years of its existence,
and finally became a monthly paper which has grown to a sixty-four
page book, and even this is inadequate to convey all that is new and
of interest to the members of the profession. This book is now current
podiatry literature in every english speaking country in the world. A
number of chiropody publications have appeared from time to time, most
of them, of no scientific value, and they died an early death. The
newest paper, “The Podiatrist,” is a thoroughly scientific journal,
that has already found a place in the profession; it is edited and
published by E. K. Burnett, one of the progressive members of the
podiatry profession, and appears once each month.
FIRST SCHOOL OF CHIROPODY
At the March, 1911 meeting of the Pedic Society of the State of New
York, Alfred Joseph, as chairman of a committee appointed to take the
matter under advisement, read a report on the question of organizing
a school, and asked that moneys be subscribed for the purposes of
incorporating such an institution. In a short time, over $1,200.00 was
subscribed and the corporation known as “The Chiropodists of America”
came into existence, with George Erff, president and Alfred Joseph,
secretary.
This school was conducted along commercial lines, and although its
purposes were good, it did not meet the standards which its promoters
were hopeful of establishing for it and which it later secured through
the action of the Regents of the University of the State of New York.
THE NATIONAL ASSOCIATION OF CHIROPODISTS
The October, 1911, issue of “The Pedic Items” contained the first
announcement of a proposed plan to organize a national association
of chiropodists. All chiropodists were invited to become members,
and after a mail vote, Chicago was selected as the first convention
city. On July 1st, 2nd, and 3rd, after the usual preliminaries, the
organization was completed, and Alfred Joseph, who was the organizer
of the association, was elected president. Ernest Graff was elected
secretary-treasurer. This organization has grown from 225 members at
its first meeting, to the present large society of over 1,000 members.
The influence of the N. A. C. is and has been decidedly salutory, and
its organizers can well be proud of the work they have accomplished.
CHANGE IN THE CHIROPODY LAW OF NEW YORK
The members of the Pedic Society of the State of New York, after a
brief experience, realized the shortcomings of the original law which
governed the practice of chiropody. They sought to advance their
calling and to provide so that those entering the profession should be
properly equipped.
A committee of the Pedic Society of the State of New York composed of
George Erff, Maurice Marks and Alfred Joseph, called upon Edward Milton
Foote, M. D., a prominent surgeon, for advice as to procedure. Dr.
Foote, in turn, advised that the secretary of the N. Y. State Board
of Medical Examiners be consulted. Thus it came to pass that these
gentlemen met Maurice J. Lewi, M. D.
Dr. Lewi listened attentively to the request of the committee that he
devise ways and means for improving the then inefficient chiropody
law, fell in heartily with their objects and after outlining a plan
of procedure, drafted a bill which, after receiving the sanction of
the State education authorities, was introduced in the legislature.
The bill was unanimously passed and became a law September 1st, 1912.
Thereupon the State Education Department delegated Dr. Lewi to outline
a standard for chiropody schools which they promptly adopted. Much to
the surprise of the officials of the New York School of Chiropody,
these standards were so high that they feared it would be impossible
for them to carry them into effect.
Conducting a school along the lines set by the State made it necessary
to engage as its head one who was a medical practitioner, an educator,
an executive and a man of character. Where was such a man to be found?
After much deliberation and numerous consultations, the committee of
the Pedic Society decided that there was but one man known to them
who combined all of these attributes and he was the very individual
who had guided them in seeking to advance their profession, Dr. Lewi.
When the proposition was put to Dr. Lewi, he declined with thanks
on the ground that his position as Secretary of the State Board of
Medical Examiners was to his liking. The committee was insistent and
pleaded with him to reconsider his determination. For three months
the committee and their friends labored with Dr. Lewi and finally,
after making certain stipulations which placed the management of the
school in his sole charge, he capitulated, and on January 1st, 1913, he
assumed the presidency of the reorganized School of Chiropody of New
York. With meagre funds, but with earnest zeal he commenced his task
and soon surrounded himself with a splendid faculty and with a modest
but sufficient equipment. The school has flourished. It behooves every
member of the profession of podiatry to remember that had it not been
for the broad-mindedness and the foresight of Dr. Lewi, this calling
which is gradually taking its place as a legitimate branch of medicine,
would still be the trade it was, and the podiatrists of today would
still be the “corn-cutters” of yesterday.
On September 27th, 1917, the Regents of the University of the State
of New York granted a provisional charter to The First Institute of
Podiatry and henceforth the School of Chiropody of New York will be
known by that title.
THE DEVELOPMENT OF OTHER SCHOOLS
After the organization of the new regime in podiatry education, the old
system of conducting schools for gain only, was gradually eliminated
and the need for schools to teach foot ills in a scientific manner,
became apparent. Since the organization of The First Institute of
Podiatry, several other institutions have come into existence whose
purpose is to equip their students to be true podiatrists. The
California College of Chiropody, situated in San Francisco, is the only
institution west of Chicago, imparting knowledge of this character. In
the middle west, the City of Chicago boasts of two schools, viz.: the
Illinois College of Chiropody and the Chicago School of Chiropody. The
State of Ohio is well represented by the Ohio College of Chiropody in
the City of Cleveland. Temple University of Philadelphia, Pa., has a
Department of Chiropody and is educating specialists in conjunction
with its medical course. The latest addition to chiropody teaching
institutions is the University of Massachusetts in East Cambridge, Mass.
All of these institutions are endeavoring to educate their students
along ethical and scientific lines, and it is but a question of time
when they will have attained the status and educational influence of
The First Institute of Podiatry.
ORGANIZATION OF PEDIC SOCIETIES
After the Pedic Society of the State of New York had been conducting
its affairs for several years, podiatrists throughout the country,
recognizing the advantages to be derived from a conjunction of
individual interests into groups, created organizations in thirty-seven
States of the Union. It is safe to predict that within the next five
years, there will be a podiatry organization in each of the remaining
States not now so organized.
Activities along these lines have not been limited to the United
States alone. In England, the Incorporated Society of Chiropodists
is a flourishing body, boasting a large membership. Ernest G. V.
Runting is president of that organization and he and many others in
the British Isles are helping to make podiatry a real profession. The
other European countries are not progressive in podiatry work (possibly
due to the war situation), but as the United States and Great Britain
advance, so will the other nations follow. It is unfortunate that the
people of many of these European countries do not fully appreciate
the value of scientific foot treatment, but, as in other educational
branches, it is only a question of time when every government in the
civilized world will recognize the necessity for a full study of this
important branch of medical science, and will also pass laws regulating
podiatry practice.
In the United States, one of the first states to follow the example of
New York, was California. In July, 1901, George Koenigstein called a
meeting of the chiropodists in San Francisco, and an organization known
as the San Francisco Chiropodists Association was formed. This society
had for its prime purpose, the passing of a law governing the practice
of chiropody in the State of California; the organization elected no
regular set of officers but held desultory meetings once or twice a
month at the office of Charles L. Scharff.
The bill that this society formulated was presented to the legislature
at Sacramento and Drs. Scharff and Koenigstein were delegated to press
it to passage. They worked like Trojans but to no avail. The bill was
pigeon-holed and nothing more was heard of it. Subsequently the Society
died a peaceful death.
In 1907, following the great fire in San Francisco, a few chiropodists
again attempted to pass legislation in California, but this endeavor
was also fruitless. In the latter part of 1911 and in the early part
of 1912, stimulated by an article relating to the subject which
appeared in “The Pedic Items,” and fully realizing the benefits of
chiropody organization, if properly conducted, several California
practitioners were elected to membership in the National Association.
Among these were Oscar L. Gruggel, S. Rutherford Levy, and Charles
L. Scharff. These men became N. A. C. propagandists, and secured the
applications of others in California for membership in the National
Association. On January 12th, 1912, The Pedic Society of the State
of California was permanently organized and chartered. Its first
officers were, S. Rutherford Levy, President; William F. Leck, First
Vice-President, Oscar L. Gruggel, Second Vice-President; H. H. Katz,
Third Vice-President; Charles L. Scharff, Secretary-Treasurer; Z. L.
Comet, Sergeant-at-arms, and F. Schilling, Counsel for the Society.
This society attempted to pass a State law regulating the practice
of chiropody (in 1913) and a bill drafted for the purpose by Mr.
Schilling, was presented to the legislature. By almost superhuman
effort on the part of every member of the society, the bill passed both
houses of the legislature, but the Governor vetoed it on the ground
that he was opposed to the creation of new State Commissions.
Dismayed, but not disheartened, the legislative committee immediately
made arrangements to carry on the fight at the next session of the
legislature. The new bill introduced, instead of creating a separate
commission, placed the supervision of chiropody practice in the hands
of the existing State Board of Medical Examiners. Changes agreeable to
all concerned were made, and in the 1915 session of the legislature,
the Benson Medical Act, 443, to regulate the practice of podiatry in
California, was passed by both houses. On June 8th, the bill was signed
by the Governor and the law became effective August 8th, 1915.
In the State of Illinois, the first organization was effected in
September, 1904. A charter was applied for and granted to Charles
Kenison, Nicholas Von Schill, Frank Johnson and Ignace J. Reis. The
officers elected were, Charles Kenison, President; Leonard Lower,
Vice-President; C. G. Sims, Treasurer and Ignace J. Reis, Secretary.
On September 18th, 1912, the temporary organization of The Illinois
Pedic Association was effected. The organization was made permanent on
October 2nd, 1912, and the following were elected as the first officers:
President, Ignace J. Reis; Vice-President, Maximilian Pincus, M. D.;
Secretary, Henry Schmidt; Treasurer, John Kenison; Trustees, Leonard
A. Lower; Henry J. Riegelhaupt; Charles Kenison; Counsellors, Frank S.
Lower, M.D., H. P. Kenison, M. Pincus, M.D.
In the year 1906, S. L. Lawton of Fall River, Mass., consulted with
F. J. Coughlin of Boston as to the advisability of forming a state
chiropody association. Harry P. Kenison of Boston was advised with
and readily fell in with the plans. As a result, a meeting was called
at the office of the latter and the Massachusetts Association was
created. The first officers were J. P. Buntin, Boston, President;
S. D. Lawton, Fall River, Vice-President; F. J. Coughlin, Boston,
Secretary-Treasurer, and the following Directors: H. P. Kenison, F. E.
Davis, C. R. Watkins, A. M. Brackett, W. E. Lee and G. M. Pettingill.
This society has flourished and, due to the efforts of several of
its members, including the present president of the N. A. C., H.
P. Kenison, the present law governing the practice of chiropody in
Massachusetts was passed. This was accomplished in spite of strenuous
opposition on the part of medical practitioners and a few disgruntled
chiropodists within and out of the organization.
In the West, there is gradually springing up a progressive spirit in
all that pertains to podiatry. Much of this spirit has been created
through the efforts of a few practitioners in the State of Colorado who
have been extremely active in the past few years. In 1914, Bertha De
Wolfe, having taken a course at the School of Chiropody of New York,
located in the City of Denver. Realizing the necessity of organization,
she immediately set to the task, and in December of that year, the
Colorado Pedic Society held its first meeting. It was incorporated,
January, 1915. Its first officers were, C. S. Rees, President; A. M.
Parker, first Vice-President; Lucy Ballou, second Vice-President;
Bertha De Wolfe, Secretary-Treasurer.
The late Benjamin Oelsner of Bridgeport, Conn., was always an active
member of the profession, and through his efforts, the Connecticut
Pedic Society was organized, in the city of New Haven, March 23rd,
1910. This organization has grown rapidly, and because of its
activities, Connecticut now has a chiropody law on its statute books.
The Rhode Island Chiropodists Society was organized November 8th, 1914,
largely through the efforts of Alfred C. Moran, who represented the
National Association of Chiropodists in that section of the country.
This organization is gradually growing, and since the convention of the
N. A. C. which was held in Providence, R. I., many practitioners who
previously showed no interest in the union of podiatry forces, have
become active workers in the interests of the profession. The officers
of The Rhode Island Chiropodists Society are Charles T. Heilborn,
President; Henry S. Batchelder, first Vice-President; F. S. Sargent,
second Vice-President; Alfred C. Moran, Secretary-Treasurer.
LAWS GOVERNING PODIATRY PRACTICE
Since the first law governing the practice of podiatry passed in the
State of New York, eighteen other states have taken similar action.
The National Association of Chiropodists has been largely responsible
for most of the success along these lines. The committee in charge
of legislation has been a most active one, and its usefulness may be
realized, when it is recorded that during the period from August,
1916, to July, 1917, six states in the union passed laws regulating
the practice of podiatry. As the profession advances, and the academic
requirements are increased, the laws are so changed as to create a
greater scope of endeavor for our practitioners. Thus in some states
the law permits the podiatrist to perform operations of a major nature,
while in others the practice is limited to structures involving the
true skin only. It is safe to predict that in a few years, every state
in the union will have enacted legislation regulating the practice of
podiatry. The states now governed by such laws (New Jersey was the
first) are Colorado, California, Connecticut, Illinois, Louisiana,
Maryland, Massachusetts, Michigan, Minnesota, New Jersey, New York,
Ohio, Pennsylvania, Rhode Island, Vermont, Virginia, Washington, West
Virginia and Wisconsin.[1]
Educators and the public generally throughout the entire country are
beginning to realize the value of scientific foot care, and where the
chiropodist was derided and scoffed at years ago, the podiatrist of
today is gradually taking the place he so rightly deserves, at the
side of the members of the other professions, honored and respected as
a well trained, educated man who is proving a benefactor to the human
race. So it is, that the schools of chiropody are being developed, and
in a few years when the academic requirements will have become the same
as for the other professions, the courses of study at these schools
will run on all fours with the schedules of study maintained at medical
schools.
CHAPTER II
THE SKIN
Podiatry deals largely with ailments involving the skin or its
appendages and it is deemed advisable to describe briefly the anatomy
and physiology of that organ, so as to refresh the memories of those
who study this work.
It is not the intention of the authors to enter deeply into this
subject and the reader is referred to the works in this series
which deal exclusively with anatomy and physiology, for a more
intimate knowledge of the skin. It is an accepted fact that no one
can intelligently comprehend pathology without knowing the normal
structure and functions of the tissues of the body to be considered,
and it is for that reason that the pages to follow have been written.
[Illustration: 1. Stratum Corneum; 2. Stratum Lucidum; 3. Stratum
Granulosum; 4. Stratum Mucosum; 5. Papillary Layer; 6. Reticular Layer;
7. Subcutaneous Tissue; 8. Hairs; 9. Fat Cells; 10. Sudoriferous
Glands; 11. Sebaceous Glands; 12. Pacinian Body or Touch Corpuscle; 13.
Connective Tissue Cells; 14. Nerve Endings 15. Vascular Papillæ and
Capillary Loops]
ANATOMY OF THE SKIN
The skin as a whole is composed of two distinct layers resting upon a
third structure, the subcutaneous tissue. The outer portion is called
the epidermis, cuticle or scarf skin, and is without blood and nerve
supply, while the inner portion is called the corium, derma or cutis
vera, and contains the capillary loops and nerve endings.
THE EPIDERMIS
=The Epidermis= is divided into four layers, named from without inward,
the stratum corneum, the stratum lucidum, the stratum granulosum and
the stratum mucosum or rete Malpighii.
=The Stratum Corneum=, or horny layer of the skin, is composed of many
layers of horny, non-nucleated scales which are being continuously
displaced by exposure to weather, water, etc., and are being as
continuously renewed by the deeper layers. This layer of the skin is
involved in the simpler foot lesions such as heloma and callositas.
=The Stratum Lucidum=, or clear layer of the skin, is composed of a few
rows of transparent cells, without distinct boundary, and, except on
the palms and soles, is considered a part of the stratum corneum. It is
composed of from two to four layers of cells, which are like the cells
of the horny layer except that they are brighter and more homogeneous.
This layer is not often clearly defined and is of no importance.
=The Stratum Granulosum=, or granular layer of the skin is composed
of several rows of polygonal shaped cells which are well marked on
the soles of the feet. The nuclei of the cells are not well defined
and the cell itself refracts light. The granules found in this layer
are varied in shape and contain a fluid called eleidin and a peculiar
solid substance called keratohyalin. This substance is derived from
the cytoplasm of the cells and represents the first process in the
cornification of the cells in the outer layers of the epidermis.
=The Stratum Mucosum=, or mucous layer of the skin, usually called the
rete, or rete Malpighii, is the deepest and most important layer of the
epidermis. The basal layers of cells are separated from the corium by a
basement membrane or membrana propria, and these layers, which are made
up of columnar cells, contain the pigment of the skin. The next few
layers show elongated, oval or rounded shaped cells, the form varying
with the locality, the tendency being to a rounded shape, owing to the
more even pressure on the cells from above and below. The cells are
irregularly formed and are made up of a soft substance with large oval
or rounded nuclei. In the intercellular spaces is found a fluid which
is nutrient in character. In the stratum mucosum are found the prickle
cells. These cells have hairlike processes on them which serve to hold
the cells together.
THE DERMA
=The Derma, or Corium=, is divided into two layers, the outer, called
the papillary layer, or pars papillaris, and the inner, called the
reticular layer, or pars reticularis. It is composed of bundles of
fibrous tissue, yellow elastic tissue and connective tissue cells, the
reticular layer being more compact than the papillary layer. The derma
contains blood vessels, nerves, lymphatics, touch corpuscles, hairs,
sweat glands and sebaceous glands.
=The Papillary Layer= of the skin is composed of small conical
elevations called papillæ, which blend with the prolongations of the
rete above. The best developed papillæ are found on the under or flexor
surfaces of the fingers and toes and attain their greatest length at
this point. They are placed in double rows that underlie the cutaneous
ridges on the fingers and toes. These cutaneous ridges remain unchanged
throughout life and are so characteristic of each individual, that they
are used as a means of detecting and identifying criminals and others.
Papillæ of two kinds are noticed, the one being very well supplied with
blood vessels, and are called vascular, the others being only scantily
supplied with blood, containing medullated nerves, and are called
sensory papillæ.
=The Reticular Layer= of the derma is composed of loosely arranged
bundles of connective tissue which merge with the papillary layer
without a distinct line of demarcation. In these bundles of connective
tissue are found the sweat glands, the sebaceous glands, the hair
follicles and the deeper lymphatics. This layer of the derma is made up
of fasciculi of connective tissue which blend into each other obliquely
and give it a plexiform appearance. As the bundles ascend towards
the surface they divide into smaller and finer bundles, and when the
papillary layer is reached, they have a close, felt-like appearance.
=The Subcutaneous Areolar Tissue=, or tela subcutanea, connects the
skin with the deeper structures and should be considered a part of the
true skin. It is made up of loosely arranged bundles of connective
tissue which cross each other repeatedly and form well defined spaces.
These spaces contain fat, and where there are large quantities of this
fat, as on the soles of the feet, the tissue is designated as adipose.
The subcutaneous areolar tissue also contains the deeper hair follicles
and the deeper sweat glands.
=Blood Supply.= The layers of the epidermis are without vascular
supply, but the derma and the subcutaneous tissue are well supplied
with blood vessels. There are two plexuses, one superficial in the
upper layer of the derma, and the other deep, in the subcutaneous
tissue. The vessels of the upper layer arise from the deeper plexus and
give off branches in all directions supplying the hair follicles, sweat
and sebaceous glands. The papillary layer is richly supplied with
delicate capillaries, which terminate in the papillæ, and are called
capillary loops.
=Lymphatics.= The lymphatics follow the vessels in a general way, there
being two plexuses, viz.: deep and superficial. Lymph spaces are found
in the rete Malpighii, which connect with the channels of those in the
derma. The papillæ and the glands also have lymph channels.
=Nerve Supply.= The skin contains both medullated and non-medullated
nerve fibres; these fibres are especially abundant in the soles of the
feet and at the ends of the toes. They enter the skin with the more
important ascending blood vessels. The non-medullated nerves terminate
in the rete as fine filaments, and the medullated nerves end in the
corium and subcutaneous tissue in special terminals called corpuscles.
Examples of these are Pacinian corpuscles, tactile corpuscles and the
end bulbs of Krause.
In addition to the sensory nerves, the skin also contains vasomotor
nerves. These nerves are found on the smooth muscles of the skin and
on all glands having such muscles, and have a direct action on these
glands.
=Muscles.= Both striated and non-striated or smooth muscles are found
in the skin. Those of the latter variety are most common, while the
former are sparingly found. The smooth muscle fibres are found in
connection with the hair follicles, the sebaceous and the sudoriferous
glands, and they act upon these organisms.
=Sudoriferous Glands.= The sudoriferous glands, or sweat glands, are
found in the reticular layer of the corium and in the subcutaneous
tissue. They are simple tubular glands which are coiled into globular
shape. The tubule of the gland empties into a gland duct which passes
through the corium and the epidermis and opens on the surface of the
skin in a funnel-shaped sweat pore. The sweat glands are very numerous,
particularly on the soles of the feet. It is estimated that there are
2,000,000 sweat glands in the adult human body.
=Sebaceous Glands.= The sebaceous glands, or oil glands, are found in
the reticular layer of the derma, usually associated with or in close
proximity to a hair follicle. They may occur independent of the hairs
however, as is the case in the lips. They vary in size from a simple
pouch to a many pouched or multilobular gland. These pouches empty into
a common duct, which in turn empties between the hair and the inner
sheath. The ducts secrete sebum, which consists of fatty degenerated
cells, in which is found epithelial waste matter. The sebum keeps the
skin and the hair soft and oily.
NAILS
=The Nails= are a specialized form of epidermis, and are considered
by many to correspond to the stratum lucidum of that structure. They
are horny, elastic, transparent, quadrilateral plates, and are found
at the distal ends of the fingers and toes, on their dorsal surfaces.
The nails are convex on the outer surface and concave within. The
nail itself is called the body and rests upon the nail bed. It has a
free edge distally and two lateral and a proximal or short edge which
latter lie in a groove called the nail or ungual fold. The ungual wall
overlies the lateral and proximal portions. The nail is embedded into
the derma at its proximal end by a root. This part of the nail is found
beneath the ungual wall and is composed of cells which have not yet
become horny.
The thin layer of skin, which extends forward from the nail groove at
the beginning of the body of the nail, is called the eponychium or nail
skin. The lunula is the little whitish, crescentic spot, a portion of
the nail bed, which is found in front of the nail fold, and extends to
the lateral edges of the nail.
The matrix of the nail is situated beneath the root of the nail,
and is so-called because it is from this structure that the nail is
produced. The matrix is thick, and raised in a series of longitudinal
ridges, which are readily seen through the transparent nail tissue. It
corresponds to the mucous layer of the epidermis, and is essentially
of the same structure. The matrix is highly vascular, which accounts
for the pink color seen through the nail, except at the lunula.
PHYSIOLOGY OF THE SKIN
The functions of the skin may be subdivided as follows:
Touch Organ
Protective Covering
Excretory and Secretory Organ
Temperature Regulator
Organ of Respiration
The skin acts as a touch organ or as an organ of tactile sensibility;
this power is supplied by special bodies found in the papillæ. The
degrees of consistency, of size, of form and of other qualities are
recognized by this function. Other sensations are conveyed by these
special nerve endings, such as heat and cold, burning, itching,
tingling, etc. The sense of touch is well developed, particularly in
the skin at the ends of the fingers, and this sense may be farther
increased, as is the case with blind persons.
The skin acts as a protective organ to the body within, by excluding
harmful agents such as bacteria, chemicals, heat, cold, etc. It is
elastic and thick and is without sensation and thus protects the
delicate structures beneath it from injury from various causes.
The functions of excretion and of secretion are performed by the
glands. The sudoriferous, or sweat glands, excrete the perspiration,
and in this way also act as elimination organs, accessory to the
kidneys. The body is continuously sweating. When there is no indication
of this function, when the skin seems dry, the name “insensible
perspiration” is applied; when the function is apparent, by the
formation of drops of moisture on the surface, it is called “sensible
perspiration.”
The sebaceous glands are organs of secretion. They give off an oily
substance called sebum, which lubricates the hairs, and gives an oily,
soft appearance to the skin. This tends to keep the outer layers
elastic and pliable; where this function is absent, the skin becomes
dry and is likely to form cracks or fissures.
The skin acts as a regulator of the body heat, by controlling the
radiation of the heat as brought to the surface from within, and
by regulating evaporation. The normal tension of the skin on the
various parts of the body has an influence in the regulation of body
temperature.
The function of respiration is, to some extent, duplicated by the skin,
the process being analogous to the respiration that takes place in the
lungs. The amount of oxygen absorbed is small, but water and carbon
dioxide are freely given off.
CHAPTER III
ASEPSIS AND ANTISEPSIS
To understand thoroughly and rationally to practise asepsis and
antisepsis, it is necessary for the operator to realize the difference
between the two terms. There is a general belief among the laity--and,
unfortunately, among some chiropodists--that these two words are
synonymous, and that asepsis and antisepsis comprehend the same system
of treatment. This is a fallacy.
=Asepsis= is a condition in which living pyogenic organisms are absent.
Aseptic surgery comprehends the performance of an operation in a field
free from pyogenic or septic germs, with sterilized hands, instruments,
etc., preventing the introduction of germs from without.
=Antisepsis= is the process whereby germs causing disease,
fermentation, or putrefaction are destroyed. Antiseptic treatment
comprehends the use of certain drugs or a group of drugs which prevent
the action of germs, which inhibit their growth, or which destroy them.
In the comparison of these two foregoing definitions the distinction
between the two words is clearly brought out. We speak of a
drug--mercuric chloride, for instance, as having an antiseptic action.
We speak of a piece of sterile gauze--sterilized, we will say, by
heat--as being aseptic. The mercuric chloride is an active substance
which, applied to a septic area, will proceed energetically to its
work of germ inhibition or destruction. The sterile gauze, placed over
a similar area, has no power to prevent or even retard the action of
the invading bacteria, let alone destroy them, but once having been
rendered free from such germ life by an antiseptic, the aseptic gauze
will keep the area in a germ free condition for a greater or lesser
length of time.
To sum up, then, the term “antiseptic” is applied to a drug or group
of drugs from whose actions bacteria are rendered innocuous or are
destroyed; and “aseptic” is applied to a condition in which no germ
life exists, having previously been freed from such contamination by
the use of an antiseptic agent.
Some years ago the term “germicide” was used in contradistinction
to that of “antiseptic.” This usage was brought about through the
belief that some antiseptics would not destroy all forms of germ life.
Germicide, at that time, was used to distinguish a drug which would
energetically attack and destroy all bacteria. Inasmuch as, on close
survey, it was found that the antiseptics which would not destroy all
germs were, in a great measure, weaker solutions, and that, if used in
greater strength, they would be efficient as purifying agents, this
distinction, today, has been done away with, and the terms germicide
and antiseptic are used synonymously and will be similarly employed in
this chapter.
ANTISEPSIS
Antiseptics to be actually efficient must be brought in direct
contact with the septic area. There is an erroneous belief that all
of the official germicidal agents and a majority of the proprietary
preparations, the advertising matter of which latter claims for them
great antiseptic proprieties, are efficient in deep-seated, septic
processes by mere surface application. This is wrong, and it is for
this reason that in all septic inflammations, free drainage must
be obtained and maintained, and the actual surface upon which the
bacterial action is in evidence must be exposed before the beneficial
action of antiseptic agents can be exerted or prove beneficial.
The skin unquestionably does, at times, absorb a drug applied to its
surfaces; but where an active infective process is present, the
antiseptic action of a germicidal agent is practically nil unless the
drug is brought into direct contact with the septic surface.
The present success of Dakin’s solution, for instance, is not so much
on account of the great efficacy of the solution itself--although
it has potent germicidal properties--as it is due to the Carrel
method of irrigation whereby this solution is carried to the most
obscure recesses in which the infective process is present. Applied
superficially, as must needs be done in chiropodial practice, we find
that Dakin’s solution is of no greater value than many other antiseptic
agents, except perhaps that, on account of its being non-toxic, it can
be used in cases where germicides with strong toxic properties are
contra-indicated.
HISTORY OF ANTISEPTICS
The story of antiseptics is one of the most interesting in all the
pages of medicine and surgery.
Antiseptics were employed as remedial agents long before the exact
causes of putrefaction or fermentation were known. The Egyptians
preserved the human body against the attacks of putrefactive organisms,
without any knowledge of the character of the organisms causing decay.
The wonderful state of preservation in which we, today, find the bodies
of their kings, was brought about by means of balsams containing,
probably, such antiseptics as benzoic and cinnamic acids.
In the sixteenth century the surgeons treated gunshot wounds with
boiling oil. They knew that if these wounds were left untreated,
putrefaction would ensue accompanied by great suffering, and the
ultimate death of the patient. They also knew, empirically, to be sure,
that boiling oil applied to the wound prevented the development of this
putrefactive process, but they did not know why such was the case, nor
did they realize that, by this use of superheated oil they were merely
cauterizing the wound.
Ambrose Pare (1510-1590), who started life as an apprentice
barber-surgeon in Paris, became a military surgeon in the army of
Francis I, in Piedmont; and he, more from a humane feeling, as his
writings tell us, than from any particular scientific knowledge, had
the temerity to dispense with this oil boiling technic and to trust to
a simple bandage saturated with a concoction of herbs. Pare, however,
has no particular place in the development of antisepsis, his principal
contribution to surgery being in the development of the use of the
ligature for large arteries, which made amputation on a large scale
possible for the first time.
Antiseptic surgery dates from the last few years of the nineteenth
century, and among the names of its sponsors which will ever remain
foremost, are Pasteur and Lister.
Lister’s use of local antiseptics in surgery, however, should not,
perhaps, be spoken of as a discovery. Without detracting in any way
from the credit due him, it should be referred to, more correctly, as a
practical application, in particular of the theories of Pasteur, and of
several previous investigators.
Prior to Lister’s use of phenol, the substance had already been
described by Reichenbach in 1832, and by Runge in 1834, as one which
would prevent putrefaction. Long before these, tar and a number of
similar products were advocated and used for foul ulcers, but the fact
remains that Joseph Lister placed the use of antisepsis in connection
with surgical procedures on a sound and practical basis.
Taking as a working basis the experimental researches of Louis Pasteur
(Communications on the Theory of Fermentation 1853, 1858; The Germ
Theory, read before the French Academy of Sciences on April 29th, 1878,
and The Extension of the Germ Theory, which appeared in 1880), Joseph
Lister, an English surgeon, developed his theory of antiseptic wound
treatment. His first experiments were made public in 1860. At that
time he stated that the evils observed in open wounds were due to the
admission into them of organisms which “exist in the air, in water,
on instruments, on sponges, and on the hands of the surgeon or the
skin of the patient.” Having accepted the germ theory of putrefaction,
Lister applied himself to discover the best way of preventing harmful
organisms from reaching the wound from the moment it was made until
it was healed, or, if this could not be done, of using some agent to
destroy the organism, either before it reached the wound or after it
had lodged there.
Acting on the advice of Lemaire, who had already experimented with
several substances which were known to be antagonistic to putrefaction,
Lister chose carbolic acid, which he used first in the crude form.
His experiments extended over a number of years during which period
he surmounted many obstacles, until in the early 80’s he finally
perfected his antiseptic treatment of wounds by means of carbolized
sprays for the air of the room, carbolized solutions for irrigation,
for instruments and for surgeons’ hands, and carbolized dressings with
mackintosh protection, as post-operative procedures. Today we smile
at the idea of a dressing of phenol in any strength, covered with
mackintosh protection; but in advocating this procedure, Lister had in
mind, as nearly as possible, to cover the wound so that no external
agencies might come in contact with it.
From this beginning, our present day antiseptic surgical technic has
been gradually developed. Mercuric chloride gradually replaced phenol,
and the use of the carbolic spray was discontinued on account of its
chilling influences on exposed surfaces, which tended to lower their
vitality.
Aseptic surgery owes its origin primarily to antiseptic surgery. Not
long after Lister’s rules for antiseptic procedure were generally
observed, the realization came to many that the success of Listerian
surgery did not depend so much upon the spray or the carbolized gauge,
as it did upon cleanliness; the surgeon’s hands, the instruments, the
area to be operated upon, and the dressings must be clean--surgically
clean.
Today we have the rule of “the soap and nail brush,” the sterilized
instruments, the aseptic rubber gloves for the operator’s hands, and
the sterile dressing. The modern surgeon uses no antiseptics during
operations; he uses instruments which are positively germless and the
dressings of aseptic gauze are not impregnated with medications.
ANTISEPTICS
The important subject of antisepsis embraces such a variety of agents
which may be employed in the numberless conditions arising, that it
is usually divided into three groups. (1) general antiseptics; (2)
local antiseptics; (3) internal antiseptics. For the purposes of
the podiatrist, some knowledge of the first group is desirable, but
his principal thought on this subject should be given to a thorough
knowledge and understanding of the second group, those for local
application. Inasmuch as the podiatrist is not allowed to prescribe
internal medicines, no discussion of the third group, comprising
internal antiseptics, will be included in this chapter.
=General Antiseptics=, or disinfectants, play so great a part today in
preventive medicine that the podiatrist should at least inform himself
on the general principles involved.
Under this group we find a number of agents which are employed for
purposes of general disinfection. First on the list comes:
=Sunlight.= The bright, direct rays of the sun, coming into direct or
immediate contact with germ life, are the best of all disinfectants.
This does not mean their merely shining on one side of a carpet, or
on small masses of blood, pus or sputum, but their penetrating each
individual microorganism. When this can be accomplished, all germ life
is destroyed in a few hours. But this cannot be accomplished in all
conditions, and, unless the penetration of sunlight is thorough it is
not dependable. For this reason we are forced to rely on other agents
(thermal and chemical) to accomplish our purpose.
=Heat.= A direct flame will, of course, instantly destroy all forms of
microscopic life; dry air heated to 160° C. (320°F.) will destroy all
disease germs--but not all spores--in one hour. Moist heat, water or
air saturated with aqueous vapor, heated to 75°C. (167°F.) will destroy
most germs.
Boiling water will even kill spores in ten minutes, if they are not in
small masses. To break up such masses the addition of a small amount
of baking soda will serve, not alone to dissolve these albuminous
collections, but will also keep instruments from rusting (see
Sterilization). Steam, or air which is supersaturated with steam, is
fatal to pathogenic organisms, and at a much lower temperature than dry
hot air.
Chemicals which may be included under this group of general
disinfectants are: formaldehyde, lime, sublimed sulphur and chlorinated
lime.
=Formaldehyde=, formalin or formic aldehyde, is widely used as a
general disinfectant. It is exceedingly powerful, one part of the gas
rendering fifty thousand parts of air irrespirable. The action of
formaldehyde is increased by moist heat, it does not actively corrode
metallic instruments nor does it injure fabrics. The formaldehyde
cabinet is used generally by podiatrists. (See Sterilization).
The official preparation of formaldehyde is a 37% solution known as
liquor formaldehydi, U. S. P. For the disinfection of rooms, the
solution may be applied directly by washing or spraying, or it may be
used in vapor form. When the latter is employed, the windows and doors
are tightly closed and all the crevices are plugged with paper.
=Lime=, calx, or calcium oxide, is extensively used but must be freshly
prepared to be effective. Unslacked lime is a cheap, and an efficient
means of destroying animal matter, but the milk of lime, freshly
slaked, is by far the most desirable form.
=Sublimed Sulphur=, or flowers of sulphur, is not so generally used
today as is formaldehyde. It should be used only in places where
nothing can be injured by the corrosive action of the resulting
sulphurous acid. As with formaldehyde disinfection, the vapor must come
into actual contact with the microorganisms and the atmosphere should
be moist.
=Chlorinated Lime=, improperly called chloride of lime, is a ready
source of chlorine, and is a convenient and inexpensive agent for
general disinfection purposes. It has a corrosive action, however, and
therefore should not be used in places where this action will do damage.
There are a number of drugs which may be more or less successfully
employed as general antiseptics and disinfectants. Phenol, cresol,
potassium permanganate, mercuric chloride and copper sulphate are
on this list, but as the podiatrist is principally concerned with
the second group, local antiseptics, these drugs, which are included
usually under that group, will now be discussed.
It is deemed wise before passing on to the subject of local
antiseptics, to bring one important point to the attention of the
student. Under no circumstances must the term deodorant be confused
with disinfectant. A deodorant is an agent which merely destroys or
conceals an offensive odor and has no power whatsoever to actually
destroy or inhibit the growth or action of bacteria. Many disinfectants
are also deodorants, but a deodorant may not always have germicidal
properties.
=Local Antiseptics= are agents which are applied locally and externally
for the purpose of arresting putrefaction. In podiatry there are a
number of drugs belonging to this class which may be safely employed
and whose beneficent action may be depended upon.
There has been a marked tendency in podiatry in the past toward the use
of a number of proprietary drugs for germicidal purposes. Happily this
practice is dying out, and a few years will find the therapeutics of
podiatry established on a sound, rational basis.
The following local antiseptics can be safely employed in podiatry
operations:
=Alcohol= is used generally in practice to render fields of operation
surgically clean. The pure grain alcohol is used for the immersion
of instruments prior to operation, but a 60% solution is found more
efficient for antiseptic action upon the body surfaces. A pledget of
sterile cotton, saturated with alcohol and placed over a part, insures
absolute asepsis in a short time. Alcohol alone cannot be practically
used as a wet dressing. In this connection it is combined with boric
acid, equal parts, and is efficient as an antiseptic.
=Liquor Alumini Acetatis=, an 8% aqueous solution of acetate of
aluminum, is used almost entirely as a wet dressing in infective
inflammations. It is non-toxic and, while it is irritant to extensive
denuded surfaces, it is usually employed for its astringent action.
=Balsam of Peru= is used chiefly in podiatry as a stimulating agent;
its antiseptic properties, however, are well known and are probably due
to the benzoic and cinnamic acid which it contains. It is used either
alone, in ointment form, 3% to 10%, or in combination with collodion,
10%.
=Boric Acid= is employed principally as a wet dressing in cases of
inflammations. It is quite free from toxicity and is but slowly
absorbed. It is also used in powder form as an antiseptic.
=Boroglycerine=, U. S. P., contains 30% of boric acid. It is found
particularly effective in the treatment of indolent ulcers where a mild
antiseptic lotion is desired.
=Borate of Sodium= (Sodii boras, U. S. P.), borax, has an alkaline
reaction and for this reason is sometimes substituted for boric acid.
It is soluble in 16 parts of water.
=Dakin’s Solution= is a solution of hypochlorite of soda, ¹⁄₂%. The
preparation of the original solution is so difficult that large
quantities of the drug are not easily obtainable. Chlorazene, an
American product which is recommended by both Dakin and Carrel, is
obtainable in tablet and in ointment form. One tablet dissolved in 8
ounces of water makes a solution, ¹⁄₂ of 1%. The solution is unstable,
necessitating its being constantly made fresh, and for this reason the
use of the drug is not practical in podiatry practice today. When used,
the solution must be changed within twenty-four hours; if this is not
done it becomes irritant, setting up an acute dermatitis. The drug is
used as a wet dressing, but never with rubber or oiled silk covering.
=Di-Chloramin-T=, the newer form in which Dakin’s solution is used, is
a 5% or 10% hypochlorite of soda solution in oil of eucalyptus. This
combination is found to be less irritating than the original solution.
It is used as an antiseptic dressing.
=Glycerinum=, U. S. P., is not alone useful as a mild antiseptic but
is also extensively used as a vehicle for many other substances in the
treatment of skin lesions.
=Hydrogen Dioxide=, peroxide of hydrogen, is used principally in
podiatry to decompose pus in which bacteria are protected from the
action of other antiseptics. As the antiseptic action of hydrogen
dioxide is dependent solely upon the liberation of its component
oxygen, it is easily seen that once the ebullition occurring on its
contact with albuminous surfaces ceases, it becomes inert. “Peroxide”
is used as a pus germ destroying agent, and to loosen dressings which
have become adherent from copious discharge.
=Iodine=, Tinct. Iodii, U. S. P., is 7% of iodine in alcohol, and
presents the best agent known at the present time by which surface
sterilization can be obtained. It is highly germicidal, but continued
applications are decidedly corrosive and not alone inhibit the
development of new granules, but also cause severe dermatitis, and at
times symptoms of iodine poisoning. The one feature which prevents its
use in some chiropodial procedures is the discoloration of the tissues
produced by its application. It may be used full strength or diluted
with water, as weak as a 1% solution.
=Iodoform=, despite its unpleasant and suggestive odor, is an efficient
antiseptic and is used in powder form. Its antiseptic action is
principally derived by the slow liberation of its component iodine.
Several forms of mercury are used in podiatry.
=Bichloride of Mercury=, or mercuric chloride, is used, ¹⁄₂₀₀₀, to
prepare fields for operation, and from ¹⁄₅₀₀₀ to ¹⁄₁₀₀₀₀ as a wet
dressing in infective inflammations. It is highly toxic and should
never be used for any great length of time, or on a denuded surface
of any size, as it is rapidly absorbed into the general system, and
its corrosive action tends to inhibit the development of new granules.
There are also systemic effects to be feared from its absorption.
=Mercurous Chloride=, calomel, can be used as an antiseptic dusting
powder on many chiropodical lesions. It is combined generally with
bismuth, equal parts, as an antiseptic and astringent application for
blisters and burns.
=Unguentum Hydrargyri=, U. S. P., is a 50% ointment, used principally
in chiropody in the treatment of parasitic diseases of the nails.
=Unguentum Hydrargyri Ammoniatum=, 10%, is an antiseptic ointment used
safely in any case where such action is desired.
=Phenol Liquefactum=, U. S. P., carbolic acid, is used as an antiseptic
in solution, 2¹⁄₂%. It is highly toxic and is never used as a wet
dressing under any circumstances. Phenol, besides its toxic properties,
has an anesthetic action on the peripheral nerves, and due to this
action, many cases of carbolic gangrene have been reported.
=Liquor Cresolis Compositas=, U. S. P., also a coal tar product, can be
advantageously used in a general spray for the foot, or for the special
field of operation. It is antiseptic, and its saponaceous properties
(it is a solution of cresol and soap) aid in softening the tissues as
well as in cleansing them. It is used in 2% strength.
=Lysol=, an unofficial phenol derivative, is also used as a general
spray, 2%, in water. Its odor is very strong and it is therefore
objectionable to many persons.
=Thymol= is a phenol occurring in a volatile oil. It possesses strong
antiseptic properties, but its comparative insolubility in water has
prevented its more general use. The only official combination of thymol
is
=Thermolis Iodidum=, U. S. P. Thymol iodide, or more correctly
dithymoldiiodid, has been better known for years under its trade name
“aristol.” It is used as a dusting powder, is actively antiseptic
by the liberation of iodine, and has become popular as an iodoform
substitute.
=Potassium Permanganate=, U. S. P., has its greatest usefulness as a
local antiseptic application where deodorant action is also desired. In
the treatment of indolent, foul ulcerations it is very efficacious.
=Sulphur= is used principally in podiatry in the form of =Unguentum
Sulphuris=, U. S. P. It is composed of 15% of washed sulphur, usually
in a lanolin base, and has a mildly stimulating and antiseptic action.
There are any number of additional drugs, both official and
unofficial, which can be and are used in podiatry practice, but it is
deemed sufficient to name the foregoing which constitute a complete
armamentarium for all antiseptic procedures.
THE FIELD OF OPERATION
For rendering the field of operation aseptic the following technic will
be found efficient:
In addition to preparing the immediate field it is found advantageous
to treat the surrounding areas to prevent the washing in of bacteria.
To accomplish this the use of an antiseptic spray is to be advocated.
Equipped as the podiatrist is with modern air compressing devices,
this is a simple matter, the principal question being the selection of
a proper spray.
An aqueous solution of alcohol is exceptionably suited for purposes of
this kind and where a lesion is already present this drug should be
used to the exclusion of all others.
Most cases the podiatrist is called upon to treat, however, present no
lesion, yet asepsis must be procured in the event of a lesion being
made during his operative procedures. In cases of this nature a spray
of liq. cresolis compositus, U. S. P., 2¹⁄₂%, will be found to be an
agreeable and efficient application. This solution has but a slightly
disagreeable odor and has marked softening as well as antiseptic
properties.
After the whole foot has been thoroughly sprayed and dried with a
sterile towel, the immediate field of operation may be coated with tr.
iodine, 3¹⁄₂%. This is one-half the strength of the official tincture
and is advocated to obviate the deep stain occasioned by the use of
the 7% tincture. In many cases, however, no stain whatsoever can be
countenanced for fear of obliterating some diagnostic point, and it
may be found advisable to dispense entirely with iodine, substituting
alcohol, 60%, in its stead.
A pledget of sterile cotton saturated in this solution of alcohol
and placed over the area under treatment, will produce asepsis in a
short time. The penetrating qualities of alcohol are, however, found
to be increased, if application is made by means of a cotton wound
applicator, the mixture being rubbed vigorously into the parts.
The use of either of these two methods will procure a sterile field
upon which any chiropodial operation may be commenced and completed in
safety.
Should hemorrhage be caused during operation, it may be arrested in a
number of ways: (1) Bichloride of mercury, ¹⁄₁₀₀₀, may be applied on a
pledget of sterile cotton. This will serve to check the blood flow by
hastening coagulation, and at the same time will procure asepsis. (2)
Tr. iodine may be painted over the lesion and digital or tourniquet
pressure applied until coagulation is complete. (3) Astringent and
antiseptic dusting powders may be applied. (4) Styptics (Monsel’s
solution is efficient and the least irritating) may be used, but it
must be remembered that these drugs combine no antiseptic qualities and
therefore it is good surgery to apply tr. iodine before their use.
A hemorrhage arrested by any of the foregoing methods should be
dressed antiseptically, as well. For this form of dressing, antiseptic
ointments or dusting powders are found to be most effective.
ASEPSIS
The topic of asepsis will be found more thoroughly, discussed under the
chapter “Sterilization.”
Aseptic procedure comprehends the employment of all instruments and
materials which have by some means been previously rendered free from
germ life. Instruments are to be thoroughly sterilized by boiling in
water for at least fifteen minutes, the hands of the operator are to be
thoroughly cleansed, or are made as nearly germ free as is possible;
the dressings used are to be surgically cleansed (usually by moist or
dry heat) before application; and no antiseptic solutions are included
in the treatment.
It is doubtful if aseptic procedures can be practised in podiatry to
the exclusion of antisepsis. It must be remembered that after most
chiropodical surgical procedures, the foot surfaces (again encased in a
shoe) teem with septic matter which present the mediums best suited for
the propagation of bacterial life,--heat, moisture and darkness.
An aseptic dressing having been employed, the length of time it
will remain germ free is problematic; so it is found advisable in
most instances where there is danger of infection, to resort to an
antiseptic method of treatment rather than to rely solely upon the
aseptic.
Dr. Edward Adams, Professor of Surgery at The First Institute of
Podiatry, lecturing to the students on “The Newer Antiseptics in the
War,” spoke as follows:
“The immense number and variety of wounds encountered in the present
war, necessitating the care of many thousands of men at one time,
and the entirely new situations created by modern warfare, have led
to an amount of research heretofore unknown. True to its traditions,
the medical profession has endeavored to discover the best methods in
treatment and to render the best service in its power to bestow. Never
has the surgeon had to face greater difficulties and never has he
recorded more brilliant success.
“Where practically every wound is infected, antisepsis has necessarily
received unusual attention, and the merits of different substances
having antiseptic properties have been thoroughly discussed and have
narrowed down to a very few. The fact is emphasized that those which
are strong enough to be antiseptic must be used with great care,
especially in cases where drainage is not free.
“After many trials and many discussions the tendency of men of the
greatest experience, however, is to reduce the problem to very simple
terms which may be expressed thus: (1) How to secure a clean wound.
(2) How to give nature a chance with a minimum of interference, since,
after all, she must do the healing.
“The early part of the war demonstrated the fact that both antisepsis
and asepsis, as heretofore practised, have been vanquished by Mars. By
some it was even considered that Lister’s work went for naught. Now,
however, antisepsis and asepsis, each in its proper place, have come
into their own again and Lister is still the apostle of good tidings.
“The reasons are plain: first, at the beginning of the war we did not
possess sufficiently effective antiseptics such as have now been given
us; second, we were not masters of an efficient technic. We owe these
innovations especially to two men, Dakin and Carrel, who have wrought a
marvelous change. Lister taught us above all how to prevent infection;
Dakin and Carrel, following his principles, have taught us how to
conquer even the most virulent infections. For nearly half a century
surgeons have been fighting strenuously against infection, but it
required the stimulus of war to enable us to win a victory. Prevention
and cure both are ours now.
“The newer antiseptics that have been discovered and used since the war
are chiefly: Dakin’s solution of hypochlorite of soda, di-chloramin-T,
eusol and eupad, both preparations of hypochlorous acid, flavin,
acriflavin, and proflavin, and a mercurial preparation known as
mercurophen.
“These newer antiseptics, especially the flavin group, have pronounced
bactericidal qualities, but it is too recent as yet for them to have
been tested on a sufficiently large scale to permit of positive
conclusions as to their value. Flavin is described in detail as to its
process of manufacture and its action in an article by C. H. Browning
and his colleagues in the Bland-Sutton Institute of Pathology of
Middlesex, London (_British Medical Journal_, January 20, 1917, page
73). For technical reasons flavin as one of the acridin group is now
called acriflavin, and a more potent preparation is called proflavin,
which is described in the _British Medical Journal_, June 9, 1917.
Dakin, in the same journal, June 23, 1917, endorses Browning’s method
of treatment with acriflavin. Its antiseptic action, instead of being
diminished by blood serum, is increased thereby, even up to five times
its potency. Moreover, as used by Browning, it is harmless to the
tissues and does not interfere with the activity of the leucocytes nor
with phagocytosis.
“The most important paper yet published on these newer antiseptics is
by Browning Culbranson and L. H. D. Thornton in the _British Medical
Journal_, July 21, 1917. The principal points brought out by their
experiments with the use of acriflavin and proflavin are as follows:
first, that the bactericidal power of acriflavin and proflavin, instead
of being diminished and even destroyed by the contact of blood serum
(as is the case with hypochlorite of soda, bichloride of mercury,
etc.), is greatly increased from 10 to 40 fold. Second, as a result,
these two antiseptics, though acting at first merely by inhibiting
bacterial growth, later become increasingly powerful and actively
destroy the bacteria. After two hours’ contact in the presence of
serum, mercuric chloride is practically equal to acriflavin in its
lethal effect on the streptococcus and bacillus coli, but by this time
the effective action of the mercury salt on the bacteria has come to an
end, and a concentration which has then failed to kill the organisms,
exerts little or no inhibiting effect on the proliferation of the
survivors. On the other hand, concentrations of the flavins, which
at this period have merely inhibited multiplication, later on prove
bactericidal, so that finally the flavin compound is ten to twenty
times more lethal than corrosive sublimate. Therefore, instead of
renewing the solution every two hours, only one or two daily dressings
are required. Moreover, they are apparently harmless to the tissues.
Experiments show that such concentrations of flavin as will effectively
control the bacteria do not interfere with phagocytosis.
“Brilliant green, like the hypochlorites, in the presence of serum,
soon loses its value as a bactericide; hence, if used it must be
renewed at frequent intervals. On the other hand, it possesses the
advantage of being an extremely potent bactericide, far exceeding the
flavins in watery solutions, while at the same time it is comparatively
harmless to phagocytosis, as well as to the tissues locally, and when
applied to a wound it is devoid of general toxic action on the body.
Its use by two hourly flushings after the Carrel method, has proved
most encouraging.
“The Dakin Solution. The value of this antiseptic has been demonstrated
by Drs. Carrel and Dakin. It is a carefully standardized solution of
sodium hypochlorite and is usually prepared from chlorinated lime
(bleaching powder), but may be prepared directly from chlorine gas. The
formula has been varied from time to time. Some surgeons use an acid
solution (anærobes do not live in an acid medium), others an alkaline
solution, while Drs. Dakin and Carrel in their method, avoid an excess
of either quality. In the solution now used by them which is made
according to the formula of Dufresne, the chlorinated lime is combined
accurately with both sodium carbonate and sodium bicarbonate, making
a nearly neutral product which contains from 0.45 to 0.5 per cent. of
sodium hypochlorite, because less is too weak and more is too strong.
The advantages of this solution are as follows: (1) It is antiseptic
and does not damage the tissues. (2) It is non-toxic and no danger is
to be apprehended from its absorption. (3) It is hypertonic, that is,
the concentration of the solution is greater than that of blood serum
and tissue fluids, and therefore, it produces an outflow of lymph. (4)
If used as an acid solution it is available against anærobic bacteria
which require an alkaline medium.
“The fact that nearly all wounds of the present war are infected, in
connection with the serious and often fatal nature of the infection,
has stimulated an unusual amount of research with the hope that a
reliable and safe disinfectant may be discovered--especially one that
will not injure the tissues of the body, since these are more easily
affected by the disinfectant than the bacteria themselves. This object
has been realized in large part by the Dakin-Carrel solution, which,
however, to be effective, must be frequently renewed according to the
Carrel technique. It is also frequently very irritating to the skin,
although this may be avoided by the use of petrolatum.
“According to the investigation of Dakin, a chemical action takes place
between the hypochlorite in the solution and the proteins in the wound
exudate with the formation of the new substances called chloramines.
One of these chloramines has been prepared synthetically and introduced
under the name of chlorazene, which is said to possess a germicidal
power four times greater than the Carrel-Dakin solution itself and
is unirritating to the skin but, like the latter, must be frequently
renewed. By dissolving one of these chloramines in an oily medium,
however, it is possible to keep it in contact with the wound surfaces
for a much longer time than can be done with a watery solution. The
advantage of this is evident.
“The solution which is used at present has been named di-chloramin-T,
the medium being chlorinated eucalyptus oil or paraffin oil. A ten
per cent. solution of di-chloramin-T and eucalyptol may be kept in
a colored bottle for at least one month with only slight change. It
is applied to the wound surface in the form of a spray after the
removal of infection foci and devitalized tissues. Deep cavities are
filled with the liquid and drainage afterwards provided for. The high
percentage of disinfectant contained in this preparation renders it
active for a period of twenty-four hours because of the slow liberation
of the germicide. It would appear that when applied with strict
attention to detail it is not only less expensive than the Dakin-Carrel
method, but will secure healing of a wound in a much shorter time. The
gradual elaboration of the remedy makes it particularly applicable
in cases that cannot be frequently dressed during transportation.
Di-chloramin-T, hypochlorites and hypertonic salt solutions all have
the power of dissolving dead tissue. A precaution to be remembered,
however, is that if used near a blood vessel hemorrhage may occur.
“For a detailed report of the use of di-chloramin-T in the treatment
of infected wounds, read Dr. H. T. Dakin’s article in the _Journal of
the American Medical Association_, July 7, 1917. For a still later
description of the Dakin-Carrel treatment of wounds, see the report of
the Surgical Commission to the Directors General of the British Army
Medical Service reprinted from the _British Medical Journal_, November
3, 1917.
“To my mind the best preparations that can be easily used are: (1)
Chlorazene (Abbott), in tablet form; (2) in form of a non-irritating
surgical powder containing 1 per cent. chlorazene; (3) in form of a
cream containing 1 per cent. of chlorazene in a sodium stearate base.
These I can recommend.”
CHAPTER IV
STERILIZATION
In the practice of medicine and its allied branches, it is recognized
that no unsterilized object is clean; it is therefore necessary for
every such object to be sterilized before being brought in contact
with, or near to a wounded surface, or to a surface about to be wounded.
Previous to the time of Lister, who was the first one to practise and
to advocate asepsis and antisepsis, it was considered normal for a
wound to suppurate and the consequent appalling results were accepted
as being in order. Today, however, asepsis and antisepsis have been
proven to be absolute essentials to intelligent treatment, and it is
accordingly necessary that every practitioner treating the human body,
should exercise the greatest care so as to prevent the invasion of
hostile bacteria.
Sterilization may be defined as the act of rendering an object sterile
(clean), by the destruction of microorganisms, preferably by means of
heat. To perform any operative work, so that there is perfect asepsis,
or freedom from bacteria, depends entirely upon the care exercised in
practising such asepsis. The instruments, the dressings, the field of
operation and the hands of the operator are all media for contamination
and the infection of wounds, and the sterilization of all these is
necessary, as infection might come from lack of care in the preparation
of any one of these details before an operation.
=Instruments.= The most efficient way of rendering instruments sterile,
is by immersing them in boiling water for fifteen minutes. To each
quart of water used in the sterilizer, is added one-half an ounce of
sodium carbonate (washing soda). This prevents rusting and also acts
as a solvent for any fatty substance that may be on the instruments.
Superheated steam is used for sterilizing instruments, but this
requires especially large and expensive apparatus which is not at the
command of most practitioners. Dry heat will destroy bacteria, but it
is not as effective as moist heat (steam). To procure absolute results
requires a high temperature, which effects the temper of the steel in
the instruments.
Instruments with sharp cutting edges, such as are used in the removal
of helomata, are blunted by boiling. They are therefore best sterilized
by immersing them in pure carbolic acid for a few minutes, followed by
dipping in grain alcohol, the instruments being handled with a pair of
forceps.
=Dressings.= Dressings such as gauze, bandages, absorbent cotton and
other cloth materials are best sterilized by steam which is allowed to
circulate through the material for fifteen minutes, and they may then
be placed in dry heat for a short time, thus allowing the moisture to
evaporate. If a steam sterilizer is not available, the dressings may be
boiled, or they may be baked for ten minutes in a temperature not lower
than that of the boiling point of water. Care should be taken that the
heat is not great enough to scorch or burn the materials.
Sterilized dressings of all kinds may be purchased in convenient,
hermetically sealed packages, and may be safely used without
preparation. Once such a package has been opened and used, the contents
do not remain sterile; the materials left over from an operation should
not be used at another operation unless they have been again thoroughly
sterilized.
=Field of Operation.= The skin of the foot is much thicker than that
on the other parts of the body and in addition it usually does not
receive the same hygienic care as does the rest of the skin surface. It
is therefore highly essential that additional precautions be taken in
preparing the foot for operation.
The entire foot should be scrubbed with soap and warm water so as to
remove as much of the exfoliated skin and dirt as possible. It is then
immersed in a solution of bichloride of mercury (¹⁄₂₀₀₀) and wrapped
in a sterile towel until ready for operation. The foot may also be
prepared by first scrubbing with soap and water, washing with alcohol,
60%, and finally painting the part to be operated upon with tincture of
iodine. Iodine has proven to be the best antiseptic in use today, but
very often it interferes with chiropodical operations due to the stain
it produces. This may be overcome to a certain extent by washing the
part with alcohol after the iodine has been applied.
Alcohol in a sixty per cent. solution is a very efficient antiseptic
and wherever iodine cannot be used, it may be substituted. A piece of
absorbent cotton, dipped into the alcohol, is placed in contact with
the part to be treated and is allowed to remain for a few minutes. Like
iodine, alcohol penetrates the layers of the epidermis and so destroys
the bacteria that lurk between the outer layers.
=Hands of the Operator.= There are several ways of cleaning the
operator’s hands, but each such procedure is preceded by thoroughly
scrubbing them with green soap and a nail brush for at least ten
minutes, in warm water. Alcohol or ether should then be rubbed over the
hands to dissolve fats, and they should then be dipped in a solution
of bichloride of mercury (¹⁄₂₀₀₀) for a few minutes. A most efficient
way of sterilizing the hands consists of the following: after scrubbing
the hands as before described, take equal parts of chloride of lime and
carbonate of soda (about one-half teaspoonful of each) and add enough
water to make a paste. This is thoroughly rubbed into the hands and
when the sensation of warmth has disappeared they are rinsed in sterile
water.
The use of rubber gloves to protect the hands is of some advantage in
that they may be thoroughly boiled before they are used; but unless
the hands are sore or the skin is tender, they should not be employed,
as they decrease the sense of touch so necessary in chiropodial
procedures.
STERILIZING APPARATUS
There are many kinds of apparatus for each form of sterilization, and
the podiatrist, in selecting a sterilizer, must be guided by the size
of his purse as well as the amount of space he can afford for such an
apparatus.
The steam sterilizer is unquestionably the best for general purposes,
and the dual compartment arrangement is better than a single chamber
outfit. Steam sterilizers for office purposes vary in size from the
small single chamber, measuring four inches wide, eight inches long and
four inches deep, to the larger double chamber which measures twelve
inches wide, twenty-four inches long, the upper chamber twelve inches
deep and the lower chamber six inches deep. The latter sterilizers are
the best possible for the podiatrist’s work, in that they allow for the
sterilization of towels, dressings and instruments at the same time,
and there is no direct contact between the instruments and the boiling
water. The apparatus may be heated by gas or by electricity, gas being
the most desirable as it is more easily controlled and regulated. The
cost of the instrument equipped for gas heating is very much cheaper,
and the operating expense is less than when electricity is similarly
used.
As its name implies, the double compartment sterilizer is composed
of two distinct sections which are easily separated, and when put
together look as if they were one section. The lower compartment is
more shallow than the upper and contains the water which is boiled for
the manufacture of the steam to be utilized in the sterilization. The
upper compartment has an inner jacket which is so arranged that the
steam passing from below is collected in it, and is admitted into the
compartment proper through a small opening at one end. This causes
the steam to be forced in under a slight pressure, which increases the
heat and adds to its power as a germ destroying agent. The opening is
controlled by an inlet valve which may be adjusted so as to prevent the
steam from entering the compartment. The steam then circulates around
it in the jacket and in this way dry heat is generated in sufficient
quantity to allow for dry heat sterilization. If space permits, it is
advisable to have two such sterilizers, one for steam sterilization
and the other for dry heat sterilization. The instruments, towels and
dressings may thus be dried which prevents the rusting of the steel,
and makes the linen more easy to handle. These sterilizers are as well,
an ornament to any office.
[Illustration: ELECTRIC STERILIZER]
Where space is limited, the smaller electric sterilizers may be
substituted for the larger outfits. There are many styles and shapes
of this kind of instrument, but the principle is the same in all of
them. There must be ample space for the reception of the instruments,
and the cover must be closed when the water is boiling. The electric
current is passed into a metallic disc, situated beneath the bottom
of the water receptacle. As the current passes through this disc, it
becomes hot, and the water in the compartment is gradually heated until
the boiling point is reached. The current must never be left on when
the machine is not in use, for when the water has evaporated, the heat
will cause the solder holding the joints of the sterilizer to melt and
cause a separation of the seams. This molten solder might even drip
on something combustible and set it alight. There are some electric
sterilizers which are equipped with safety devices which prevent this
possible accident. The device provides so that when this heat is great
enough, it melts a small piece of an alloy with a very low melting
point. This metal is held in position by a clamp which is attached
to the current flow and when this melts, the current is cut off and
further heating is impossible. This is a very valuable attachment,
particularly when one is inclined to be careless.
Another form of smaller electric sterilizer consists of a glass
compartment into which is placed the heating apparatus. This latter
is composed of coils enclosed in a metal protector. The protector is
attached to a handle, through which pass the electric wires. This coil
and handle is placed into the glass bowl and is held fixed by a small
clamp. A cover is then placed over the bowl, which is so arranged as to
allow the wires to pass through it.
For sterilization with pure phenol and alcohol, it is necessary to
have two wide mouth, glass stoppered, two-ounce bottles. When the
instruments are being sterilized they may be left standing in either
bottle until ready for use. A piece of felt, cut to fit the inside
bottom of each of the bottles, should be placed in situ, so that when
sharp edged instruments are placed in the bottles, their points will
not be broken, by coming in contact with the hard glass.
[Illustration: FORMALDEHYDE STERILIZER]
Formaldehyde gas is an agent which has germicidal properties, and is
used to a great extent where steam sterilizers are not available.
Formalin, a concentrated solution of the formaldehyde gas, readily
gives up its gaseous constituent so that when the liquid is placed on
a flat tray, the gas will penetrate objects around it. Cabinets have
been constructed which are so arranged that the lower shelf contains
the solution, and the upper shelves may be used for instruments,
dressings, towels, etc. When the cabinets, which vary greatly in size,
are tightly closed, the gas will penetrate every object contained
therein, thus destroying any microorganisms which might be present.
CHAPTER V
THE CARE OF THE FOOT
=The Naked Foot.= For many centuries the human foot was allowed to go
naked, and our aboriginal ancestors never knew what foot clothing of
any type meant. Much the same as with the rest of his body, unaided
nature was allowed to minister to the needs of his pedal extremities.
Research has shown that primitive man was very strong and able to
withstand the abuses of the elements to a marked degree. The body
adapted itself to nature and the elements, so that it could bear
extreme heat or cold, wind or rain, or any condition of the weather,
without giving way before these nature forces.
So it was with the foot of man during this period. The skin of the
soles became thickened so that even the roughest surfaces caused no
discomfort when borne upon by his bare feet. Even to this day, savage
tribes that still go barefoot have skin on the soles of the feet that
is tough and hardened. The author has seen natives of Central America,
who are of this class, step on objects such as glass, lighted cigars,
etc., without experiencing any appreciable discomfort.
In aboriginal man, muscular action of the entire foot was developed
to its maximum. The muscles of the toes were under perfect control so
that objects could be felt and lifted with them, much the same as with
the fingers of man today. The leg muscles were well developed so that
the position of the body in walking could be altered quickly and the
body weight could be rapidly changed from one foot to another, so as to
avoid contact with sharp pointed objects, such as burrs, sharp twigs,
pointed stones, etc.
Nature was primitive man’s physician. Being continuously exposed to
the air, skin exfoliation, evaporation of moisture and other normal
functions were never interfered with. The objects with which the body
came in contact in wading through small streams, or in walking through
the wet grass and dewy underbrush, acted much the same as the bath
brush of modern times. Further, man of that period, living on nature’s
foods, was never subject to the various conditions brought about by
improper diet and which in turn manifest themselves in the feet as well
as in other parts of the body.
=Advent of Foot Clothing.= As time went on and man became more and
more civilized, clothing for the foot was gradually adopted, and from
that time to the present the foot has undergone changes that make it
necessary for the human race to resort to treatment for lesions that
could not have developed if nature had had her way, and man had never
adopted covering for the foot.
The first style of foot covering was the sandal. This caused no special
trouble, but when man began to depend upon them for protection for the
soles of the feet, nature consequently no longer required the tough,
protecting, heavy skin, and gradually the integument of that region
became thinner. The result has been, that today, slight trauma or
irritation causes many disturbances on the soles, among which are the
common helomata dura and verrucæ.
An evolution of footgear followed the use of the sandal, and with
civilization came vanity in foot dress and finally the modern shoe,
completely at variance with nature’s demands and causing so many
disturbances that specialists in treating foot lesions became requisite
to care for them.
=Modern Footgear.= The modern shoe, as compared to the normal foot, is
worthy of special consideration. As a rule, the men who build shoes
have from time immemorial been pure commercialists. Their purpose in
engaging in the manufacture of footwear always has been and is to do
business. They have attempted to create styles that would sell. They
have produced wares that would be popular and therefore saleable.
The question of the niceties of the anatomy and physiology of the
foot and leg played no part in their calculations because they knew
nothing about these features as factors in gaining results. The foot
was treated as a whole, much as the hat manufacturer considers the
human head when building a head covering. No consideration was given
the natural beauties of the foot, so much appreciated by the ancient
Greeks. The need for conserving the functions of the small bones of the
foot so that their articulations would not be disturbed, caused them no
pause. The necessity for allowing free play to all of the muscles which
abduct, adduct, evert, invert, flex and extend the foot was and is a
negligible quantity with the shoe-builder. There are few exceptions to
this rule.
Suppose the dentist were to make sets of teeth to be fitted to the
jaws of those who had become toothless, basing their manufacture of
these dental adjuvants on the prevailing needs of groups of these
tooth-defectives, and tooth-shops were to be instituted to fit
these sufferers from wares in stock! The public would deride such
an innovation. And still it is almost as ridiculous to suppose that
our shoe-shops can properly clothe the feet of the public as they
should be clothed from a stock of shoes which are made without careful
relevancy to the anatomy and physiology of the foot. Let us take one
feature of the modern shoe as a sample of this pandering to style:
the high heel, so common on women’s shoes, is a pure conceit. It is
responsible for many of the foot lesions of today, and in addition
causes systemic disturbances of a serious nature. When the body in
standing is erect, the foot should be at right angles to the leg.
When the heels are raised, however, it would be necessary to tilt
the body forward to still maintain the right angular posture. It
therefore becomes necessary in maintaining the erect position to allow
for the malalignment of the body, due to the high heels, and this is
accomplished in the knees, hips and spine. The knees are flexed, the
hips rotated and the abdomen thrust forward. This latter interferes
with the normal position of the abdominal organs, and thus arise many
diseases common to women. The high heel is the etiologic factor.
Locally, the calf muscles become contracted and an inward lateral
displacement of some of the tarsal bones results. Gradually the other
bones of the foot are displaced, and weak and flat foot result.
Further, the high heel causes the foot to slip forward in the shoe and
the toes are thus crowded. When the body weight is brought to bear upon
the ball of the foot in walking, this crowding prevents the normal
spreading of the metatarsal bones, and there is distortion of the
bones, causing anterior displacement, or dropping of the anterior arch
with resulting metatarsalgia.
Another illustration: the function of the sudoriferous glands, namely,
the elimination of liquid waste, in the form of sweat or perspiration,
is going on continuously. As the fluids are brought to the surface
by the gland ducts, evaporation takes place immediately, except
under unusual circumstances, such as mental excitement, increased
temperature, etc., in which instances the production may be very
rapid or may be retarded. When the foot is encased in a shoe, or in a
stocking that does not absorb moisture, such as silk or lisle, this
evaporation is retarded to a greater or lesser degree, depending upon
the leather of which the shoe is made. Such interference with normal
functions is productive of many foot ills elsewhere noted in these
pages. In this connection the podiatrist should be familiar with these
facts: Vici kid is the most porous of all the leathers used in shoe
manufacture, so that most if not all of the moisture excreted by the
glands evaporates. Calf skin is not so efficient for foot covering, in
that evaporation is limited; both of these leathers are far superior to
either patent leather or colt skin, which latter are absolutely air and
water tight, and should never be used as a foot covering. The stocking
should be of a material that will absorb moisture, and cotton or woolen
hose are best for this purpose and will assist in keeping the feet dry
and normal.
Again, the nails of the toes are often unfavorably affected by the
modern shoe, especially the nails of the great toes. The toe box of
the average shoe is made of stiff, unyielding material so that if
the shoe is narrow or short, irritation or undue pressure is brought
to bear upon the nail or the surrounding tissues, causing disease.
It is especially necessary to obviate the possibility of pressure of
the soft tissue of the nail groove against the hard nail substance,
because if such a condition arises and is allowed to persist, calloused
nail grooves, helomata and often ingrown toe nails result. In the
same manner, pressure on the various parts of the nail may cause club
nail, onychia or paronychia. Simple packing of the nail grooves with
absorbent cotton, if properly done, is often the means of avoiding
serious nail lesions, which, as a rule, are very painful.
In this connection it would be well to remember that it is most
important that the nails be cut properly. The corners of the nails
should never be removed, unless there is some trouble beneath the
part. Removal of the corners of the nails changes the position of the
surrounding soft tissues, which depend upon the hard nail substance
for support, and thereby causes them to collapse. This is one of the
primary etiologic factors of ingrown toe nail.
The bony structures of the foot have suffered extensively since the
advent of modern footgear, and the treatment of the lesions in which
the osseous tissue is involved is of importance to the podiatrist as
well as to the surgeon or orthopedist. Many deformities of the foot are
such that only the surgeon is qualified to successfully treat them, but
the more common lesions properly come under the care of the podiatrist,
and should be treated by him.
Pointed shoes cause displacement of the metatarsal bones, with
subsequent nerve compression; hallux valgus is a common deformity due
to misfitting shoes. These latter conditions are the result of improper
footgear, as also of incorrect posture and of faulty locomotion.
The soft tissues of the foot have suffered to a great extent because of
the modern shoe, especially the muscles that arise in the leg and are
inserted in the foot. Upon these muscles principally depend the motions
of the foot, especially those of flexion, extension, adduction and
abduction. The calf muscles, as previously stated, become shortened,
due to the high heels. Additionally the muscles on the outer side of
the leg are shortened while those on the inner side are lengthened. The
long extensors of the toe are also shortened.
When it is remembered that there are twenty muscles in addition to the
twelve muscles of the leg inserted into the foot, the limited motion
of this area, as compared to other parts of the body, is apparent.
Take for instance, the movements of the toes in the average adult. The
action of the great toe is markedly limited and that of the lesser
toes is almost lost. This loss of action is brought about by a lack
of use of the digits of the feet. The hands and fingers being used
continuously, the movements of these digits are active and numerous.
The toes have a like muscular supply, but are far less efficient. The
ability of the barefoot races to use their toes as accessory fingers,
is proof that lack of development is due to lack of motion because of
the toes being encased for most of the time in footgear.
=Hygiene of the Foot.= The many perverted functions of the foot that
have been brought about by the use of modern footgear have made it
essential that this part of the body be given special attention
both by the specialist and by the individual himself. There are
several essentials for proper foot care with which everybody should
be familiar, and it is the duty of the podiatrist to instruct his
patients in these essentials. The general hygiene of the foot is little
understood by the average layman, and the fact that a patient takes a
daily bath is no indication that the feet are being properly cleansed.
To accomplish this the foot should be washed with soap and water, care
being taken that any excrementitious matter which may have accumulated
between the toes is thoroughly removed. It is best to use warm water
for this purpose, and when the feet have been thoroughly cleansed
they should be rinsed in cold water. This closes the glands which
have become dilated by the heat; if allowed to remain open, they will
over-functionate. The foot must be dried well, especially between the
toes, and after this has been done, alcohol may be applied to assist in
this purpose. Alcohol is both astringent and dehydrating. In cases of
a normally dry skin, alcohol may be dispensed with; instead, a small
quantity of an animal oil should be rubbed into the skin; lanolin is
very efficient for this purpose.
Water, as a therapeutic agent, is used extensively and has many
advantages that are lacking in other remedial measures. It is one of
the most ancient of remedies, and its value has been recognized to such
an extent that there are large institutes in this and other countries
devoted exclusively to hydrotherapy.
No other agent is capable of producing so great a variety of
physiologic effects as water; it is easily obtained and is also readily
adaptable for the various conditions in which it is of benefit. Pastor
Kneipp obtained excellent results with his water cure in Europe, and
although his methods are not original creations, and their application
was largely empiric, they attracted international attention. The entire
system of treatment as practised by him was based upon some hygienic
principle, and most of the results achieved were due to the application
of common sense.
Water has three properties to which its value as a therapeutic agent
are due; first, its power to absorb and communicate heat; second, its
solvent properties; third, the ease with which it changes its physical
state from the liquid to the solid or gaseous form. These three
properties, either alone or combined, are to be considered when water
is applied to the body as a therapeutic agent.
A given quantity of water by weight can absorb more heat than any other
substance. The readiness with which this heat is absorbed makes it
possible to apply either heat or cold to the body. Thus, ice applied to
the body will melt, and in doing so will extract a large amount of heat
from the tissues. It is valuable therefore in conditions such as local
infections, in which the heat of the body is above normal.
Every substance is more or less soluble in water. Water is therefore
called the universal solvent. Water is the medium by which foods are
dissolved and absorbed in digestion; water also dissolves and carries
off the waste products to the various organs of elimination.
For therapeutic application, the temperature of water varies from 32
degrees, F. to 120 degrees, F., depending upon the condition in which
it is used and also the purpose of its use. Foot baths are of special
interest to the podiatrist, so that it is necessary to be familiar with
the particular type of foot bath that is valuable in the treatment of
foot lesions.
The _alternate foot bath_ is used for stimulating the cutaneous
circulation, and acts as a general tonic for the nerves and other
tissues. The bath is given as follows: the feet are placed in hot water
for two minutes and then plunged into cold water and kept there for 30
seconds. They are then returned to the hot water for two minutes and
back into the cold water for 30 seconds. This is repeated a number of
times, always starting with the hot water and finishing with immersion
in cold water. This bath affords great relief to those suffering with
tired feet after having worn shoes for a long period. As a general
hygienic adjunct, the alternate foot bath is of great benefit, and
should be employed at night before retiring.
=Foot Care of Infants and Adolescents.= About eighty per cent. of the
civilized, shoe wearing people, are foot afflicted to a greater or
lesser degree, and most of this can be traced to neglect of the feet
in infancy and youth. Many of the most common diseases found in adults
might have been avoided if proper care had been taken and the causative
factors removed in proper time.
The foot of an infant, which has never worn a shoe, is really a perfect
foot, and it is the only stage in life in which the perfect foot is
commonly found. The toes are spread and the forefoot is slightly
adducted. When the first footgear is selected for the infant (it must
be borne in mind that the foot grows rapidly at this age) the shoe
should be of sufficient length and width to allow for this growth. The
softest materials should be used for the first shoes of the infant, for
as the feet are not used in walking at this age, the necessary support
to locomotion received from the material in the shoe, is a negative
factor.
When the child commences to walk, the shoes should be changed, and a
sole should be provided. The upper should be of kid, and should extend
slightly above the ankle. Laced shoes should be used, and continued
throughout the entire period of infancy and youth. The normal adduction
of the forefoot should be considered and the outer border should curve
inward in a gradual line. The foot should be measured for shoes with
the child bearing its weight on the foot. This allows for the spread
of the foot in weight bearing, and measurements taken under these
conditions give assurance of a proper fit.
As the infant grows, the muscular strength of the legs is increased,
and eventually the limbs are strong enough to support and carry the
body weight. It is at this time that the child will commence to walk
by natural impulse or instinct. From the short, jerky, uncertain
step, there is a gradual improvement and, with time, the infant gains
confidence and strength and the step soon becomes firm and steady.
The question is often asked of physicians and podiatrists by anxious
mothers: “why is it that my baby does not walk?” It seems to be a
source of worry to them, for as these mothers watch other children
walking, they become envious and attempt to teach their children to
walk. Walking is a natural function and it is foolhardy to insist upon
infants attempting this foray until the bones to which the muscles are
attached are sufficiently unyielding and the muscles involved can
coordinate for that purpose. The use of artificial means of assistance
for the child, viz., the various contrivances on the market that
support the child under the arms and allow the feet to drag on the
ground, should be discouraged.
Premature locomotion causes an unnatural strain upon the legs and feet
and is often the cause of malformations which continue on in later
life. Many foot and leg lesions can be attributed to an over-anxious
mother who insisted upon her child walking before the time was ripe for
it to do so. Therefore it behooves every mother to allow nature to have
its way, and to wait until the legs are strong enough. In cases where
walking is unsteady, it may be advisable to assist the strengthening of
the muscles by massage and passive motion.
The use of appliances to assist a child which already walks should be
guarded, and only when there is something pathologically wrong should
they be employed. Weak-ankle shoes, or weak-ankle braces or supports,
although they apparently help the child’s gait, really retard the
normal motions at the ankle joint, and there is little possibility of
a compensatory increase in strength of the parts as a result of their
use. When the ankle is continuously supported by some outside agent,
the normal support, i.e., the muscles of the leg, become weaker.
This is because they are not used, and atrophy is the result. When
conditions are such that assistance must be sought, the part should
be exercised by massage, exercises and passive motion. It is often a
difficult matter to prescribe exercises for a child, but if given in
a cheery way, so that the child thinks it is playing a new game or
is having heaps of fun, the results are often remarkable. The First
Institute of Podiatry is now planning an exercise room for children
of the poor whose locomotion is impaired and the experiment will be
watched with interest.
As the child grows into adolescence, the shoes should be changed often
enough to allow for the normal growth of the foot. It is better to buy
shoes oftener, than to attempt economy at the expense of health. The
parents should acquaint themselves with an orthopedist or a podiatrist
to advise and a competent shoe man, under the direction of the advisor,
should fit the shoes of the growing child. Thus, caring for the same
foot over a protracted period, such a specialist is better able to
judge the size and shape best adapted for the individual. Walking
and other forms of exercise should be encouraged, especially those
exercises that develop the muscles of the foot and leg. It must be
borne in mind that the flat foot and weak foot of later life are caused
by deficient muscular action of certain groups of muscles.
=Foot Care of Adults.= After the foot has attained its full growth, and
the bones have become calcified, correction of the lesions involving
the bony tissue is difficult. Young persons who have been accustomed
to wearing shoes with a straight inner line, and with broad toes, will
pass into middle age without much, if any foot trouble. Slight friction
or pressure may produce small helomata, but these are of little
consequence and are easily relieved by intelligent care and treatment.
As previously stated, pointed and narrow shoes with high heels are
responsible for many of the local foot lesions, and corrective
treatment should be begun at as early a period as possible. When a
person reaches middle age, the bones of the foot have become set.
Attempts at correction, such as the prescribing of shoes with a
straight inner line for such persons, cause the foot to be put into an
entirely new position, and because the bones have become firmly set,
such a new departure is frequently fraught with discomfort, and at
times causes other bone and muscle troubles which are painful.
In younger adults, correction should be gradual. It is inadvisable to
adopt radical measures for those who have been wearing incorrect shoes,
or who have been walking and standing incorrectly for a long period of
time. A woman who has been wearing high-heeled shoes for a few years,
has a shortening of the calf muscles which should be corrected, but to
change from a two-inch heel to one a half-inch high, without gradually
reducing the height, will cause extreme discomfort. Appropriate
exercises should be advised and the style of the footgear should be
gradually and not abruptly changed as the foot responds to treatment.
Walking is one form of exercise in which every able-bodied person
can indulge, and is a means of maintaining body health as well as of
keeping the muscles of the foot and legs strong. Like every other form
of exercise, it should be practised with caution. The individual who
walks long distances is placing an undue strain upon the muscles of the
lower extremity, and instead of being benefited, he is being harmed.
The position of the foot is important in walking. The foot should point
forward, and the forefoot should swing slightly inward with each step.
In this way all of the muscles of the leg receive their proper share of
work. The pace should be brisk and steady, yet not fast enough to cause
the person to suffer in breathing. Slow, leisurely strolls are useless
as a medium for muscular improvement, and are simply a waste of time.
=The Care of the Soldier’s Foot.= The foot of the soldier is subjected
to unusual strain, both on the march and while in the trenches, and
special care is necessary if the maximum of efficiency is to be
maintained. Hygiene should be practised to a greater extent than under
ordinary circumstances, and immediate attention should be given to
minor troubles that might pass unnoticed in civil life.
The feet should be washed daily, and if long marches are contemplated,
they should receive this attention both before and after the march. The
feet should be thoroughly dried after each washing, and dusted with
some foot powder that will absorb moisture. Lycopodium is the best
base to use in foot powders. Socks should be examined and if found
torn or badly mended, should be discarded because the pressure of the
spots that have been darned may result in painful troubles. Shoes
should be large enough to accommodate the spreading of the anterior
arch in walking, yet should be snug in the heel to prevent the foot
from sliding and creating friction. When soldiers are to serve in the
trenches their feet should be given special attention, to prevent the
possibilities of trench foot and other foot lesions that are the result
of trench life. It has been proven by those who have gone thoroughly
into the matter that the water and mud which is found in the trenches
is responsible for these lesions, therefore it is necessary to guard
against it reaching the feet of the men. In addition to wearing rubber
boots, the feet should be thoroughly rubbed with some greasy substance
immediately before entering the trenches. Mineral oils are best, and
although the process of rubbing the feet and legs with oil is repulsive
to the men, it should be compulsory, as it is the means of preventing
loss of limbs. Cloths dipped in melted paraffin and then wrapped around
the feet will suffice to keep the water from the skin.
Immediately after a siege in the trenches, the feet should be
thoroughly washed with soap and warm water, carefully dried, and dusted
with an antiseptic foot powder. One containing boracic acid and talcum
will answer ordinary purposes. If abnormal lesions develop, these
should be treated in keeping with the requirements.
The men should receive instructions at regular intervals, and lectures
on the care of the foot should be given by the officer in charge of
that particular branch of the medical department. Foot inspections
should be made at prescribed times, and during these inspections, the
podiatrist can easily determine whether or not the men are in need of
foot attention beyond that which comes with self-care. The feet should
also be examined before a march of ten miles or more, and should be
re-examined immediately after the march. This procedure will save
the men from developing any serious trouble, as the beginning of any
such trouble is thus detected, and proper preventive treatment can be
applied, sufficiently timely.
One or two podiatrists should be attached to each ambulance train
while the troops are on the march, so that they are available at short
notice. The immediate application of a shield or pad over some part of
the foot that is being irritated will often save the individual from
foot infection that may be serious. Too much care cannot be given the
feet of the soldiery as their efficiency is based upon their powers
of locomotion. It was the opinion of the first Napoleon that an army
moved upon its stomach. By that he meant that plenty of proper food was
essential to every fighting force. In these times, it is conceded that
the foot-whole alone can be counted as competent soldiers, important
as may be the food question. It behooves us, therefore, to give to the
men who are willing to offer up their lives for their country’s weal,
the very best possible care, and although the foot of the soldier has
received no special attention in the past, the time is now ripe for the
recognition of the podiatrist as an integral part of every officered
unit in the Medical Corps of the Army and of the Navy. From a national
economic standpoint alone, this recognition should be accorded because
it must be clear that unless proper precautions are taken to note the
condition of the soldier’s feet before he goes overseas, thousands
will be found unavailable for first line work and will thus constitute
themselves an incubus rather than an aid to the fighting force of our
country.
CHAPTER VI
DRESSINGS AND BANDAGING
DRESSINGS.
=Definition.= A dressing is the material applied to a wound for the
purpose of excluding the air, stimulating repair and protecting the
affected areas from irritation and from other untoward conditions.
Four classes of dressings are used in podiatry, viz.: the moist
dressing, the dry dressing, the ointment dressing and the occlusive
dressing.
=The Moist Dressing.= The moist dressing is generally composed of
several thicknesses of gauze applied to a part and moistened with some
germicidal, antiseptic, astringent, antiphlogistic or sedative solution.
There are two forms of moist dressing: the evaporating and the
non-evaporating.
=The Evaporating Moist Dressing=, generally known as the wet dressing,
is an application of several thicknesses of gauze saturated with a
solution and allowed to remain uncovered so that evaporation of the
solution takes place. The gauze is remoistened from time to time so
that it is kept continually wet. The action of this form of dressing,
independent of the specific action of the solution employed, is heat
reducing and causes localized anemia. It may be employed wherever
infection or inflammation is present.
=The Non-Evaporating Moist Dressing= is composed of several thicknesses
of gauze saturated in a solution and covered with some impervious
covering such as gutta percha tissue, oiled silk or fish skin. This
form of dressing, independent of the action of the solution employed,
is heat producing and locally hyperemic. It is contra-indicated in
the presence of pus, as the warmth and moisture produced by its use is
congenial to the growth of bacteria. It should only be used when the
skin is unbroken, in such cases as sprains and bruises, or where the
action of a poultice is not contra-indicated.
=The Dry Dressing.= The dry dressing is composed of several thicknesses
of sterile gauze applied to a part and allowed to remain dry. There are
two forms of dry dressing, (1) that in which the gauze itself is alone
applied, and, (2) one composed of dry sterile gauze or cotton used for
the purpose of applying a dusting powder, having either antiseptic,
astringent or stimulative qualities or in some instances, all three.
The plain gauze dressing is used where asepsis and drainage alone are
desired in a wound, all symptoms demanding the treatment by means of
drugs having been eliminated. The gauze is used either as a “wick” and
packed into a cavity as a drain, or in a series of thicknesses covering
the whole affected area.
The dusting powder dressing consists in applying a powder to the
affected surfaces and covering the same with several thicknesses
of sterile gauze, or with a pledget of sterile cotton. The dusting
powder is used when astringency is desired, as from bismuth subgallate
(dermatol); or where stimulative and antiseptic action is desired, as
from thymol iodide (aristol).
=The Ointment Dressing.= The ointment dressing is one in which an
ointment, held in place either by lint, gauze or cotton, plays a
conspicuous part in the repair of the lesion. The ointment is either
spread upon the fabric used, or is applied directly to the affected
areas by means of a spatula. This form of dressing can be used in the
treatment of superficial inflammations, blisters, pernio, etc., but is
contra-indicated in the presence of a discharge, as the fatty or oily
base of the ointment interferes with the absorption of such a discharge
and so prevents proper drainage of the part.
=The Occlusive Dressing.= The occlusive dressing is one employed for
the purpose of excluding the air and of completely sealing the parts.
In podiatry this occlusion is obtained by the use of collodion, either
plain or medicated, by a combination of collodion and cotton, or by the
application of compound tincture of benzoin.
FABRICS.
There are a number of fabrics which may be used for dressing materials
in podiatry. The three most important are gauze, cotton and lint.
=Gauze= is a thin meshed, loosely woven cloth employed in the
manufacture of bandages and used for wound dressings; such gauze should
be sterilized or impregnated with antiseptics.
The varieties of gauze which are of practical use in the practice of
chiropody are:
(1) _Plain aseptic gauze_, either dry or moist; a gauze
sterilized either by dry heat, so that the fabric remains dry,
or subjected to moist heat (steam) sterilization from which
the gauze retains a certain amount of moisture. The dry gauze
is put up commercially in pasteboard boxes, and can be thus
obtained in quantities of one square yard and upwards. The
moist aseptic gauze is obtainable in as small a quantity as the
former, but comes in sealed glass jars which may be kept upon
the operating stand or cabinet.
(2) _Corrosive sublimate gauze_ is put up in glass jars in
quantities of one square yard and upwards. The gauze is
saturated in a solution of mercury bichloride and may be
obtained in strengths from ¹⁄₂₀₀₀ to ¹⁄₁₀₀₀₀.
(3) _Iodoform gauze_ is put up for surgical use in the same
manner and quantity as No. 2. The medication impregnates the
whole fabric and constitutes an excellent method of applying
the drug. On account of the suggestive odor of iodoform,
however, this gauze has lost favor with the podiatrist.
(4) _Borated gauze_, or gauze impregnated with boric acid in
10% strength, is used in podiatry where a mild antiseptic
dressing is desired. It comes in glass jars in quantities
similar to the two foregoing varieties.
The forms in which gauze are used in podiatry practice are numerous.
The following are the most important:
(1) _Bandage._ Gauze, in varying widths, makes a highly
practical bandaging material. Cotton bandages are used, but
cannot compare with even the poorer grades of linten gauze
for durability. The reader is referred to the sub-heading,
“Bandaging,” at the end of this article.
[Illustration: LARGE GAUZE SQUARE FOR DRESSING INGROWN NAIL]
(2) _Large gauze squares._ It is a common practice among
podiatrists to cut large quantities of gauze into pieces
about three inches square. These have two uses: (a), to dry
off instruments dripping with alcohol or whatever germicidal
solution has been used, before operation, and (b), as a
dressing applied over the affected area. In the latter instance
this size square is practical where the whole distal end of
the toe is to be covered, as in applying a moist dressing in
the treatment of ingrown nail, or where there is a large area
to be covered on the dorsum, plantar or lateral sides of the
foot or upon the lower leg. As a “wipe” for instruments, one
thickness, and as a dressing, three or four thicknesses are
used.
(3) _Small gauze squares._ These are about an inch-and-a-half
square and have their principal use as a dressing to cover
one side of a toe nail, or to cover a small area of the
integument, or as a “wick” in the drainage of a large sinus or
deep ulcerative condition. Both the large and small squares,
cut to size, are sterilized by heat and are then placed in a
formaldehyde sterilizer until used; this assures their absolute
asepsis.
(4) _Nail Groove and Sinus Pledgets._ For the more confined
areas of the nail groove or for a small sinus, gauze is cut
into small pieces measuring about one-half inch long and
one-eighth inch wide. Several thicknesses of the fabric are cut
together so that even from a small amount of gauze many small
pledgets or “wicks” are obtainable. These small gauze pieces
are very practical for packing a nail groove, and, as the fibre
is looser and the pledgets do not harden, they make a much
softer and more yielding pad for the nail than does cotton.
In the drainage of a small sinus, these small pieces of gauze
offer a very practical material for use as a “wick.” Three or
four strands of the fabric may be inserted at the mouth of the
sinus to prevent surface granulation, while the repair in the
deeper tissue is still incomplete.
=Cotton.= Cotton is the white, fluffy, fibrous covering of the seeds
of the cotton plant which, when ginned and refined to a uniform
smoothness, furnishes a medium which is used extensively in surgical
dressings.
Aseptic absorbent cotton is manufactured by a number of firms and,
except in the cheaper grades, no irregularities or foreign matter are
found in the fabric.
Cotton is used in podiatry practice by winding it on the end of a
wooden or metal applicator. The fabric, thus fashioned about the
applicator, is used either dry or dipped in some medication for
applying solutions to the foot. It is also used to dry parts or to wipe
instruments; as a dressing, it is used principally in combination with
collodion to make the cocoon dressing. This name is derived from its
resemblance to the cocoon of the silkworm or the butterfly.
A cocoon dressing is a pledget of cotton, the fibre of which is
smoothed and is placed in one direction, while the edges of the pledget
are thinned out or “feathered.” The cotton is applied over the part and
collodion (preferably flexible collodion) is painted over it by means
of a brush or a glass rod in such a manner as to bind the edges of the
cotton firmly to the skin. The collodion when applied is semi-liquid,
and as its constituents, ether and alcohol, evaporate upon contact
with the air, the pyroxylin remaining becomes an integral part of
the cotton, joining intimately with its fibres and with the surface
of the skin. After the edges are bound down in place, the collodion
may be painted once along the length and once across the fibre at the
centre of the dressing, so as to bind the dressing into one cohesive
whole; it is not wise, generally, to saturate the whole pledget with
collodion, as when dried, the dressing will be hard and unyielding.
In the procedure first described the dressing is semi-occlusive; in
the latter, occlusive. The cocoon dressing is used principally as a
covering for a part when an ointment has been applied and, as in these
cases the parts beneath are tender, it is wise to have the dressing as
soft and pliable as possible.
This form of dressing may be used alone or it may be applied as a
covering and protection over the aperture of a shield after an ointment
has been applied to the part. It is found very practical when applied
over a nail fold and groove in which an ointment has been used. The
dressing will confine the unguent to the proper areas and prevent it
from running over that side of the digit. In dressing a blister or
other irritated area, due to ill-fitting shoes or mended hosiery, the
cocoon is also very practical. The cotton not alone serves to hold the
medication in place, but acts as a padding so that the part may not be
subjected to further irritation.
Cotton is also used in the form of a small pledget for packing a nail
groove. The pledget or roll should be small and thin and is used to
hold a medication in place; at the same time it constitutes a soft pad
upon which the edge of the nail rests.
=Lint.= Lint is a flocculent material procured by ravelling or scraping
linen.
Surgeon’s absorbent lint as a dressing and shielding material, is
continuously coming more into vogue. Otto Sjogren of New York is a
great believer in its efficacy and in his demonstrations at The First
Institute of Podiatry strongly advocates its use. The late W. A.
Kennedy of Philadelphia was also strong in his advocacy of lint as
a dressing and is on record as follows: “The essentially favorable
feature in utilizing lint for shielding purposes is that, when properly
adjusted, there is no pressure on the parts which it serves to protect.
Most, if not all, of the material of which shields are ordinarily made,
is of an unyielding character, and, in consequence, the capillary
circulation of the compressed part is disturbed. If such a condition
exists, absorption is prevented and the treatment is in most instances
harmful rather than helpful. Because lint is a loosely woven cotton
fibre, it does not pack in a hard mass, but always remains soft and
yielding; nor is it necessary to apply it excepting in thin layers.
“The method of use should be as follows:
“Select a perfect sheet of lint and cut off a square or oblong piece
slightly larger than the lesion and round off the corners so that they
will not bulge when plaster strips or bandages are applied. Then cut a
round opening in the lint, slightly larger than the lesion. Spread such
medicament as is desired on the part requiring it, and then place the
fluffy side of the lint next the skin, in situ, with the edges of the
opening surrounding the part under treatment. Over this dressing, place
a piece of lint so as to cover the existing dressing in its entirety
and apply ordinary adhesive plaster to retain the whole in place. The
thickness of the dressing represented in layers of lint will depend
upon the necessities of each individual case, but in the experience
of the writer, the most satisfactory results are obtainable where the
dressing is least bulky. At times, when several layers of the lint are
requisite to the patient’s comfort, it will be found advisable to cut
out the sides of one of the under layers for the purpose of making a
half-moon dressing; then apply the top covering.
“In the accompanying illustrations most of the required dressings shown
are of two thicknesses only, the under layer having the round opening
and the upper layer acting as a protective as well as an absorbing
medium. This method will be found useful, in that drainage may take
place properly where there is a suppurating surface, and even though
the patient does not return for treatment at the time suggested, there
will be no danger of septic infection because of a damming in the flow
of exudate, a menace which is so common in some forms of dressing.
Patients will rarely complain that the plaster ‘draws’ offensively if
the above dressing is properly applied.
[Illustration: DORSAL LINT DRESSING]
[Illustration: PLANTAR LINT DRESSING]
“The plantar aspect of the foot exhibits four full dressings and half
of another.
“The dressing covering the great toe may be utilized for any lesion
from a callous to a perforating ulcer; the one on the distal end of the
middle toe, for heloma or for any other condition usually met with in
this region.
“The dressing covering the fifth metatarsophalangeal articulation can
be applied for perforating ulcer, for callous or for vascular heloma
and can be placed anywhere after treating this lesion. The dressing
covering the os calcis region is of a single thickness and can be used
in varying sizes for any lesion found on the plantar surface.
“The partial dressing, covering the first metatarsophalangeal
articulation is used from one to any required number of layers for
covering bunions, enlarged joints, etc.; the other section of this
dressing is shown on the dorsal aspect of the foot in the other
illustration.
“The dressing covering the dorsal aspect of the great toe is used after
any ingrown nail treatment and the dressings on the third and fifth
toes are applied after the removal of helomata.
“The dressing covering the fifth tarsometatarsal articulation is very
useful in combating the calloused and oft-times inflamed area produced
by the side seam of shoes, especially of the low-cut type.
“Lastly, the dressing covering the tarsal aspect is a comfortable
arrangement to apply after removing the minute helomata produced by the
eyelets of a shoe or for any other lesion found on the dorsal surface.
“In case of extensive ulceration or of profuse discharge from a lesion,
it is advisable to use several layers of sterile or medicated gauze
before applying the absorbent lint to the surface.”
=Collodion.= Plain flexible collodion is used extensively in podiatry
as an agent to bind cotton into place upon a part or as a vehicle of
application for a number of drugs, or whenever an occlusive dressing is
applied. Flexible collodion is ordinary collodion to which is added
castor oil and turpentine. These drugs serve to reduce the contraction
of the film during evaporation. Plain collodion, as evaporation
takes place, contracts in area and when applied is liable to draw or
“pucker” the skin about the part. Flexible collodion has practically no
contractile tendencies during evaporation.
Flexible collodion, unmedicated, is used as an application over
chilblains or in other conditions where occlusion is desired.
=Medicated Collodions.= Flexible collodion, medicated with various
drugs, is also used extensively in podiatry. The four named and
described below are the most important, and are most generally used.
=Iodized Collodion= (C. Iodatum, N. F.). Iodized collodion is a five
per cent. solution of iodine in flexible collodion.
It is used in podiatry as a covering for the exposed tender tissues
after removal of a callositas or an heloma. The film formed by
the collodion serves as a protection against friction to the part
and the iodine contained in the mixture acts as an antiseptic and
counter-irritant. This combination may also be used where any
counter-irritant action is desired and wherever the tincture may be
used.
=Ichthyolated Collodion=, 5 to 15% of ichthyol in collodion, is used
for the same purposes as the iodized collodion in the protection of a
previously pared callous, and as an antiphlogistic and stimulant in
erythematous chilblain, this form of medication is used extensively and
with good results. It forms an occlusive film over the chilled parts,
and by the action of its constituent, ichthyol, serves to stimulate the
deranged functions and to promote absorption in the congested parts.
=Benzoated Collodion=, 5 to 10% of tinctura benzoini composita in
flexible collodion, may be applied in post-operative procedures in
heloma, etc., as described in preceding paragraphs, and is also
efficient as a stimulant in the treatment of pernio and as a covering
for blisters and other superficial lesions where no discharge is
present.
=Salicylated Collodion= is a medicated collodion with the following
formula:
Salicylic acid, 30 parts;
Ext. of cannabis Indica, 5 parts;
Collodion, 240 parts.
It is extensively used in the medical treatment of heloma or
callositas. This combination is disintegrative in its action and should
not be applied on sound or normal integument.
Collodion, either plain or medicated, is contra-indicated in the
presence of a discharging surface. By sealing the lesion, no drainage
is possible, and the waste materials thrown off are kept confined to
the detriment of the healing process.
=Paraffin Preparations.= Barth de Sandfort, a French naval surgeon, in
experimenting for drugs to treat the cases of burns developing from
the liquid fire and burning oil attacks of the Great War, discovered
and perfected a substance known as “ambrine.” The exact composition of
this paraffin is a secret, and for this reason it has been received
coldly in this country, but a number of similar paraffin preparations
have been developed and are in general use today. The four most popular
of these are known commercially as paraffin No. 7, paraffin No. 7-11,
parresine and redintol.
Paraffin No. 7 (Dr. Hull) consists of paraffin (hard), 67%; paraffin
(soft), 25%; olive oil, 5%; oil of eucalyptol, 2%, and resorcin, 1%. To
prepare paraffin 7, first melt the hard paraffin, then add in the order
named the soft paraffin, olive oil, oil of eucalyptol and resorcin.
Paraffin No. 7-11 (Dr. Adams) consists of paraffin (hard), 69%;
paraffin (soft), 25%; olive oil, 3%, and thymol iodide, 3%. The
preparation of paraffin 7-11 is similar to that described for the
preceding combination.
Parresine (officially adopted by the United States Army and Navy) is a
wax-like substance, containing about 95% of paraffin; this is treated
by the addition of a vegetable wax and mineral and vegetable resins so
as to modify its physical character, especially as regards plasticity,
ductility, pliability and adhesiveness. It also contains eucalyptol,
a valuable antiseptic, which is added to cover the characteristically
disagreeable odor developing from burned surfaces and other large
abrasions during the process of healing.
Redintol is a mixture of paraffin and resins, having similar melting
points. The firm manufacturing it have prepared a special form of sheet
cotton for use in connection with the application of this product.
_Technic._ The technic of the application of these paraffin
preparations is similar and is described in detail in the chapter on
“Burns.” The advantages of the wax treatment are numerous.
(1) It is an inexpensive dressing (a pound of wax and a pint of liquid
petrolatum, together costing about sixty cents, will dress many burns).
(2) It is a comfortable dressing because it is smooth, and the
granulating surface does not grow through it as with the gauze. The
paraffin is hard enough to make the dressing somewhat rigid and to act
as a splint.
(3) It is a cleaner dressing, because the wound discharge is not
permitted to soak through the impermeable wax covering, soiling all the
linens that come in contact with the patient.
(4) Superficial burns heal more readily under this treatment than with
any other previously used method.
(5) It is a most comfortable dressing, for the reason that the
granulations do not grow through it, and the dressing is lifted off
painlessly.
(6) The resulting scars are not as pronounced.
(7) It is a stimulant of granulations.
_Disadvantages._ The disadvantages of the wax treatment are:
(1) Some patients refuse to be treated with the wax (it is applied hot
directly to the injured area) because of the pain.
(2) So many extravagant claims have been made for it, that the one who
uses it for the first time will probably be disappointed.
(3) An infected wound is covered with a sealed dressing.
(4) We have no way of controlling the temperature of the wax. Taken
from the boiling water at 212 degrees Fahr., it is too hot. Cooling
at 114 degrees Fahr., it is too cold. The degree of pain caused the
patient is the only means one has of knowing if it is too hot, unless
one tries it first on the back of the hand.
(5) Around the skin edges it is painful.
IMPERVIOUS COVERINGS.
In connection with moist dressings, several varieties of impervious
covering may be used.
=Oiled Silk= is a rubberized material of great strength, usually yellow
in color and soft and smooth to the touch. The use of this material is
quite general in podiatry for all moist, non-evaporating dressings.
The technic of application consists in cutting a square of the fabric
of sufficient size to cover the whole of the gauze dressing, also all
sides of the toe (if this be the location of use) and a considerable
amount of the surrounding healthy tissue. It is held in place either
by a roller bandage, or by means of adhesive strips fastening down its
edges to the adjacent surfaces. Dressings covered by oiled silk are apt
to be bulky and for this reason, when the shoe is to be worn, it is not
generally used.
=Gutta Percha Tissue= is a thin perishable material placed on the
market by several firms. It is not to be compared with oiled silk for
durability, but the dressing covered by gutta percha is not nearly so
bulky, and for this reason it is popular and practical for use in
podiatry. It is generally applied over the gauze by vulcanizing its
edges to the surrounding integument. This is accomplished by means of
heat, and, when completed, presents a neat dressing which is absolutely
occlusive, and from which none of the solution used on the gauze
underneath can escape. A square of the rubber tissue of sufficient
size to more than cover the dressing is cut and held in place with the
hand. A match is then applied to the edges of the square and while
they are still melted they are lightly adhered to the surrounding
skin. The tissue will adhere to the skin and will remain intact for
a considerable period of time. The gutta percha is then covered by
several turns of a roller bandage to protect the thin tissue from the
rubbing of the shoe. Gutta percha tissue may also be held in place
by means of adhesive strips as with oiled silk, but the vulcanizing
process is by far the most popular and, insofar as confining the
solution is concerned, it is also far more practical.
=Fish Skin= is a manufactured material of tissue paper thinness and has
proven very popular for use as an impervious covering. The technic of
application is similar to that described for oiled silk and it is held
in place by the same means. It does not make a bulky dressing and for
this reason its popularity has probably exceeded that of oiled silk.
BANDAGING.
A bandage is a strip of gauze, muslin, flannel or other material of
varying widths and lengths, used in the various branches of medicine
for retaining dressings, applications and splints and to produce
compression. Occasionally they are applied to retain heat. Bandages
also help keep a wound clean by preventing the ingress of foreign
matter.
Bandages are made of different materials, chief among which is gauze.
This is made of lint, woven into a soft material, which is easily
applied to all parts of the body. Muslin is a heavier cotton material
and is made of cotton or silk or of a mixture of both (lisle) with
rubber. Flannel is wool woven into a soft, firm, semi-elastic material.
Rubber bandages are used to induce excretion and for compression.
Bandages vary in width and length, depending on the size of the parts
for which they are intended. For convenience, bandages are usually
manufactured in widths varying from one-half inch to six inches, and in
length from one to ten yards or more. Those which are used in podiatry
vary in width from one-half inch to three inches. The standard length
of bandages is five yards and ten yards. These may be cut and the
unused piece preserved. A table of the widths of the various materials
used in podiatry practice, showing the parts for which they are best
adapted, follows:
LESSER GREAT TOE ANKLE ANKLE WRIST LEG LEG
TOES FINGERS WRIST LEG FOREARM FOREARM
Gauze ¹⁄₂″ 1″ 1¹⁄₂″ 2″ 2¹⁄₂″ 3″
Muslin 1″ 1¹⁄₂″ 2″ 2¹⁄₂″ 3″
Flannel 2″ 2¹⁄₂″ 3″
Elastic 2″ 2¹⁄₂″ 3″
Rubber 2″ 2¹⁄₂″ 3″
_A roller bandage_ consists of one piece of material rolled in the
shape of a cylinder, having a core and a free end, and is the kind used
in podiatry.
_A double roller bandage_ consists of one piece of material, rolled
from both ends, so that when it is completed there are two cylinders
and no free end.
_A plaster of Paris bandage_ is composed of a piece of gauze or
crinoline into which is rubbed powdered plaster of Paris. This bandage
is placed in water and then applied to a part; after a few moments the
entire bandage becomes hard and solid. This form of bandage prevents
mobility and is used for fractures and dislocations. In podiatry it
is used for taking impressions of the foot for fitting mechanical
appliances. Bandages are classified as follows:
_Circular_--being circular turns around a part.
_Figure of eight_--the turns crossing each other like the strokes of
the figure 8.
_Oblique_--covering the part by oblique turns.
_Recurrent_--the turns returning to the point from which they
originated.
_Spica_--the turns crossing and recrossing, resembling in arrangement
the husks of an ear of corn.
_Spiral_--the turns ascending or descending, each turn covering about
two-thirds to three-fourths of the preceding turn.
_Spiral reverse_--when the bandage is turned in reverse position so
that the inner side becomes the outer and the outer side rests against
the skin, in order to better adapt itself to the part.
Bandages are designated by various names, according to the shape they
assume when completed, and they are sometimes named after the men who
first used them; for example, “Barton’s bandage” of the head.
The bandages used in podiatry are designated by the shape they assume.
The names of the various bandages of the foot follow in the order of
their importance:
Spiral bandage of the toes.
Spica bandage of the foot.
Figure of eight bandage of the ankle.
Spiral reverse bandage of the leg.
_The Spiral Bandage of the Toes._ This bandage is applied to the great
toe more often than to the lesser toes. Gauze, one inch wide for the
great toe and one-half inch wide for the lesser toes, is used.
This bandage may be started by a few circular turns around the ankle,
then diagonally across the dorsum of the foot to the base of the great
toe; but this may be simplified by making a simple circular turn around
the proximal end of the toe, with the free end towards the heel, which
will firmly lock the bandage. If the distal end of the toes is to be
covered, the bandage is now applied from the proximal end of the toe
on its plantar surface, over the distal end to the proximal end on the
dorsal surface. This is repeated back and forth as often as necessary
to cover the parts by what are known as recurrent turns. The spiral
turns are now started and as the bandage moves toward the distal end
of the toe, each turn must cover about two-thirds or three-fourths of
the preceding one. When the toe is covered, the spirals are continued
back to its base, where the bandage is tied off. Many toes are not
cylindrical but taper to a point; so that when the spirals reach the
distal end of the toe, the bandage bulges on the inner side. This
bulging may be avoided by making a reverse turn over the part instead
of a simple spiral.
_The Spica Bandage of the Foot._ Bandage 1¹⁄₂ to 2 inches wide is
used, depending on the size of the foot. The free end of the bandage
is placed on the dorsum of the foot at the ankle joint, and is locked
by several circular turns around the ankle. The bandage is passed
diagonally forward across the dorsum of the foot to a point opposite
the head of the metatarsal bone, then across the plantar surface of the
foot to the opposite metatarsal bone, and diagonally backward across
the dorsum of the foot, crossing the first half of the turn, producing
an X. The turn is finished by passing the roller back over the tendo
Achillis. This is repeated, the second turn covering about two-thirds
of the first and so on backward until the desired area is covered. The
bandage is finished by a few circular turns around the ankle and is
tied off in the usual manner.
_Figure of Eight Bandage of the Ankle._ This bandage resembles the
spica bandage of the foot in every way except that the first turn
extends to the base of the metatarsal bone instead of to the head and,
instead of tying it off at the ankle, a few spiral reverse turns are
made up the leg. It is tied off as are the other bandages.
_The Spiral Reverse Bandage of the Leg._ This bandage is considered by
many to be the most difficult of all the bandages of the extremities to
apply. A few figure of eight turns are made around the ankle and then
the spiral turn is made; the bandage is reversed so that the inner side
becomes the outer and the outer side rests against the skin. Each turn
should cover about three-quarters of the preceding one, and care should
be taken that at the point of reversing the bandage, no wrinkles or
uneven folds are produced. The reverse turns should not be made over a
wound or a part that may be irritated by additional pressure.
CHAPTER VII
INSTRUMENTS
TYPES, VARIETIES, USES, THEIR SELECTION AND CARE
No comprehensive monograph has yet been written discussing at any
length the instruments of the podiatrist, and in compiling the
following data there must necessarily be omissions. Up to the present
moment no great amount of standardization has been accomplished along
this line, either in the general use of a given instrument or in its
name. It is the object of the author of this chapter to at least build
a foundation upon which a complete and standardized line of instruments
may be developed.
Many special instruments developed by practitioners who have refrained,
for reasons best known to themselves, from giving their ideas and
discoveries to the profession at large, must necessarily be omitted,
and it is to be greatly desired that the next few years will be rich in
the development and standardization of our instruments and appliances.
The instruments in general use today and manufactured by several
companies, are all made practically of the same material and in the
same manner, the differences between them, being due principally,
to the finish. All such instruments as chisels, scalpels, spatulas,
curettes, etc., are made from Sheffield steel, and are hand forged.
The handles of these instruments are made of a silver or aluminum
composite. Scissors, nail clips, thumb forceps, etc., are made also of
Sheffield steel, but are drop forged.
Most instrument makers today have discarded the older method of
finishing, known generally as the “crocus” polish. This has come about
principally for the reason that the application of the crocus polish
or finish demands that the instrument be subjected to extreme heat. In
accomplishing this, many instruments are rendered useless owing to the
fact that the temper of the blade is ruined by the added heat.
What is commonly known as a “satin” finish, accomplished by buffing,
is now generally employed and does not tend in any way to injure the
already highly tempered steel.
HISTORY OF INSTRUMENTS
With the exception of possibly two or three, it is doubtful, if
chiropody has developed any really individual instruments. Our scalpels
are similar to or are modifications of those of the surgeon; the nail
chisels and excavators in general use have been borrowed from the
realms of the dentist, as has the rotary drill; the nail clips, of
course, are instruments which are purely for the purposes coming within
the jurisdiction of the podiatrist; so, also are the various forms of
the nail file.
The chisel used by a great number of practitioners for the surgical
removal of helomata, is one of the oldest of chiropody instruments and
is one which was unquestionably developed by the chiropodist for his
own needs. There is no instrument in use by the surgeon which bears
any resemblance to the chisel, and for this reason we can safely say
that it is a true chiropody instrument and may therefore safely be
called the helotomon--the podiatry surgical instrument. This also, in
a measure, can be said of the soft corn spoon. This is, to be sure,
nothing but a very shallow curette, but nevertheless no instrument
in use in general surgery can be rated as being similar to it; it is
therefore properly styled the podiatrist’s curette.
Prior to 1909, the chiropodist found it necessary to select his own
manufacturer and have his instruments made according to his own ideas,
or to select them from the catalog of the surgical supply house. This
condition of affairs resulted in a wide diversity of styles. No two
practitioners had similar instruments, and it seemed to furnish keen
delight to one chiropodist to outdo his neighbor as to the size, finish
and appearance of his instruments. Pearl handled scalpels were much
in evidence and, when so, served to prove, without question, that the
owner did no sterilization by boiling. Gold-plated blades and inlaid
handles were frequently to be seen, proving nothing, unhappily, but the
eccentricities of their owners.
In the year 1909, however, the manufacture of instruments as individual
appliances for the chiropodist was started at the instigation of the
late George Erff, by an instrument maker in Jersey City, N. J. His
wares found such instant approval and the sales of his product so
increased that it was not long before several other firms embarked in
the business of manufacturing instruments solely for chiropodical work.
This has done much to standardize instruments and today men and women
in all parts of the world are beginning to use similar instruments made
from standard patterns.
[Illustration: Fig. 1. SCALPELS]
=The Scalpel.= Several varieties of scalpel are used in podiatry
today. Some of them have been developed from an absolute need and some
from the personal desire of the practitioner. The scalpel should be
about five-and-one-half inches long, having a blade length of from
one-and-one-half inches to one-and-three-quarters inches. Made from
these dimensions, the instrument is practical as to size and has a
working surface sufficient for any purpose.
Fig. 1 shows several varieties of scalpel. No. 2 in this group is a
practically shaped blade to be used for work on callositas or heloma.
This instrument will maintain a good shape with honing and is used by a
great number of practitioners.
This No. 2 is used for the removal of heavy callous and general work.
Nos. 3 and 5 may be successfully used for the dissection and removal of
helomata. These pointed scalpels are indicated whenever delicate work
on small surfaces is demanded.
[Illustration: Fig. 2. CHISELS]
=The Chisel.= The heloma and callosity chisels, Nos. 1, 2 of Fig.
2, are about five-and-one-half inches long with a blade length of
one-and-one-quarter inches. Nos. 5 and 6 are nail chisels and will be
discussed under that heading.
A series of chisels which are advocated by Harry P. Kenison, of
Boston, differ from those shown in Fig. 2 only in that the handles are
one-quarter of an inch in diameter and are round, being corrugated to
prevent slipping. These instruments are five-and-one-quarter inches
long.
[Illustration: Fig. 3. HELOMA AND CALLOSITY CHISELS]
Fig. 3 shows heloma and callous chisels (helotoma) recommended by E.
C. Rice, M.D., of Washington, D. C. This variety of instrument is
used principally for dissection work, but is also useful for shaving
or paring methods. No. 1 of this group is used principally for large
calloused areas on the plantar surfaces of the foot. The handles of
these instruments are hexagonal and are five-and-one-quarter inches
long.
=The Nail Chisel.= Varieties of straight chisels for the removal of
ingrown portions of nail are shown in Fig. 2, Nos. 5 and 6.
Curved nail chisels are shown by Nos. 1 and 2 in Fig. 4. Their use is
described in the chapter on Ingrown Nails. Nos. 3, 5, 6, in this group,
are nail packers used for packing gauze or cotton in the nail groove.
No. 4 in this figure is a curette excavator used for the removal of
nail splinters or callous from the nail groove.
There is a newer type of nail chisel with a guard along one edge. This
is to prevent the instrument from penetrating the soft tissues of the
nail bed while removing an imbedded portion of nail. This flange also
aids in lifting the nail from its bed and in breaking up adhesions
which may have formed in advanced cases.
No. 2, Fig. 5, is a nail groove gouge used for the removal of callous
in that location.
[Illustration: Fig. 4. NAIL CHISELS]
[Illustration: Fig. 5. MISCELLANEOUS INSTRUMENTS]
[Illustration: Fig. 6. SOFT CORN SPOON]
=Soft Corn Spoon.= (_Podiatrist Curette._) The soft corn spoon, Fig. 6,
is in reality a shallow curette used for the purpose of dissecting an
epithelial growth between the toes. The working edge of the instrument
is sharp.
A modification of this spoon is shown in Fig. 5, No. 1. This instrument
is commonly known as a “golf stick.” It is used for the same purpose
as the soft corn spoon. These instruments are of the same length, in
fact, are uniform in every way to the scalpel and nail chisel.
=The Spatula.= This is an instrument used almost entirely for the
mixing of ointments and their application to a part. It is not sharp.
(Fig. 7, No. 1.)
=The Nail Scraper.= The scraper is used for cleaning around the nail,
and for the removal of any callous which may be adherent to the nail
body in or about the grooves. Two varieties are shown in Fig. 7, Nos. 2
and 3.
[Illustration: Fig. 7. MISCELLANEOUS INSTRUMENTS]
[Illustration: Fig. 8. EXCAVATORS WITH DETACHABLE HANDLE]
=The Excavator.= Excavators for use in the nail grooves are of great
service to the podiatrist. Probably the most practical variety of this
instrument is that borrowed from the dentist. This form of excavator
is composed of two parts, a handle, called commercially a cone socket
handle, and an excavator point which screws into the hand piece. These
points may be obtained in a great number of styles but the two shown in
Fig. 8 are practical in all cases. No. 2 has a small semi-sharp point,
while No. 1 has a larger point and is dull. These instruments can also
be used as packers for placing gauze or cotton under the nail and in
the grooves.
Other forms of excavators are shown in Fig. 9. No. 1 is a combination
excavator and packer; No. 2, a packer; No. 3 an excavator; No. 4 a
combination spatula and packer.
[Illustration: Fig. 9. EXCAVATORS]
[Illustration: Fig. 10. INGROWING NAIL INSTRUMENTS]
=Special Ingrown Nail Instruments.= A set of special instruments for
use in surgical procedures in ingrown nail cases is shown in Fig. 10.
Nos. 1, 2, and 3 are used for the removal of ragged edges of nail. No.
4 is a nail elevator, used for pre-operative examination, and No. 5 is
a special oil stone used for sharpening Nos. 1, 2, and 3.
=Ingrown Nail Forceps.= Two types of forceps for the removal of the
imbedded portion of the nail after it has been loosened from the
nail body, are in general use. One is of a curved variety and is
particularly practical; the other has a straight point and a locking
device and is in reality a small artery forceps. Fig. 11 shows the
straight point forceps.
[Illustration: Fig. 11.
STRAIGHT NAIL FORCEPS]
[Illustration: Fig. 12.
NAIL SPLITTER]
=Ingrown Nail Clippers.= The clipper shown in Fig. 12 is used almost
entirely in ingrown nail operations. It is extremely light and if used
in the general cutting of nails will surely be sprung. The clipper
illustrated is more correctly a nail “splitter.” These clippers may be
obtained in two sizes, four and one-half and five inches.
=Nail Clippers.= The nail clipper should be of heavy stock so that all
nails may be easily cut without injury to the instrument or pain to the
patient. A heavy nail clip, even though it be dull, will do much more
efficient work in general, than will a sharp light clipper.
Two styles of nail clippers are shown here. Fig. 13 is a clip for
general work while Fig. 14 finds its particular efficacy in club nail
cases. Notice the angle of the blade in this type of instrument.
[Illustration: Fig. 13. NAIL CLIPPERS]
[Illustration: Fig. 14. CLUB NAIL CLIPPERS]
=Thumb Forceps.= Thumb forceps are used extensively in podiatry
practice. All sterile dressings are handled with these instruments to
insure immunity from the contamination of the hands.
Three varieties of thumb forceps are shown in Fig. 15. No. 1 has needle
point corrugated jaws; No. 2 has curved, corrugated needle jaws; and
No. 3 is a heavy pointed corrugated jawed instrument. These three
styles are all four inches in length.
=Iris Tooth Forceps.= This instrument is used where the dissection
method of treatment is employed. The sharp teeth at the end of the
jaws, grasp the thickened mass as it is loosened from its bed. (Fig.
3-A.) The ordinary thumb forceps may also be used in this connection
but they are much more liable to slip than are those of the iris tooth
variety.
[Illustration: Fig. 15. THUMB FORCEPS]
[Illustration: Fig. 16. HEAVY STRAIGHT SCISSORS]
[Illustration: Fig. 17. HEAVY CURVED SCISSORS]
=Scissors.= The podiatrist needs at least four styles of scissors in
his general practice.
For buckskin, felt and adhesive plaster a heavy scissors with straight
blades is necessary. This scissors should be six or six and one-half
inches in length and should preferably have round ends (Fig. 16).
A pair of heavy, curved scissors is also useful for shaping shields,
cutting apertures and for other similar work. It is suggested that
these be not too large for they are apt to be unwieldy. Four and
one-half or five inches is ample size, and one point should be rounded,
and one pointed (Fig. 17).
[Illustration: Fig. 18. CUTICLE SCISSORS (Curved Blades)]
[Illustration: Fig. 19. CUTICLE SCISSORS (Straight Blades)]
[Illustration: Fig. 20. BANDAGE SCISSORS]
Cuticle scissors are useful in many chiropodical procedures. Fig. 18
shows a four-inch, lance point curved scissors. Fig. 19 shows a four
and three-quarters inches straight pointed cuticle scissors.
A small bandage scissors, (Fig. 20) should be included among the
podiatrists’ instruments. It is not necessary to have a large pair, but
one about four and one-half or five inches in size is very useful.
=The Hypodermic Syringe.= The choice of the hypodermic syringe is
purely a matter of preference, but certainly an all-glass syringe (both
barrel and piston) appears to be more practical from the standpoint of
use and of sterilization. The metal barrel syringe is fast going out of
use excepting of the type in which no washers are employed. A syringe
having a capacity of 2 c.c. is ample for the use of the podiatrist
(Fig. 21).
[Illustration: Fig. 21. HYPODERMIC SYRINGE]
[Illustration: Fig. 22. ROUGH CUTTING BURS]
=The Rotary Drill.= One of the greatest boons to modern podiatry is the
development of the rotary file or drill for their use. This instrument
has become so all important in the treatment of many nail diseases,
and, in fact, in the prophylactic treatment of the normal nail, that we
may well wonder how any results were obtained before its advent.
It is not the purpose of this chapter to go into the mechanism of
the drill, but the selection of burrs is a subject which is of such
importance as to merit mention.
Fig. 22 shows several varieties of rough or “cutting” burs for use
in grinding down club nails. In this group “B,” “D” and “E” are
particularly practical.
Finishing burs are those used to smooth off the nail after the use of a
cutting bur, for filing the edges of a normal nail, or for thinning the
nail in prophylactic treatments (Fig. 23).
=The Nail File.= The hand file, for smoothing the edge of a nail after
clipping (Fig. 24), should have a smooth and a rough side. The rough
side is used in cases where the use of a drill is impossible.
=Toe Separators.= These are appliances used for the purpose of holding
the toes apart while operating between them. The implement shown in
Fig. 25, depends upon the tension of the heavy wire for its efficacy.
There is also an appliance used for similar purposes which is dependent
upon a screw adjustment.
[Illustration: Fig. 23. FINISHING BURS]
[Illustration: Fig. 25. TOE SPREADER]
[Illustration: Fig. 24. HAND FILE (SHOWING ROUGH SURFACE)]
=Applicators.= Applicators, used for solutions, may be obtained in
metal and in wood. Those of metal have a short hexagonal handle and are
corrugated at the distal end so that cotton may be wound about them.
The wooden applicator is a small round stick about six inches long.
Such applicators are more practical than those of metal, for they may
be thrown away after use. The metal applicators corrode after several
applications of a corrosive drug and soon become useless.
=The Skiving Knife.= The choice of a knife for the manufacture of
shields of felt or buckskin depends principally upon the fancy of the
user. Some prefer an all-metal, flat-handled knife similar to those
used by leather workers (Fig. 26); others find it more practical
to employ a blade set in a larger wooden handle, claiming that
more purchase can be brought to bear upon the material to be cut,
and consequently more accuracy is obtained. An instrument, known
commercially as the “Murphy” knife, is a practical example of this
latter variety. It has a wooden handle about four inches long, and a
blade of similar length. The cutting edge is narrow toward the point
and gives the operator a bias edge with which to do his cutting. The
all-metal knife blade is similarly slanted. Skiving knives need not be
made of the finest, highly tempered steel, and the edge placed upon
them, when honed, need by no means be a “razor” edge.
[Illustration: Fig. 26. SKIVING KNIVES]
CARE OF INSTRUMENTS
Instruments need care just as do any fine machine. Knives and other
pieces of fine metal will rapidly lose their usefulness unless proper
and unceasing care is taken of them.
=Honing.= Nearly every chiropodist at the present time hones his
own knives or chisels. This is an art which comes naturally to some
but usually is only developed through constant practice. The first
important point that needs to be considered in this connection is the
selection of a hone. A hone is a plane true block of fine compact stone
for sharpening edged tools, and there are a number of these which may
be used for podiatry instruments.
=The Belgian Hone= is in all probability the most popular of the
sharpening stones and when genuine and of fine quality, they are
superior to all other forms of stone. One of the principal drawbacks
in the purchase of a hone of this variety is the fact that many are
manufactured of a composite substance which is extremely hard and upon
whose surface no impression can be made with the instrument. All hones
should be fairly soft, so that the knife blade, as it is drawn across
the surface, will take hold, and not “rough” or “gritty.” Any stone
which has a tendency to roughness or coarseness will never put a real
fine “razor” edge on a delicate instrument.
=The Swatty Hone= has been popular for years among barbers and others
who are called upon to use razor-like blades. The one disadvantage
in the use of this variety of stone is that they are hard, and
considerable honing is needed to place a proper edge upon the
instrument.
=The Oil Stone= is used more particularly for heavy instruments not
demanding a fine surface for finishing. Skiving knives and the like may
be successfully sharpened on stones of this kind. Some practitioners
prefer to “rub down” an instrument on an oil stone or a “carborundum”
stone and then smooth the edge or “finish” it on a genuine old rock
Belgian hone. Carborundum hones cannot be obtained, as a rule, fine or
smooth enough for real delicate work on podiatry instruments, but they
are efficient for heavier instruments.
=Technic of Honing.= Having selected a stone the block is placed before
you on a table. The knife is grasped firmly by the handle with the
thumb and the third, fourth and fifth fingers. The second or index
finger is placed at the junction of the blade with the handle on the
upper surface. The blade of the knife is now laid upon the hone in such
a manner that it is flat upon the stone’s surface, and, using the whole
forearm, the fingers and wrist remaining stationary so that the angle
of the blade remains unchanged, the blade is drawn in an oblique (right
to left) direction toward the operator’s body. It must be remembered
that the blade be drawn _obliquely_ for if it be drawn straight no edge
will be placed upon the instrument.
Having completed this oblique stroke, the whole instrument is turned in
the hand and laid upon the stone so that the other side of the blade is
now upon its surface. An oblique (left to right) stroke is then made
toward the operator using, as before, the whole forearm. This stroke
having been completed the whole procedure is recommenced.
The marks appearing on the blade of the knife caused by contact with
the hone, plainly tell the operator whether or not he has the proper
angle or whether he is holding the blade at the proper level through
its long axis. Testing the sharpness of the blade on the finger-nail or
skin, or judging from the appearance of the contact marks, tells the
operator whether or not the instrument be sufficiently sharp.
Do not overhone! This is a bad fault and will develop a “wire” edge on
the instrument which may take hours to remove. An edge may be “wired”
also by continued heavy pressure during the honing process. This should
also be avoided. Usually several heavy strokes on either side of the
blade, followed by a series of lighter ones, is sufficient to place an
instrument in serviceable condition for a considerable period of time.
=Polishing.= Instruments which are subjected to boiling sterilization
are bound to become discolored (not rusted) no matter what chemical may
be put in the water to prevent this condition. For this reason it is
found necessary, if the brightness of an instrument is to be retained,
to clean or polish it from time to time.
Scrubbing with sapolio or some similar substance, not too gritty,
will serve to remove most of the stains but the labor occasioned by
a procedure of this kind is considerable and is greatly lessened by
the use of a motor buffer or polisher. In cases where rust stains
are present, this machine is indispensable, for no amount of manual
rubbing will remove these marks. The buffer wheel should be of some
soft material, usually chamois, bound firmly. Machine buffing can never
be used on delicate, sharp blades, as it will ruin whatever edge may
be present. Handles may be cleaned efficiently as can scissors, thumb
forceps, and similar instruments by this method.
=Wiping.= After an instrument is removed from boiling water it must
be thoroughly dried if it is to be kept in good condition. The
ideal sterilizer is one combining a superheated steam chamber, or a
water boiling receptacle, and a dry hot air chamber for drying the
instruments after sterilization. If such an apparatus is not included
in the podiatrist’s equipment, the instruments must be thoroughly wiped
until dry. This must be done with a sterile wipe to maintain surgical
cleanliness and the process must be thorough.
Care must be exercised in using superheated steam as a sterilizing
agent that the instrument does not remain for too great a length
of time in the vapor. Boiling water can only reach 212° F., and
an instrument will stand subjection to this degree of heat for a
considerable time, but steam is often heated to twice this degree and
this terrific temperature is bound to untemper an instrument which is
allowed to remain in the vapor over 30 or 40 seconds.
CHAPTER VIII
SHIELDS AND SHIELDING
Shielding is one of the most important branches of practical podiatry.
A great amount of study must be given to this work, and to afford his
patient relief and comfort through the application of shields and
strappings, the operator is continuously called upon to exercise his
mechanical ingenuity or to develop this trait if it be not already
existent.
The surgical treatment of a condition may be faultless, and yet upon
the application of an ill-fashioned or poorly-fitted shield, the
patient will experience even a greater amount of discomfort or pain
than before the treatment was commenced, and the operator’s previous
good work is thus undone.
=Definition.= A shield is an appliance fashioned from some skin or
fabric and used for the purpose of relieving pressure or friction,
or to protect a tender part upon the foot. The nomenclature which
is adhered to under this heading is comparatively a simple one. The
various forms and varieties of shields mentioned and discussed are
named either for their shape or for the particular parts of the foot to
which they are applied. In some instances the two are combined. Thus a
“lateral plantar half-moon or crescent shield” has a crescent shaped
body and is used for the protection of an area on the lateral part of
the plantar surface.
MATERIALS
Various materials are in general use today in the practice of podiatry
for padding or shielding. The object is to give here a brief yet
comprehensive description of each in its turn, together with a general
survey of when, where and how they may be used.
=Chamois.= This skin presents a material which may be used in shielding
parts where a pad of great thickness is not required. Chamois skin
is quite thin and has not a great deal of stability or “body” in
its make-up, and skins of a uniform thickness throughout are seldom
obtainable. The hide thins out considerably toward the belly of the
animal and for this reason there is a great amount of waste. However,
in many cases chamois may be used with success in connection with
helomata on the dorsal or outer lateral surfaces of the fifth toe, the
dorsal surfaces of the intermediate, and the ends of all the toes. For
heloma molle, shields of chamois may also be used to good advantage,
as they are soft and pliable and when placed between the digits they
readily take the shape of the toes without causing the irritation
following the use of shields of a coarser or stiffer “body” in like
positions.
=Buckskin.= Buckskin is probably the most generally used material for
shielding in practice today. This hide has good “body” and even when
skived to paper thinness retains a great amount of its stability.
Buckskin can be obtained in thicknesses ranging from one-sixteenth
to one-quarter or even three-eighths of an inch, but care should be
exercised in its selection that no pieces of coarse-grained skin be
chosen. This is noted because the coarse or “pebbled” skin does not
skive readily, and when bevelled off, the edges remain ragged and
uneven. There are several firms manufacturing excellent grades of
buckskin. Shields of buckskin may be generally used in all conditions
and locations, the thinner skins on the toes and dorsal surfaces and
the thicker on the plantar surfaces and on the metatarsophalangeal
joints of the great and fifth toes.
=Adhesive Moleskin.= A so-called moleskin having a prepared medicated
adhesive substance on one side is becoming very popular with the
profession. It may be obtained in rolls of from one to ten yards
long, and from seven to twelve inches wide. It is very thin but has
good “body,” and under the pressure to which it would be ordinarily
subjected as a shielding material, does not stretch nor pull out of
shape. Because of this thinness and its pliability and softness,
no skiving of its edges is necessary, and it makes a neat, clean,
practical material from which thin shields may be fashioned. Adhesive
moleskin may be employed wherever chamois or the thinner grades of felt
or buckskin are used.
=Sheep Skin.= Sheep skin is one of the lesser used but, nevertheless,
practical shielding agents. Its one disadvantage is that the finished
surface is smooth and shiny and an adhesive substance does not remain
intact unless applied at the time the shield is to be used. This,
however, does not present any serious objection to the use of the skin,
as it is easily skived, has good “body” and presents a neat, clean
appearance on the foot. It is employed wherever chamois may be used.
=Felt.= Plain white piano felting, of the softer and more pliable
grades, is largely used at the present time. This felt can be obtained
in thicknesses of from one-sixth to three-eighths or even one-half
inch. The last mentioned thickness is very seldom used, and then
only in cases where a slight support is needed for the longitudinal
arch or as a pad in cases of painful heel. In both these instances
the felt is pasted in the shoe rather than adhered to the foot. The
one-sixteenth inch grade is used (1) between the toes (applied usually
without adhesive); (2) as a substitute for chamois, kid or buckskin
in all places where these latter may be used. The thicknesses ranging
from one-eighth to three-eighth inch are used generally on the lateral
surfaces of the first and fifth metatarsophalangeal articulations,
on the plantar surface under the prominences of the same joints, and
for protecting painful areas on the dorsum of the foot (its lateral
borders), or in the region of the heel and the tendo Achillis. Felt
shields may be applied with or without adhesive, and strapping should
be done dependent upon the length of time the shields are required to
remain.
For badly inflamed or tender helomata, felt presents an ideal material
for shielding. Shields of this material are softer and more yielding,
and while they cannot be expected to stand the same amount of usage as
those of buckskin they are, nevertheless, strongly recommended in the
above named condition. After the aperture is cut to fit the part to
be protected, its (the aperture’s) edges are nicked with scissors so
that when applied they will expand and readily take the shape of the
indurated areas. While they naturally pack down and become of denser
consistency than at the time of application, felt shields never become
as hard as those made of buckskin.
=Adhesive Felt.= This is the ordinary prepared felt manufactured by
several firms, one side of which is covered with a preparation of dry
gum arabic. Upon moistening this adhesive, the shield may be adhered
to any part. Shields of adhesive felt are very handy to use when
protection is desired for a short time and are very seldom strapped
unless they are to be applied to the plantar surfaces. They have no
specific use and may be applied wherever shields of other materials are
used.
=Lamb’s Wool.= This material is used principally for insoles in shoes
in cases of painful heel or severe callosities on the plantar surfaces,
and in conditions where the integument of the foot is thin and the
patient experiences pain or burning sensations when walking. The wool
is left on the hide, so that there is ample body for the application
of adhesive substances. This material, in the uses mentioned above, is
seldom adhered to the foot itself, but is, rather, placed in the shoe.
PREPARATION OR MANUFACTURE OF SHIELDS.
The definite points to be considered in the making of a proper fitting
are not many; these are important:
1. Location of the part to be protected so that the size and shape of
the shield may be determined.
2. Thickness of the shield.
3. Skiving.
4. Aperture.
=Location of the Parts to Be Protected.= Extreme care should be
exercised in deciding upon the size and shape of the shield. The
location and size of the area to be protected should be taken into
consideration and the shield should be so fashioned that no part of it
extends on the tissue upon which its presence might cause irritation.
For instance, a shield is to be applied on the dorsal surface of one of
the intermediate toes; it should be wide enough to cover the surface of
that toe, but should not be allowed to curl downward upon the digit’s
lateral surfaces or to lap over or extend upon the adjoining toes.
Again, a shield applied on the plantar surface should never be allowed
to extend forward to a point where it might crowd under the toes and
come in contact with their webs.
No shield applied for the protection of one area should be allowed to
extend over and press upon another area which is not normal integument.
The reason for this is obvious, for in covering an heloma, for
instance, a greater amount of pressure is brought to bear upon that
excrescence, with the result that it is subjected to a greater amount
of irritation and pressure than would be caused by the shoe itself.
=Thickness of the Shield.= Just as great harm is brought about by
using a shield that is too thick or too thin as follows the absence of
the protection which a shield provides. If it be too thick, the great
amount of pressure put upon the surrounding area will depress those
tissues to such an extent that severe congestion, with its accompanying
pain and discomfort, is liable to ensue. In making a shield too thin,
no protection is afforded to the area where it is desired and at the
same time the toe is bundled up with a lot of padding and plaster
which is entirely unnecessary, in that it does no good. The use of a
shield should be avoided in all cases, when possible, but there are
many situations in which a shield is indicated and which, when applied,
proves highly effective. Shields naturally pack down more quickly when
the weight of the whole body is constantly being applied, and so,
naturally, the thicker varieties of shielding are used on the plantar
surfaces. This applies to all shielding materials and in particular to
felt.
=Skiving.= Skiving is a process by which the edges of a shield are
thinned or bevelled to a “feather” edge. This is done for three
principal reasons:
(1) When a shield’s outer edges are skived to a “feather” edge, it no
doubt adheres to the integument in a much more satisfactory and lasting
manner than if those edges were allowed to retain a uniform thickness
with the main body of the shield.
(2) By thinning the shield down at the edges any danger of unneeded
and detrimental pressure upon the underlying and surrounding areas
is removed. The object is merely to protect a certain part, and,
therefore, if a pad is used which is of sufficient thickness around the
painful area to protect the diseased tissue, the aim is accomplished,
and to have any considerable thickness to the shield, except as it is
immediately adjacent to the area to be treated, is entirely unnecessary.
(3) Skiving a shield at its outer extremities does away with, or at
least minimizes, the danger of the shield being loosened or shifted,
and consequently it will remain longer in place and with better results.
The inner edges of the aperture made in the shield for the protection
of the diseased part should also be skived. This is done with the idea
of conforming the shield, as nearly as possible, to the shape of the
indurated integument and does away with any irritation to the part
which might be caused were these edges left perpendicular.
[Illustration: Fig. 1.
A. Oval; B. Half-moon or Crescent; C. Interdigital; D. Dorsal
(Intermediate Toes); E. Fifth Toe (Right and Left); F. Boot Shield;
G. Dorso-digital Half-moon (Built Up); H. Modified Half-moon I.
Medio-plantar Crescent (With Cut-out for 1st or 5th Joint)]
=Aperture.= For the purpose of protecting a diseased part from the
pressure of footgear, an aperture or opening is made in the body
of the shield. The size of this aperture is so fashioned as to be
slightly larger than the part to be protected. Many mistakes are made
in shielding, due to the aperture not being cut in the proper place,
and care should be taken in this connection. This opening is not
always made in the centre of the shield; in many instances it must be
placed either to one or to the other side of the median line, running
anterio-posteriorly, and in other cases it should be nearer the front
rather than the back of the shield, and vice versa.
For example: we are to shield an heloma on the fifth toe. Upon
examination of the part we find that the growth occurs on the dorsal
ridge of the digit and that while there is a considerable area of the
normal integument on the toe’s outer lateral side, the space between
the inner edge of the growth and the fourth toe is very narrow. The
aperture must then be so made in the shield that a very narrow portion
of the skin or fabric rests upon the strip of normal tissue toward the
fourth toe and that the wider edge extends down the side of the fifth
digit. Again: in some instances we find that the spot to be protected
is much nearer the distal end of the toe and the nail than the proximal
part. The opening should then be made much nearer the anterior part of
the shield than the posterior, so that when applied, the anterior part
of the shield will not cover the nail or overlap the distal end of the
toe. Too much stress cannot be laid upon this particular feature of
shield-making and their application, and the student and practitioner
alike will do well to give these points great consideration.
=Method of Skiving.= The most generally used and in all probability the
most efficient method of skiving a shield is as follows: the material
used, after being cut to the shape and size desired, is placed with the
left hand. The skiving knife is then taken firmly in the right hand and
with an oblique stroke away from the operator, the edges of the shield
are cut away and thinned to a “feather” edge. This is continued around
the whole outer circumference of the shield until a uniform thickness
is obtained. After this procedure, should the centre of the shield
present any inequalities or uneven ridges, these are pared away in a
like manner until the whole surface is uniformly smooth.
One side of all pieces of buckskin will be found to be firmer and
have a better body than the other. This is the surface to be allowed
to remain intact, the bevelling being done on the reverse side. This
insures a firm surface for the application of an adhesive substance.
=The Skiving Knife.= The knife which seems to be most practical for
our purpose in this procedure should have a blade from three and
one-half to five inches long, about three-quarters of an inch wide at
its base and tapering gradually until, at the end, the width of the
blade is about three-eighths of an inch. This insures a large cutting
surface and the blade, being tapered instead of an even width from
point to base, allows the operator to employ an oblique movement in
skiving the shield.
The handle of this instrument should be fairly large and round, so that
it will admit of a firm hold. A so-called “Murphy knife” is found to be
a very practical and inexpensive instrument for skiving.
APPLICATION AND STRAPPING OF SHIELDS
In applying a shield, care should always be taken that the aperture
is of sufficient size to protect all of the affected area. If this is
not done, great inconvenience and perhaps severe pain is caused to the
patient, in that the shield rests upon tender tissue which should be
protected. It is also good policy to allow for any shifting which may
take place. As for example, in the instance of an heloma: the shield
should be applied so as to leave some space between the anterior edge
of the indurated integument and the anterior edge of the shield’s
aperture. The foot in the process of walking (and particularly if the
patient wears high-heeled shoes) is being constantly pushed towards
the forward part of the shoe, and, therefore, a shield protecting an
heloma on the dorsum of any of the toes will be pushed back rather
than forward. By taking this into consideration the shield, if it does
shift, will still have a sufficient amount of sound integument to rest
upon before it pushes back on the growth itself.
=Adhesive Substances.= Adhesive substances for adhering the shield to
the integument should have no irritating properties whatsoever. The
late George Erff perfected a small, neat alcohol lamp with a “sauce
pan” attachment in which these adhesive substances, usually sold in
stick form, are easily and quickly melted to a fluid consistency when
they may be easily applied to a shield by means of a fine camel’s hair
brush. This enables the operator to spread the adhesive substance in a
thin and even coat over the whole surface and is a much superior method
to the older way of applying it directly from the heated stick.
=Strapping.= In adhesive plasters, by means of which shields may be
securely held in place, we have a great assortment from which to
choose. Plain rubber adhesive plasters are manufactured by many firms,
as is the zinc oxide (medicated) adhesive plaster. Special plasters,
medicated in various ways, are also on the market in abundance and no
doubt find their use in special cases. It is found, however, that the
zinc oxide plaster is perhaps the most practical in all instances,
although by no means the cheapest. This plaster retains its adhesive
properties much longer than the numerous other plasters which have
been experimented with from time to time, and, being at the same time
medicated with zinc oxide, an antiseptic, it makes a practical, cleanly
and non-irritating adhesive plaster.
There are several important points to take into consideration in
applying adhesive plasters for fastening shields more firmly on the
surfaces of the foot.
(1) =No Strapping Should be Applied Too Tightly.= Too much cannot be
said or written relative to allowance being made in strapping a shield
for the natural movements of the foot. It must always be remembered,
in the first place, that a patient’s foot, elevated on the support
of the operating chair, is at rest. There is no weight upon it, and
consequently the tissues of the foot are not expanded to their fullest
extent. For this reason circular strapping placed around a toe to hold
a shield in place may seem sufficiently loose to allow perfect comfort;
but when the patient steps down and walks for a few minutes, this same
toe is expanded to a considerable extent, with the consequence that the
plaster either cuts into the tender integument between or under the
digit, or if not that, at least causes a severe enough irritation to
occasion great annoyance every time a step is taken. Therefore, one of
the first important points to be taken into consideration in applying a
shield is the tightness with which the adhesive strips may be drawn.
This is equally important in applying shields to the plantar surfaces,
because, here also, allowance must be made for a great amount of
expansion. In applying shields to these surfaces the toes should be
extended as far as possible (drawn back toward the dorsum of the foot),
the strapping to be applied while the toes are held in this position.
Were the adhesive strapping applied whilst the toes are in a flexed
position, the integument on the plantar surfaces would be found in a
series of folds or wrinkles. This integument is not always in that
condition, however, and, consequently, when the patient allows the
weight of his body to come upon the foot, in taking a step, and the
toes are extended to their fullest, the tissues covering the plantar
surfaces would be drawn and the strapping will pull on the skin, making
the patient decidedly uncomfortable, or it will tear away altogether
and so become useless.
(2) =Allowance Made for a Swollen Toe.= In this connection particular
attention must be paid to the strappings of a shield. In many cases of
helomata, or more particularly in acute conditions of interphalangeal
bursitis, the integument immediately adjacent to the induration is not
alone inflamed, but the whole toe is ordinarily swollen. In cases of
this nature it will be found advantageous not to carry the strappings
completely around the digit, but rather to place them so that, while
they will hold the shield in place, they do not cover or come in
contact with more of the swollen areas than is absolutely necessary
to secure adhesion. This applies, of course, more particularly to the
dorsal and lateral surfaces of the four lesser digits. To accomplish
this two strips of half-inch plaster, each about one inch in length,
are placed parallel to each other, one over the anterior and one over
the posterior end, and adhered to the integument on each side of the
shield. In many instances it will be found advisable to do away with
adhesive straps entirely and merely allow the shield to remain on for
a day or two, when, the inflammation and swelling having subsided, a
shield may be applied and strapped if necessary.
(3) =Edges of the Shield to Be Covered as Much as Possible.= It should
always be the endeavor of the operator to cover the anterior and
posterior edges of the shield and as much of the lateral surfaces as
is possible. This minimizes the danger of those edges being raised
from the integument during the normal movements of the foot. With this
in view, it is perhaps wise to use as wide plaster as possible on the
plantar, and, in many instances, on the dorsal surfaces as well.
There are five widths of plaster generally used in chiropody for the
purpose of adhering shields. The narrow strip, manufactured by Johnson
& Johnson expressly for chiropodists, the one-half-inch strip, the
one inch strip, the inch-and-a-half strip and the two-inch strip.
The two-inch width is seldom used, and then never in connection with
shielding, but rather for strapping weak ankles and arches.
(4) =End of the Plaster to Be Rounded.= This is for the purpose of
preventing the tendency of the plaster to loosen up at the ends. By
doing away with as many “corners” as possible and instead making
rounded ends, the plaster is found to adhere much more firmly and the
tendency to curl is reduced to a minimum.
SPECIFIC SHIELDING
=Great Toe.= The shields necessary in connection with affections of the
hallux are four in number:
1. Those used in connection with bunions or metatarsophalangeal joint
affections.
2. Those used in connection with corneous developments over the
extensor tendon on the dorsum.
3. Those used in connection with corneous developments along the inner
border or on the plantar surface.
4. Those used in connection with corneous developments on the adjacent
sides of the great and second toes.
_Location 1._ Affections of the first metatarsophalangeal articulation
or of the superadjacent tissues, usually require shields of
considerable size, thickness and “body.” Buckskin or felt are the
materials to be used in this situation, as they can be skived to
considerable thinness at the edge where pressure is unnecessary and
often detrimental.
There are two forms of shields which may be used in this connection,
viz.: the metatarsophalangeal oval or the metatarsophalangeal
half-moon. In a majority of cases the half-moon shield is the most
practical, but the full oval may be used at times with equal or even
better results.
The metatarsophalangeal oval (Fig. 1-A), is an oval shield about three
inches long and two inches wide, which is used principally where the
pressure causing the painful affection comes from the under lateral
side of the joint. The aperture is so placed that it is much nearer
the edge of the shield which goes under the joint, for it must be
remembered that this shield should not extend down and to the plantar
surface of the foot, where it might cause an inequality and undue
pressure. The greatest amount of protection should come from the
position of the shield, and for this purpose that portion of the skin
or fabric is left thick, so that its elevation will equal at least, if
not exceed, that of the affected part.
In strapping a shield in this location the half-inch, one inch, or
inch-and-a-half strips may be used. The inch plaster is probably the
most practical, as it is of sufficient width to bind down the anterior
and posterior edges of the shield and still will not extend over on the
affected part in the aperture. These strips should each be about four
inches in length and should be so arranged as to cross each other on
the dorsum, one binding down the other. Thus the anterior and posterior
edges of the shield, as well as the lateral surface on the dorsum of
the foot, are covered. Some practitioners even advocate the use of
strips of sufficient length to “criss-cross” both on the dorsum and
on the plantar surfaces. It will sometimes be found that the anterior
strips of adhesive plaster will extend too far up on the dorsal surface
of the great toe and thus may interfere with its proper movement. In
these instances it is advisable to cut out a curved portion of the
strip so as to allow normal extension of the toe, without irritation
from the plaster. The same holds good if the plaster should for any
reason extend over the affected part in the aperture. The plaster
should be cut away with curved scissors so that it remains only on
the body of the shield. The half-inch plaster is sometimes used in
strapping the metatarsophalangeal oval shield and is most generally
adhered in the form of a triangle, the strips to be of sufficient
length to cover each other on the sound integument, and so applied as
to bind down all edges of the shield. The inch-and-a-half plaster is
generally used in this manner in cases where it is desirable to cover
the affected part of the joint as well as the shield, making the whole
dressing practically waterproof. Then two strips of the inch-and-a-half
plaster are used; each strip is split on both ends and lapped over so
that it may be drawn down tightly on all sides of the shield. Three
strips of the inch width would answer the same purpose but would make a
larger and more bulky dressing.
The metatarsophalangeal half-moon (Fig. 1-B) is used in all cases where
the pressure or friction comes upon the dorsum or the dorso-lateral
part of the affected joint. The reason for its use in these instances
is obvious. If the pressure comes only upon one or both of these
locations, there is surely no need of protecting the joint from
plantar-lateral pressure, and the use of the full oval shield is
contra-indicated in that its one lateral surface, resting on tissue
upon which there is already much pressure, might become uncomfortable
and detrimental to the general condition of the joint.
The shield is adhered to the dorsal surface in such a manner that its
two points are anterior and posterior to the affected part, with the
broad lateral portion resting alongside on the dorsal surface. It will
generally be found advisable and necessary to fashion the “anterior
point” of the shield somewhat narrower and thinner than the posterior,
as the former usually extends over upon the dorsum of the great toe
and interferes with its movement if allowed to remain thick and bulky.
In any event the greatest amount of protection is derived from the
“posterior point” and the broad lateral surface of the shield, and
this anterior point may be safely thinned or entirely eliminated (see
_Modified Half-moon Shield_). In strapping the metatarsophalangeal
“half-moon” shield, three strips of the inch width plaster, each four
inches long, are adhered, one over the anterior tip of the crescent and
extending well upon the dorsal and plantar surfaces, and the remaining
two strips across the posterior part of the shield, overlapping each
other and the two ends of the first applied strip (Fig. 2).
[Illustration: Fig. 2.
STRAPPING FOR METATARSOPHALANGEAL HALF-MOON SHIELD]
_Location 2._ Shields are often required on the dorsum over the tendon
of the extensor muscle for the protection of corneous formations or
denuded spots due to rubbing of a new shoe on this prominence. Felt
shields of considerable thickness are most generally used in these
instances, as they are more pliable than those of buckskin and, in
consequence, are not so harsh. They are usually cut in oval shape
(though not so large as those described under _Location 1_), and are
strapped in triangular arrangement with half-inch strips. In some
instances, where pressure upon those portions of the tendon anterior
and posterior to the affected area is undesirable, two straight pieces
of felt of considerable thickness (so as to be of higher elevation than
the prominence of the tendon) may be substituted with good results.
They are placed on each side of the tendon and parallel with it. The
strapping in this case consists of two half-inch strips placed across
the felt shield at right angles to the long axis of the toe. A very
practical protection of tender areas in this location is a half-moon
shield whose opening is only of sufficient width to protect the
affected spot. This shield is made from adhesive felt, and after it is
fashioned and skived, a strip of the glazed adhesive, slightly wider
than the tender prominence, is removed without disturbing the balance
of the felt constituting the body of the shield. The shield is then
applied and the adhesive substance thus comes only in contact with
integument on each side of the tendon, allowing that cord to move at
will without interference; at the same time ample protection is given
the affected part.
This shield is usually strapped by using two strips of one inch
width plaster, each about three inches long. They are adhered, each
overlapping the other, on the body of the shield, thus binding down
its posterior and two lateral edges to the sound integument. Where a
strapping of this nature would interfere with the normal movements of
the tissues of the toes or of the great toe, one strip, three inches
long and an inch-and-a-half wide, may be substituted and placed across
the body of the shield (at right angles to the toes), thus binding down
its posterior and a portion of its lateral edges.
_Location 3._ In cases of tyloma or heloma on the plantar or inner
lateral border of the great toe, oval shields of buckskin are almost
entirely used (same as Fig. 1-B, only smaller, to accommodate the
smaller surfaces). There are two impractical points to be considered
and avoided in this connection: (_a_) on shielding a part on the
inner border of the great toe, the shield should never be allowed to
extend up on the dorsum of the toe and lap over or cover the lateral
and posterior nail folds. The tissues about the nail are sensitive to
a degree, and any untoward pressure will in most instances start new
troubles in this region. The adhesive strappings will, of course, cover
a greater portion of the nail; but as the plaster is unusually thin, a
great amount of trouble from the strips is seldom experienced. (_b_) In
shielding the plantar surface of the hallux, the pad should never be
fashioned to such length as to interfere with the natural bending of
the toe at the web. If this be allowed the patient will experience a
feeling of “fullness” at that point which may seriously interfere with
his natural gait and comfort, besides which, irritation may be caused
in these parts.
The strapping of shields applied to the plantar or to the inner border
of the great toe is of necessity similar, as the pad is merely in a
different position and the strips must practically cover the same
territory. One-half-inch plaster answers most purposes and two strips
are cut of sufficient length to encircle the toe and overlap each other
on the side of the digit opposite the shield. Too many thicknesses of
plaster between the toes should always be avoided, and to make this
effective many practitioners prefer the narrow chiropodist strip, using
one strip to encircle the toe twice, once on the posterior and once on
the anterior edge of the shield. This is a matter of preference, but
the writer favors the half-inch strip, as it has more adhesive surface
and will consequently fasten the shield more firmly to the integument.
_Location 4._ Corneous excrescences, whether hard or soft, are not
commonly found between the great and second toe but, when so located,
a shield is generally needed as an aid to treatment. A shield for this
condition may be of buckskin or chamois, if intended to last for any
time, and should be strapped in place. Felt shields are often used,
minus adhesive and strapping, where temporary protection is needed.
Using a shield without adhesive in any interdigital disturbance enables
the patient to remove it and set it back at will, in this way avoiding
the hardening or shifting when the shield is allowed to remain in place
during and after a bath.
In fashioning any shield to be used in an interdigital location, the
lower edge (that applied next to the web of the toe) should be cut on
a slant (Fig. 1-C), to conform with the angle of the toe web. This
procedure not alone makes the wearing of the shield more comfortable,
but also gives it a steady base to rest upon, whether adhesive be used
or not. In shielding an heloma between the great and the second toes,
and particularly if the heloma be of any size or on either toe, it will
usually be found advantageous to adhere the shield to the great toe.
The second toe is uncommonly long and slender, and in most instances
presents a very small surface around the heloma, to which a shield may
be made to adhere.
The strapping of a shield in this location is similar to that applied
on the opposite side (inner border) of the great toe; in most cases the
half-inch plaster is employed and the ends are fashioned to overlap
each other on the plantar or inner lateral surfaces of the digit.
=Intermediate Toes (2d, 3d, 4th): Dorsal Surfaces.= In shielding the
dorsal surfaces of the intermediate digits, pads of buckskin, adhesive
moleskin or chamois are exclusively used. On most feet the dorsal
surfaces of these toes are quite narrow and care should be taken that
the shield is not so wide as to interfere or rub against the toes
adjoining or to lap around the toes on their interdigital surfaces. The
shield should be wide in the centre (in which location the aperture is
cut) and should taper slightly toward each end. “Tapering slightly”
does not in any sense mean to a point, but merely sufficient to conform
to the general shape of the toe. Proper skiving is essential to a well
fitting shield in this location, as it must adhere firmly on all sides
and must not act as an irritant to the underlying and surrounding areas
nor to the adjacent toes. For a sample of this shield see Fig. 1-D.
In strapping a shield to the dorsal surfaces of the three intermediate
toes, the narrow chiropodist strip is generally found to be the most
practical and probably the most generally used. It is best made to
adhere in the following manner: strip to be six inches in length; with
one end of the strip start on the side of the toe carrying the plaster
downward on a tangent to a point opposite the rear portion of the
shield, then crossing this posterior part of the shield, so bringing
it (the strip) completely around the toe to the place of beginning.
Cover the beginning “end” with the strip and carry it over the anterior
portion of the shield; complete the dressing by adhering the remaining
end of the plaster to the side of the toe opposite the beginning. We
thus have two strips of plaster over the anterior of the shield lying
next to each other and making approximately a quarter-of-an-inch of
adhesive surface and only one strip over the posterior portion. In
this way the anterior portion, which is most liable to loosen up from
the constant rubbing of the stocking and shoe in walking, is doubly
bound to the toe (Fig. 3).
In many instances where a shield is to remain for a day or so only,
glazed felt will admirably answer all purposes. It is cut similar
in size and design to the buckskin or chamois shield, but is most
generally applied without strapping.
[Illustration: Fig. 3.
SHIELD APPLIED TO DORSUM OF FOURTH TOE]
=The Dorso-Digital Oval Shield.= One more practical method of
shielding an heloma on the dorsum of any of the intermediate toes
may be described. In many instances, whether distinct hammer toe be
present or not, the first interphalangeal articulation will be found
decidedly prominent, and enlarged to such an extent as to make the
application of an individual shield impractical. A large oval shield
of buckskin or eighth-inch felt (Fig. 4) should then be used. The
aperture is fashioned to fit the part to be protected and the long
axis of the shield is allowed to rest across and upon the adjacent
toes. A shield of this nature is seldom if ever strapped, and is
removable by the patient while at rest or during the bath, to be
replaced when the shoe is worn. The writer has observed many cases
where the proximal phalanges of the intermediate toes were in a state
of constant extension due to the contraction of the extensor tendons,
and leaving a decided hollow in the dorsum of the foot directly over
their metatarsophalangeal joints. In a condition of this nature a thick
shield of this pattern is particularly practical and may be used not
alone to protect a tender part, but also to fill up this hollow and
allow the shoe to fit more firmly.
Where helomata are present on the dorsum of all of the phalangeal
joints, this variety of shield is, of course, contra-indicated, as
undue pressure would be brought to bear upon the already troublesome
excrescences and a great amount of trouble would in this way be
invited. In some instances a full oval shield is not used, but a
dorso-digital half-moon, as shown in Fig. 1-G, is substituted. No
definite ruling can be made as to which form of shield should be used,
as each case presents a different aspect and the mechanical work must
be applied accordingly.
[Illustration: Fig. 4.
DORSO-DIGITAL OVAL SHIELD APPLIED TO THIRD TOE]
=End of the Intermediate Toes.= Shielding is often necessary on the
ends of the toes, and in such instances the padding should, as a
rule, be made very thin and the subsequent dressing not bulky. This
is advisable for several reasons: first, helomata in this locality
are usually under or immediately adjacent to the nails and too great
an amount of pressure cannot be put upon these structures; second,
that there is trouble on the end of the digit is proof positive of
the shoe being too short and, therefore, if too thick a shield be
used, the pressure on the surrounding tissues will be too great to be
comfortable; third, helomata in these locations are seldom found to
be elevated to any extent above the normal surface of the integument
and when removed, the tissues are usually at their normal elevation,
so that shields of material as heavy as those used in connection with
helomata in other localities are unnecessary.
A shield of thin buckskin, adhesive moleskin or chamois is best in
these cases. It is applied, generally, so that the long axis is
across the end of the toe and seldom so that the ends of the padding
overlap the free edge of the nail or compress the plantar surface of
the digit. Where the heloma to be protected is situated close to the
nail, and it is advisable that the padding extend over that structure,
by clipping the nail closely and filing it down and at the same
time using an exceedingly thin shield, successful protection can be
secured without unfavorable results. Such shortening of the nail is,
however, not advisable in all cases. This article deals entirely with
shielding, but attention must be here drawn to the fact that there are
many instances of an heloma occurring on the end of one of the lesser
toes, when a shield is contra-indicated. There are many cases where
the toe nail, if allowed to grow long, will protect the tender part
far more successfully than will a shield. Therefore, it is always well
to consider if protection can be obtained from the nail itself before
applying a shield in this location.
=Strappings.= The application of adhesive strips to a shield in this
locality demands considerable ingenuity on the part of the operator,
but there is no stereotyped method to be employed. One general method
may, however, be explained: cut two pieces of chiropodist strip, each
about two-and-one-half or three inches long. Apply the centre of one
strip over one end of the shield, lateral to the aperture, and carry
one end of the strip on a line running toward the proximal end of the
toe and in a manner so as to cover as much of the edges of the shield
on that side as possible.
Overlap these plaster ends on the interdigital surface of the toe
opposite to the place of beginning. Adhere the second in like manner to
the other surface of the shield on the side of the aperture, and carry
the plaster ends in such a way as to cause them to overlap each other
on the interdigital surface of the toe opposite the place of beginning.
In this way both lateral and nearly all of the plantar edges of the
shield will be covered and bound down with adhesive plaster. It will
be found generally that the edge of the shield coming under the free
edge of the nail needs no reenforcement by adhesive strips, as the
length of the nail will prevent any tendency to loosen up the plaster
in that location. Cut a third strip about two inches long and with it
circle the toe, binding down all four ends of the two strips already
applied. Trim off the ends of the plaster, which extend from under this
last applied strip, and the whole makes a neat practical shielding for
trouble in this situation. (Fig. 5).
[Illustration: Fig. 5.
SHOWING SHIELD APPLIED TO END OF FOURTH TOE]
There are many ways in which a shield in this location may be strapped,
but as always, and particularly in this instance, there are so many
circumstances which go to alter the mode of strapping that it would be
well-nigh impossible to explain them all or to outline a set method of
procedure.
=Interdigital Surfaces.= Helomata, both hard and soft, often occur
between the toes and, in these cases, to insure complete relief to the
patient, a shield is usually an absolute necessity.
Buckskin, sheepskin, adhesive moleskin, and chamois are the materials
most generally used for interdigital shields although the thinner
varieties of white felting, with or without adhesive, may be
substituted in some instances. The shield should be fashioned of equal
length to the surface of the toe, from the web to the distal end, and
should be only wide enough to correspond to the thickness of the toe.
If the shield be allowed to lap over on the dorsum of the toe or under
on its plantar surface, new pressure is brought to bear on these parts,
to the discomfort of the patient. It must always be remembered that
the toes bend during the various movements in walking, and that if a
shield be allowed to curl under the toe, the thickness of the material
used will interfere, to a great extent, with the normal flexing and
extending of the toe, even to such a degree in some instances as to
cause lesions of more or less severe character on the skin.
To allow any shield to cover or to press upon the tissues directly
adjacent to the nail is always to the discomfort of those parts, and in
this, as in all other instances, should be avoided.
The bottom of the shield (Fig. 1-C) should be cut on a tangent, so as
to conform to the corresponding slant of the toe web. This insures not
only the minimum danger of irritation on those tender parts, but also
allows the shield a firm base upon which to rest, and prevents any
possible tilting or shifting.
Shields for application to the interdigital surfaces seldom need to be
of great thickness, and the thinner the shield used the more flexible
it is, and the less pressure is brought to bear on the outer surfaces
of the toes. It must be remembered that everything placed between the
toes, of necessity, spreads those members further apart, and naturally
this causes a greater amount of pressure from the boot on the outer
surfaces. Skiving is an essential requirement in interdigital shields,
although in some instances where they are to be used between the great
and second toes, this (skiving) may be omitted.
Thin felt shields, minus adhesive, are often employed between the toes
for transient protection, a fresh one being usually placed in position
daily.
=Strapping.= The most practical method of strapping an interdigital
shield is by means of the narrow chiropodist strip. The method used is
similar in every particular to that employed in the use of the same
width strip in applying a shield to the dorsum of the intermediate toes.
Another less used method is as follows: take a six-inch chiropodist
strip; at its centre adhere it to the upper end of the shield (that
nearer the distal extremity of the toe), and carry both ends around
the toe, crossing them on the side opposite to the starting point.
Then bring the loose ends around the toe again to the side upon which
the shield is adhered and overlap them over the bottom of the shield,
allowing the ends to run for attachment on the sound integument.
=Fifth Toe: Dorsal Surface.= There are more corneous developments on
this digit than on any of the others, and as this toe presents a free
surface on its outer side, which is not the case with any of the other
lesser digits, many varieties of shielding and of strapping are used.
As with the dorsal surfaces of the intermediate toes, buckskin and
adhesive moleskin are the most generally used shielding materials, and
pads of the thinner varieties are in most cases sufficient for the
needs. But, as this toe is probably the most abused of any and is often
found distorted into positions of extreme flexion or extension and is
sometimes lapped over the fourth toe, shields of a greater thickness,
or “built up” pads, are very often indicated. The ordinary buckskin or
adhesive moleskin shield is fashioned oval in shape, but the anterior
end is cut either straight across or slanted toward the outer lateral
edge, so that we have a shield, round at its posterior extremity and
tapering toward the anterior end, having a straight edge (Fig. 1-E).
Shields for the fifth toe must be carefully skived, especially at
the anterior end which goes toward the nail. The writer has often
seen cases in which new helomata, sometimes as many as three or four,
have developed on the dorsum of this toe anterior to the original
callosity, exclusively caused by the habitual wearing of thick shields.
The size of the shield depends wholly upon the size of the toe
and the area to be protected, but the length of the shield should
never be allowed to interfere with the bending of the toe at its
metatarsophalangeal articulation. If this precaution is not observed,
in walking the shield rubs against the dorsum of the foot and is not
alone loosened at its posterior edge, but causes irritation to the skin
in that region. As with those used on the dorsum of the intermediate
toes, the aperture of a shield for the fifth toe should be cut of
sufficient size to allow a space between its (the aperture) anterior
edge, and that of the calloused area; this is to allow for backward
shifting.
Another form of shield used in cases where the small toe is flexed
to a degree and an heloma has developed on its apex, is what may be
called the fifth digital half-moon (Fig. 1-B). It is usually necessary
to build up a shield of this variety. By “built up” is meant that two
thicknesses of material are used, one pasted upon the other, to give
the shield greater thickness and stability. The upper thickness is
formed so as to protect the rear and lateral sides of the corneous
area, but not the front. The second, or under thickness, is fashioned
round at its posterior edge and straight at its anterior surface.
This, being placed under the upper layer, gives the shield sufficient
thickness to be of equal height to the elevation of the heloma or even
higher, thereby avoiding all undesirable pressure upon the painful
area, and at the same time filling out whatever hollow there may be in
the foot at this point.
=Strapping.= There are five general methods of strapping to adhere a
shield to the dorsal surface of the fifth toe. Some conditions demand
the use of one of these and none other, but in most instances any
method may be used with good effect. These five methods are as follows:
1. Narrow chiropodist strip.
2. Combination narrow and half-inch strip.
3. Half-inch strip (using one strip).
4. Half-inch strip (using two strips).
5. Inch strip.
=Number 1.= In using the narrow chiropodist plaster, the strip is
applied in a similar manner to that already described for toes,
arranging the plaster so as to cover the anterior of the shield with
two widths of the strip and the posterior surface with but one (Fig.
6). As an alternative for this, the method described in the second
instance in connection with interdigital shields may be utilized.
[Illustration: Fig. 6.
STRAPPING OF 5TH TOE SHIELD WITH CHIROPODIST STRIP]
[Illustration: Fig. 7.]
=Number 2.= The narrow strip and the half-inch combination consists
of a narrow strip, about four inches in length, adhered to the inner
surface of the toe and carried twice around the toe across the surface
of the shield, anterior to the aperture. This, as will be seen, binds
down the distal end of the shield. The half-inch strip, about three
inches in length, is then cut as shown in Fig. 7-B.
Taking this strip in both hands, insert it between the toes in such a
manner as to allow the narrow portion of the plaster to fit into the
narrowest part of the toe web. Then carry the outer broad end of the
strip around on the dorsum of the toe and adhere it across that part
of the shield posterior to the aperture, taking care, however, that
the adhesive plaster is half on the shield and half on the integument
adjoining it. Adhere the remaining broad end of the plaster (that
coming from between the toes) over the first applied posterior strips,
taking the same care that shield and skin are both covered by the
plaster (Fig. 8).
[Illustration: Fig. 8.
SHOWING SHIELD STRAPPED WITH NARROW AND HALF-INCH STRIP]
[Illustration: Fig. 8a.
SHOWING DRESSING COMPLETE WITH COCOON OVER APERTURE]
This alternate style of strapping is particularly useful in cases where
the narrow strips of method No. 1 are found to irritate the skin of
the toe web, or if there be a corneous excrescence developed there
which cannot be covered by the plaster; instead of using the half-inch
strip, as just described, a half-inch or inch strip, about two inches
in length, is cut and placed across the posterior of the shield and is
adhered to the integument on the dorsum and plantar of the foot. Should
any portion of this posterior strip lap over the aperture, it should,
of course, be cut away.
[Illustration: Fig. 9.]
=Number 3.= In this manner of strapping (using one one-half-inch strip)
we have one of the most practical methods in vogue today. A strip about
six inches in length is fashioned in the manner of Fig. 9. The wide
portion in the strip’s centre is then adhered to the anterior surface
of the shield and the ends are carried around, one on each side of the
toe, in such a manner as to allow the narrowest portions to criss-cross
in the narrow part of the toe web on the plantar surface. The wide ends
are then carried around the dorsum of the toe and are overlapped on the
posterior portion of the shield. This method of applying the plaster
supplies a greater amount of adhesive surface than by the use of the
narrow strip and is just as practical, or more so, in many ways.
=Number 4.= In using two one-half-inch strips to adhere a shield to
the dorsum of the fifth toe, the plaster is fashioned as shown in A
and B (Fig. 7). The strip marked “A” is cut about two inches in length
and split on the square end. That marked “B” is about three or three
and one-half inches in length. The strip “A” is laid over the anterior
surface of the shield with the split end toward the inner side of the
toe. The anterior one of the two split ends is then drawn tightly over
the anterior edge of the shield and adhered to the inner surface of
the toe; the remaining split end is adhered over the first and should
also be drawn tightly, so that the anterior portion of the shield
is closely bound to the dorsum of the toe. The rounded end of the
plaster strip is then carried around the outer side of the toe in such
a manner as to allow the narrow portion of the plaster to rest over
the corresponding narrow part of the toe on its plantar surface. The
wide extremity is brought around to the inner side of the toe and is
placed over the split ends already adhered. This binds them securely to
the interdigital surface of the toe. Any loose ends showing after the
foregoing is completed should be clipped off. One wide end of the strip
“B” is then adhered across the posterior surface of the shield and
the plaster carried around the toe (the narrow portion of the plaster
fitting in the narrow part of the toe web) and the remaining wide end
is overlapped on the posterior portion of the shield, thus securing the
other wide end already adhered to the shield.
Another method, differing merely in the position of the last wide
end of the strip “B,” is as follows: instead of adhering this end
criss-cross over the posterior portion of the shield, bring it further
toward the anterior of the toe and adhere it directly across and over
the aperture, fastening the end upon the inner side of the toe. This
makes a waterproof dressing with none of the shield showing when the
dressing is complete; it is contra-indicated when a soft dressing is
desired over the inflamed parts.
[Illustration: Fig. 10.]
=Number 5.= The other method which may be used is to cut off about
six inches of one inch plaster (although the length used depends upon
the size of the toe), and fashion it as shown in Fig. 10. The split
ends are then adhered on the inner side of the toe, so that the wide
portion next to them is drawn tightly over the anterior surface of the
shield. The narrow portion is then carried around the outer side of
the toe and is placed, as previously described, on the corresponding
narrow surface of the toe web, and the remaining wide end is brought
between the toes and over the posterior surface of the shield, entirely
covering the pad and adhering it to the integument on the outer surface
of the shield, over the metatarsophalangeal joint. This also makes a
practically waterproof dressing (Fig. 11).
[Illustration: Fig. 11.
SHOWING ANTERIOR PORTION OF ADHESIVE STRIP APPLIED]
[Illustration: Fig. 11a.
SHOWING DRESSING COMPLETED]
=Fifth Digital, Built Up, Half-Moon Shield.= In strapping a “built up”
half-moon shield in this connection there are one or two methods which
will answer in all cases. The first method is the use of but one strip
of plaster, either of one inch or of one-and-a-half inch width. This is
placed transversely across the body of the shield so that no plaster
extends over into the aperture, and it is adhered to the integument
on the dorsal and plantar surfaces of the foot. As this shield is so
much wider than the toe, it is not practical to encircle the toe with
adhesive strips in fastening it. The other method at times employed,
and the one that is advocated, in that it binds down the “points of
the crescent,” situated laterally to the corn when the shield is in
place, consists in the use of two strips of the one inch plaster. These
are each cut about two inches in length, one being placed diagonally
across the body of the shield in such a manner as to cover the outer
lateral point of the shield, and the other in a like manner, so as to
cover the inner lateral point of the shield and overlapping the first
applied strip on the body of the shield. In many instances, however,
this variety of shield is not strapped and is removed and reapplied by
the wearer at will.
It may sometimes be found advisable, when a small shield cannot be used
and where the spot to be protected is nearer the distal part of the
toe, and in consequence would not receive sufficient protection from
a half-moon shield placed at its proximal end, to apply to the part
a full oval shield, slightly modified as to its anterior edge. This
shield is of the same shape as that shown in Fig. 1-E, except that
it is larger. It is made from the thicker grades of buckskin and is
fashioned so as to rest on the fourth toe and over the fifth nail, and
for this reason these two contact surfaces of the shield must be well
skived. This shield is seldom strapped and then only at its posterior
surface, and in like manner to the strappings described for the fifth
digital half-moon. A large shield of this kind evens up the whole
surface of that part of the foot and so equalizes the pressure that it
is distributed generally.
=Lateral Surfaces.= Helomata on the outer lateral surface of the fifth
toe are generally shielded in a manner similar to those occurring on
the dorsum; the shield in the lateral location, however, should never
be of great thickness. In most instances corneous developments of the
small digit on these surfaces are situated adjacent to the nail and the
shield, and to be comfortable, should not be allowed to overlap the
nail structures. If, however, to obtain proper protection, overlapping
must be allowed in order to cover these areas, the shield should be of
paper thinness, especially at its anterior end.
In this situation a shield is often used which gives protection from
the anterior, posterior and outer lateral but not from the inner
lateral surface, which would of necessity have to be adhered over the
dorsum of the toe and the nail.
This form of shield is practically of the same shape as the ordinary
fifth toe protector but with the inner lateral surface next to the cut
away aperture. It is particularly practical in cases where the spot to
be protected is directly next to or in the corner of the nail. By a
shield so fashioned, the protection of the part is derived from all but
the nail.
=Strapping.= The narrow chiropodist strip affords the most practical
method of strapping a shield in this location, and the method is
similar to that employed on the dorsum of the fifth or intermediate
toes.
In strapping the last mentioned form of shield, the strips are applied
in a similar manner. Care is taken to adhere the plaster over both
points of the shield, anterior and posterior to the affected part.
=Interdigital Surfaces.= The shielding of helomata occurring on the
inner surface of the fifth toe is similar in method to that employed
in shielding like parts on the intermediate toes. This applies to the
strapping as well. Thick shields are contra-indicated, as they force
the fifth toe out against the shoe; if used on that part they will
undoubtedly create trouble to the toe in question. Both hard and soft
helomata often occur in this connection; they are located, not on the
sides, but rather well down in the web of the toe. In such cases a
specially fashioned shield is required which, from its shape, is known
as a “boot shield” (Fig. 1-F). This shield is of material such as is
used in making the ordinary interdigital pad, being the thinner grades
of adhesive moleskin, buckskin, or chamois. It is applied usually on
the adjacent side of the fourth toe, the narrow portion uppermost and
the wider part with its concave surface directly above the uppermost
ridge of the corneous area. This not alone prevents lateral pressure,
but, by means of the tongue-like shape at one side of its base, it also
prevents pressure on the part from the plantar surface.
It is often found that helomata, developing in the interdigital web of
these toes, are caused by pressure on the part, due to the dropping
of the fourth metatarsal bone. To bring the head of this bone up into
position, and in that way relieve the pressure, it is often found
necessary to apply a felt or buckskin shield on the plantar surface
of the foot under this articulation. This may be done in addition to
applying a shield between the toes or each may be used separately, as
experience dictates. Alfred Ahrens, of New York, one of the teaching
staff of The First Institute of Podiatry, has devised a shield, known
by its shape as the “duck shield,” which is so fashioned as to present
a shielding surface between the fourth and fifth toes, as well as an
expanded end which extends down upon the plantar surface and throws the
head of the fourth metatarsal up into normal position.
=Strapping.= The narrow strip is the most practical means of strapping
a “boot shield” to the fourth toe. Two turns of the plaster are
carried around the digit, the first covering the shield about at its
centre and the second crossing near its uppermost end. One half-inch
strip may also be used, its two ends crossing each other on the side of
the fourth toe, opposite the shield; or in some instances, if the shape
of the toe permits, the ends may be adhered to the dorsal and plantar
surfaces of the foot.
=Metatarsophalangeal Articulation.= In protecting a part in this
location three styles of shield may be employed:
1. Oval.
2. Half-moon.
3. Modified half-moon.
=Number 1.= The thicker grades of buckskin or felt are generally used
for this protection, as the part, if affected, is usually considerably
elevated above the surrounding integument. As in connection with the
first metatarsophalangeal articulation, the oval shield is so fashioned
that the principal protection will be derived from the upper lateral
and posterior surfaces. The anterior and under lateral surfaces are
made correspondingly thin and narrow, so that no undesirable pressure
is brought to bear on the integument beneath these surfaces. In
this instance, two reasons may be given for such a course: first,
all unnecessary pressure is naturally contra-indicated; second, the
protection from these sides is, in nearly every instance, useless and
unproductive of results. Usually, if the point to be protected be
near the band of the fifth toe, the shield must be scalloped so as
to allow for the backward movement of this digit when in an extended
position. Great care must be taken in applying all shields to allow for
the natural movements of the parts in walking. In this position, more
particularly, a cumbersome, ill-fashioned shield may become a source
of irritation during the movements of the foot in exercise. Ninety per
cent. of shield troubles are due to their being improperly fitted or to
their imperfect fashioning.
If a shield used in protecting the fifth metatarsophalangeal
articulation is not scalloped, as previously mentioned, to allow
for the backward movement of the proximal phalanges of this digit,
irritation is not only bound to occur, but the movement of the toe
will loosen up the anterior rim of the shield (despite strapping), and
consequently shifting of the shield is sure to occur.
In strapping an oval shield to this part, two strips about four or five
inches long are cut from the one inch width plaster. They are adhered
so as to cover the anterior and posterior portions of the shield and
the upper loose ends, made to overlap on the dorsum of the foot, are
carried firmly over the side to the plantar surface, overlapping also
on the sole of the foot.
From experience, the writer much prefers the substitution of the
so-called half-moon, or the modified half-moon shields (Fig. 1-H) in
place of the oval just described.
=Number 2.= The metatarsophalangeal half-moon shield supplies all the
necessary protection from its upper lateral and posterior surfaces
without extending down around and under the plantar surface of the
joint. It must always be remembered that the insole of the shoe joins
its shank at this point and, in many instances, particularly if the
shoe has been worn to any extent, the insole is inclined to curl up and
to thicken, and in nearly every case where the shield is allowed to
run over the edge of the foot, undue pressure, with its train of bad
effects, is made on the parts.
The half-moon shield is placed on the dorsum of the foot, the “points
of the crescent” extending anteriorly and posteriorly to the part to be
protected. The anterior is made narrower and thinner than the posterior
point for, as is the case with the oval shield, the greatest amount of
protection must come from the wide lateral surface (the main body of
the shield) and from that portion lying posterior to the protected part.
As is the case in any shield, the anterior part of the crescent or
half-moon variety must be placed far enough forward so that if it does
shift, there will still be sufficient normal integument for it to rest
upon before it comes in direct contact with the anterior edge of the
calloused area. However, care must also be taken and allowance made so
that backward movement of the fifth toe does not tend to loosen up this
anterior edge.
In strapping the half-moon shield, two strips, four inches long and one
inch wide, are used in like manner as that described in the strapping
of the oval shield. In some instances the anterior point of the
crescent is found to be narrow enough so that a strip of the half-inch
plaster, cut the same length, may be substituted with equally good
results. The inch width, or in some cases the inch-and-a-half width, is
used across the posterior portion of the shield.
=Number 3.= The modified metatarsophalangeal half-moon shield is
practically the regular half-moon minus its anterior point. Many
practitioners have suggested a shield of this nature for protection
of the first and fifth metatarsophalangeal joints for the reason
that the anterior point is of little or of no use and may become a
decidedly detrimental feature should the shield shift in any way. Its
application and strapping is similar in every particular to that of
the half-moon. The writer, however, has often used two strips of one
inch width plaster, each about three inches long, and has adhered them
in criss-cross fashion over the posterior of the shield so as to cover
the entire posterior portion and some part of the lateral edge, and has
also found this method entirely satisfactory.
=Plantar Surfaces.= The plantar surfaces of the foot, being subject to
continued pressure and at times to considerable friction, are prone
to develop many calloused and corneous areas. In many of these cases
shielding is absolutely imperative to successful treatment.
It must always be remembered that these excrescences are, in a
measure at least, a protection to the underlying parts, and their
removal often makes the patient conscious of their loss. Ofttimes the
tissues so exposed become congested and decidedly tender. This, of
course, is to be considered at all times, but particularly so on the
plantar surfaces of the foot. Another point which must be taken into
consideration in this connection is that the normal tissue padding (fat
and muscles) of some people’s feet is very thin; in consequence, the
heads of the metatarsal bones are unprotected. In most cases of this
kind shields must be applied to take the place of nature in order to
insure any degree of comfort to the patient.
Shields to be placed on the plantar surfaces, and particularly those
to be applied to the metatarsophalangeal regions on the “ball” of the
foot, must of necessity be of decidedly heavier quality and contain
more “body” than those applied to the dorsal or lateral regions. The
reason is that the constant weight of the body quickly flattens the
shields out to such an extent as to render them useless as far as
protection is concerned.
The full oval shield (Fig. 1-A) is the agent best calculated to protect
sensitive areas on the plantar surfaces, and it can be safely said that
it may be and is used in almost every case of this kind. Naturally
the most general locality for the formation of helomata is under
the metatarsophalangeal articulations. These areas, particularly in
persons whose feet are thin and lack the proper natural padding, become
the seats of severe callosities and helomata. The shield to be used
should always be of sufficient size to allow surface enough so that
the patient will rest upon the shield rather than on the integument;
but they should never be allowed to extend up under the toes or be
placed in any way so as to irritate the tender tissues surrounding
the diseased area. For this reason many practitioners have advocated
the use of the medio-plantar crescent shield (Fig. 1-I), so placed
that the greater body of the shield is posterior to the heloma and
the “points of the crescent” extend forward laterally to the heloma
and point toward the toes. This variety of shielding is particularly
efficient when the part to be protected is located rather anterior to
the metatarsophalangeal articulations, as is often found in cases of
blisters and verrucæ. However, in most instances where the trouble is
situated directly over these joints, an oval shield may be used with
perfect impunity and good results will usually follow.
The long axis of the oval shield is placed, as a rule, crosswise on
the foot, as the greater amount of protection is derived from the
surfaces immediately adjoining the affected area, laterally rather than
anteriorly and posteriorly. In cases of excessively arched feet (not
necessarily _pes cavus_) and when the integument is quite thin, a great
deal of protection may be afforded by “building up” the shield on its
surfaces, which are to be posterior to the areas to be protected. This
fills up, to some extent, the hollow caused by the high longitudinal
arch and gives the patient a larger surface upon which to stand or
walk. This same theory of shielding may be successfully applied in
cases where the calloused area covers the whole “ball” of the foot,
making it impractical to shield any one spot without jeopardizing the
comfort of the rest of the integument by placing a shield over it.
A large piece of felt may then be applied directly posterior to the
callosity, the felt to be of sufficient thickness to allow the patient
to rest upon the shield rather than upon the painful calloused area.
=Strapping.= In strapping the plantar oval shield, the one inch width
plaster is most generally used. Three strips are cut, one about two
inches and the remaining ones approximately three or four inches in
length. The short strip is then placed over the anterior edge of the
shield and is adhered to the integument, adjacent laterally to the
shield. One of the longer strips, placed diagonally over the shield’s
lateral edge, starting from and covering the plaster strip already
adhered transversely across the anterior end and running backwards and
covering the whole lateral surface of the shield, is adhered to the
integument immediately posterior. The remaining long plaster strip is
then placed in like manner over the other lateral surface of the shield
and is adhered so as to cover the posterior end of the first placed
lateral strip. This lapping of the plaster ends lends reenforcement
to the strapping and undoubtedly minimizes the danger of the plaster
loosening and at the same time all the edges of the shield are bound
down to the integument (Fig. 12).
[Illustration: Fig. 12.
SHOWING COMPLETE STRAPPING FOR MEDIO-PLANTAR OVAL SHIELD]
It should be remembered that when applying adhesive strips in the
strapping of a plantar shield, the toes should always be drawn backward
towards the dorsum of the foot to their fullest extent, the straps to
be applied whilst the toes are held in this position. This is to allow
for the extension of the toes in the last position of walking and
prevents the plaster from pulling on the sound integument.
In several instances it has been advocated that but two one inch width
strips be used on a shield of this nature, and the same method may
well be applied to the strapping of the medio-plantar crescent shield
previously described. These strips are cut of equal length, each about
four-and-a-half or five inches. About one inch from one end, each strip
is narrowed from the sides so as to allow the admission of the plaster
between the toes. This one end is then adhered to the integument on
the dorsum of the foot, the narrow portion being carried between the
third and fourth or the fourth and fifth toes (as the size of the
shield may indicate) and the remaining portion of plaster is adhered
diagonally across the outer lateral surface of the shield. The other
strip, adhered in like manner on the dorsal surface, is carried between
the toes (usually the great and second) over the inner lateral surface
of the shield, lapping over the end of the first strip applied. This
method of strapping covers, to a considerable extent, the anterior
portion of the shield and does away with the transverse strip which in
many cases becomes an irritating agent to the tender integument under
the toes.
The argument against this method of strapping may be the danger of
irritation between the toes. From the experience had in using this
method, the writer has had no bad results, and if the strips are
properly adhered, the normal movements of the foot being taken into
consideration and the plaster lying between the toes cut sufficiently
narrow, no bad results can take place and there is no doubt of the
greater efficiency and lasting power of the strapping.
=The Lateral Plantar Half-moon.= When the area to be protected is
situated on the extreme lateral edges of the plantar surface, as
often found in these locations, and the callosity extends to or
sometimes over the lateral border of the foot, the full oval shield
is contra-indicated. In its place the lateral plantar half-moon is
substituted with better results in all cases.
This variety is identical with the dorsal half-moon shield and is
applied so that the main body of the shield lies laterally on the
plantar surface, while the “points” are allowed to extend somewhat over
the lateral border of the foot so that some protection is afforded from
this source. The major protection, however, is, of course, obtained
from the main body of the shield on the plantar surface.
The anterior “point of the crescent” is generally fashioned so as to be
narrower and thinner than the posterior, for in nearly every instance
this must extend near the under surface of the great toe and of the
small digit, and must in no way be allowed to interfere with their
movements. Two strips of one inch width plaster are generally used in
strapping the lateral plantar half-moon, although in some instances
it will be found necessary (due to the close proximity of the digital
webs) to substitute a strip one-half inch in width for the anterior
strapping.
The straps are so placed as to overlap both on the dorsal and plantar
surfaces and to bind down the anterior and posterior edges of the pad.
In all strapping the result to be obtained is the binding down of the
edges of the shield rather than merely binding down the main body.
=Lateral Borders.= Practically the only spot on the lateral borders
of the foot where callous formations may be met is over the expanded
base of the fifth metatarsal bone, although blister formations or other
tender areas may develop anywhere along the edges.
The full oval shield is almost entirely used in connection with
protection in these locations and is usually strapped with three strips
of the inch width plaster or, if the shield be small, three strips of
one-half inch width plaster will answer.
These are placed as follows: one strip slightly shorter than the other
two is adhered transversely across one end of the shield and the
other two are applied diagonally from the ends of the first, so as to
completely cover the lateral edges of the shield and overlap each other
on the sound integument beyond its end.
=Os Calcis Region.= Many cases coming to the notice of the podiatrist
require the application of a shield in the region of the os calcis,
either on the plantar, lateral and posterior surfaces of the heel
itself, or further upward on the prominence of the tendo Achillis. The
oval shield is most generally used in these instances, and felt will
usually be found to be the most practical shielding material. Felt,
in particular, is advocated because it is softer and more yielding
than most other materials, and in shielding a tender area on the
tendo Achillis, nothing harsh can be used without danger of causing
irritation to the surrounding and underlying soft parts.
Strapping is similar to that used in adhering the oval shield to the
lateral border, but naturally the operator must exercise his own
ingenuity in the method of strapping to meet the conditions present.
The art of applying a shield is not one to which any set rules can be
applied. Each case is individual and the operator who goes about this
branch of his work in a stereotyped manner will find his efforts devoid
of results.
Often a half-moon shield is used where the part to be protected is
so located that a full oval shield may not be applied. Sometimes the
“points” are applied upward and sometimes the main body of the shield
lies above the protected area and the “points” are downward. The
strapping is similar to a strapping for any such shield and the strips
are applied in such a way as not to interfere with normal movements of
the heel or of the tendon.
There are many instances in which incipient bursal inflammations are
developed adjacent to the tendo Achillis, due to the wearing of a new
or stiff pump or boot. Many cases of this nature were found among the
militiamen preparing to go to the “border” last Spring. The constant
marching in new and stiff shoes, which was part of their training,
caused a great amount of trouble just above and at the insertion of
this tendon. In these cases two pieces of felt, shaped to the tendon
and thick enough to fill up the hollows at its sides, were applied and
then strapped securely in place by strips of adhesive plaster, one inch
in width, which covered felt, tendon and all. This strapping served not
alone to secure the felt shielding in place, but also to immobilize the
part so that these deeper inflammations had a chance to subside.
=Dorsal Surfaces.= On the dorsal surfaces of the foot, over the
articulations of the metatarsal bone with the internal cuneiform and
the cuneiform with the navicular, small and seemingly insignificant,
helomata miliare (seed corns) are found to develop. In many instances
the removal of these growths will not bring relief unless a shield is
applied with the final dressing. This is due to the lack of muscular
padding over these bones and the skin becomes irritated by tight lacing
of the shoes.
A small oval shield, not too thick and usually of thin buckskin, kid or
adhesive moleskin, is usually applied, although the thinner varieties
of felt may be used with good results. The shield is generally strapped
in a manner similar to those applied to the lateral borders or to the
os calcis region, that is, with three strips of one-half inch width
plaster applied to cover all edges of the shield in triangular form.
MORTON’S TOE AND METATARSALGIA
The treatment of anterior arch trouble is usually and wisely
recommended to the orthopedic specialist, but there are numerous
incipient and advanced cases for which the podiatrist must necessarily
give at least temporary relief. Shields, as well as strapping, play an
important part in the rectification of these annoying conditions, and
under this heading the shielding in particular will be discussed.
The heads of the metatarsal bones forming the anterior metatarsal arch,
having dropped from their normal positions, cause pressure upon the
digital nerves and bring on the varieties of pain which are found in
these conditions. It seems a logical theory that in order to alleviate
these painful manifestations, support so designed as to return these
bones to their normal position and hold them there would constitute a
practical and efficient treatment.
From the podiatrist’s standpoint, this may be accomplished by means
of shields of felt or buckskin, adhered to the plantar surface of the
foot in this region or by placing such supports in the shoe. These
methods may at least afford temporary relief and in some instances,
if their use be persisted in, permanent cures have been effected. The
cure, however, is usually attempted by means of metal appliances which
are worn in the shoe and which have a raised portion or “button” just
posterior to the metatarsal heads.
There are several forms of shields (or rather in this instance pads
or supports) which are in general use for the correction of anterior
arch trouble. These vary in size, shape, and thickness according to the
number of bones involved in the displacement. Varying success is met
with in the use of these supports and each individual case is usually
found to demand changes or modifications in the support, so that the
following description should be taken for the general points alone:
=Morton’s Toe.= This affection, being limited to a displacement of
the head of the fourth metatarsal bone with the lateral pressure from
it upon the digital nerve, naturally does not need so large a shield
as would be demanded were the bones of the whole anterior arch out of
alignment.
A pad of felt, about two-and-one-half inches long, an inch-and-a-half
wide at the anterior point, made to taper slightly towards the
posterior end, and three-eighths-of-an-inch thick, will be found to
give relief in most cases. The felt is skived at the posterior end so
that its thickness lessens gradually as it extends posteriorly along
the metatarsal bone. The pad is applied directly to the rear of the
head of the fourth metatarsal bone, and the thickness of the pad serves
to force the depressed bone upwards and thus into proper alignment.
It may be found necessary at times to use even thicker material in
the manufacture of the pad or to place a small piece of felt upon its
upper surface, so that as it is adhered to the part, this elevated area
will come directly posterior to the depressed metatarsal head and thus
elevate it.
In strapping the piece of felt, two or three strips of one inch plaster
are used. These are long enough to cover the width of the plantar
surface and to extend upon the dorsal surface on each side. One end of
the plaster is firmly adhered to the dorsum of the foot, the plaster
being carried around under the foot over the pad, to be then adhered to
the inner dorsum of the foot. Sufficient tension should be put on the
adhesive strips to pull both borders of the foot down, thus aiding the
pad in pushing the heads of the affected metatarsal bones up in place.
In fact, in some cases a strapping of this nature with adhesive plaster
will serve to give at least temporary relief to the patient without the
use of a pad. Some practitioners advocate a pad of sufficient length to
cover a greater portion of the metatarsal bone.
If the pad is entirely covered by the three lengths of adhesive
plaster, it will not alone last longer but the danger of its slipping
out of place is minimized.
=Metatarsalgia.= When the whole anterior arch is involved in a
displacement, a pad of sufficient size and thickness to support the
heads of all the metatarsals is necessary. There are two principal
forms of support in general use. A strip of buckskin or felt of
sufficient length (which will, of course, vary in different feet) to
cover the four lesser metatarsal heads and about one-and-one-half to
two inches in width, is adhered to the foot just posterior to the
depressed parts. This is covered with adhesive plaster and serves as a
support to the whole anterior arch region.
In the writer’s experience, however, the fifth metatarsal bone is
rarely involved in this general depression, and this seems natural when
it is considered that the first and the fifth metatarsal bones act as
pillars for this arch in the normal foot.
Should complaint be made of a pain coming from the anterior arch
trouble and occurring between the fourth and fifth toes, it usually
will be found to emanate from the depression of the fourth metatarsal
head. Keeping this in mind, a pad or support, which has found great
favor, is fashioned from thick felt or buckskin (one-quarter to
three-eighths) in such a way as to allow its anterior edge to come just
behind the metatarsal heads. This pad should be about four or five
inches long and the portion that extends back under the longitudinal
arch should be skived so that it easily conforms to the contours of the
foot in that region. In order to obtain support to the three middle
metatarsal heads, the corners of this pad, which would extend over
those of the first and fifth, are to be cut away; otherwise the pad
would cause undue pressure upon parts requiring no support and thus
prove detrimental.
The pad is held in place with adhesive strips extending from the outer
to the inner dorsum, applied in the same manner as described for the
Morton’s toe pad.
This pad practically gives the patient a new sole to walk on, and at
the same time holds the depressed bones up in place. It will often be
found advantageous to apply a pad of this kind, about one-eighth or
one-quarter of an inch thick, in conditions where the patient complains
of a burning sensation in the soles of the feet, even though there be
no apparent lesion or displacement of the metatarsal bones.
A number of devices are on the market for the relief of all forms of
affections common to the arches of the foot. The relative merits of
such contrivances will be fully discussed in the forthcoming volume on
Podiatry Orthopedics (Schuster and Stafford), to be published under the
auspices of The First Institute of Podiatry.
CHAPTER IX
LOCAL ANESTHESIA
Local anesthesia is a condition of insensibility brought about in
a part of the body by the use of agents called local anesthetics.
The person in whom the local anesthesia is produced does not lose
consciousness as in general anesthesia, the part alone being made
insensible.
There are many agents which, when applied to a part, by one means
or another, cause that part to become insensible to pain, but for
the podiatrist the following agents are best calculated to serve his
purposes: cocaine, novocaine, alypin and urea hydrochloride, ethyl
chloride, ethyl bromide, carbon dioxide snow, apothesine and ice. (See
footnote page 148.)
_Cocaine_ is an alkaloid extracted from coca leaves. These latter are
not to be confused with cocoa, the seed of the chocolate tree. When
cocaine is treated with hydrochloric acid, hydrochloride of cocaine is
produced which occurs in a white crystalline powder, soluble in water
and alcohol. When injected into the skin, or applied to an open wound,
it acts as a paralyzant to the vasodilators and as a stimulant to the
vasoconstrictors. When applying this drug, a tourniquet should be used
wherever possible, so as to prevent absorption. This precaution is
essential, as cocaine[2] is very toxic, and even small quantities may
produce bad effects in some persons. There are cases on record in which
¹⁄₁₀₀ of a grain of this drug has produced all the symptoms of toxemia,
whereas there are persons who can stand doses up to one grain. It is
therefore essential to use judgment and care in administering a drug
which on account of the idiosyncrasies of some people, is likely, even
in minute doses, to produce serious, if not fatal symptoms.
In podiatry, a ¹⁄₂% solution is strong enough for general use, provided
that time enough is allowed for the drug to be diffused. For an
ordinary ingrown toe nail, two cubic centimeters of the above solution
is usually sufficient to produce anesthesia of the part.
_Novocaine_ is a synthetic preparation and occurs in colorless needles.
It can be heated to 120 degrees Centigrade, without undergoing
decomposition, which is not the case with cocaine hydrochloride.
Although not quite as efficient as an anesthetic, novocaine is only ¹⁄₇
as toxic as cocaine and therefore can be used with greater safety and
podiatrists generally have abandoned cocaine for novocaine. It has a
slightly irritating action while being injected, but on the whole it is
preferable to cocaine for podiatry practice. Physiologically, it has
the same action as cocaine, and is indicated wherever the latter drug
is used. It is usually injected in one per cent. solutions.
_Alypin_ occurs as a crystalline powder. It is a most efficient
anesthetic and because of its non-toxic action, it is to be preferred
in cases in which there is a fear of toxemia. Maximilian Stern, M.D.,
Professor of Surgery at the First Institute of Podiatry, has used this
drug extensively for producing local anesthesia, and his results have
been very satisfactory. For use in podiatry, a ¹⁄₄ to ¹⁄₈ per cent.
solution is often sufficient. It may be used freely in ¹⁄₄ per cent.
strength without danger of toxemia. When injected, it produces no
anemia, and consequently there is no danger of subsequent hemorrhage,
such as might accompany the use of either cocaine or novocaine.
_Quinine and urea hydrochloride_ is one of the quinine salts,
consisting of one molecule of quinine hydrochloride and one molecule
of urea. It has no toxic action when injected into the tissues, but it
retards healing, and scar tissue forms over operated areas where it has
been used. Many operators prefer this drug on account of its non-toxic
action when used in large quantities, despite the likelihood of a scar
and slow union. In parts of the body where contraction of the tissues
is a desirable after-effect (such as would be the case in hemorrhoids),
quinine and urea hydrochloride is to be preferred over other local
anesthetics. David H. Levy, M.D., a well known surgeon of New York
City, prefers it to all other local anesthetics.
_Ethyl chloride_ and _ethyl bromide_ are clear volatile liquids, and
upon their rapid evaporation depend their anesthetic qualities. When
a substance evaporates rapidly, it extracts the heat from surrounding
bodies in doing so, and, consequently, when such a substance is applied
to the skin, it soon extracts the heat from the part and with the
local anemia thus produced, sensation is lost. Ethyl chloride and
ethyl bromide are manufactured in tubes so arranged as to eject a fine
stream of the liquid. When this stream comes in contact with the skin,
evaporation is rapid and gradually the part becomes numb; continued,
it becomes frozen. This method is not as efficient as the hypodermic
injection because the anesthesia is not so lasting, moreover, the
reaction is severe and painful. Otto Sjogren and Fred Schmitt,
practitioners of known repute, have entirely discarded both of these
drugs from their list of local anesthetics, for reasons above mentioned.
_Carbon dioxide snow_ is prepared by allowing liquified carbon dioxide
gas to slowly escape from its container into a glove finger, where it
solidifies into a mass, assuming the shape and form of the receptacle;
it is called the _carbon dioxide pencil_. When this mass or pencil is
applied to a part, it extracts the heat and anesthetizes by freezing.
The dangers attending the use of the carbon dioxide pencil are the same
as with ethyl chloride or ethyl bromide and, due to its extremely low
temperature, there is danger of causing death of the tissues and of
producing conditions giving rise to subsequent ulcerations that are
slow to heal. As an anesthetic, it is not advised for podiatry.
=Technic of Producing Local Anesthesia.= There are three methods of
producing local anesthesia: (1) the hypodermatic method: (2) the
pressure method: (3) freezing.
The freezing method is of no great value to the podiatrist, and having
been already briefly described, further comment is deemed unnecessary.
The pressure method of producing local anesthesia is new, and although
extensively employed in the practice of dentistry, podiatry offers but
little opportunity for its free use. It is necessary to have an exposed
nerve, such as is found in the cavities of painful teeth, or an open
wound into which the drug can be absorbed, before this method can be
used. In cases of ingrown toe nail, in which the groove is lacerated,
either by the patient or by the nail itself, pressure anesthesia is
often efficacious. Small pellets containing cocaine or novocaine,
with adrenalin, are put on the market for this purpose. One of these
pellets is placed in the nail groove, and a drop of alcohol is made to
fall on it. The contents of the pellet are promptly dissolved by the
alcohol, whereupon the operator places his thumb over the nail groove
between the nail and the nail flap and exerts downward pressure. This
forces the dissolved fluid into the tissues, where it acts the same
as if it were injected. This procedure is painful for just a moment
while the pressure is being applied, but the pain soon ceases and nerve
sensibility is lost.
The most generally used method of applying local anesthetics is by
means of the hypodermic syringe and is called the [3]hypodermatic
method. This is preferable to all other forms of inducing local
insensibility, and if the technic is mastered, operations will be
painless with the exception of the initial prick of the needle.
=The Hypodermic Syringe= should be so constructed that it may be
sterilized by boiling. There are many types of such instruments sold,
and in making a selection, only those which will permit such boiling
should be considered. The all-glass syringe or the glass and metal
syringe with the metal piston are best, because the fluid contained
therein is visible, thus preventing the injection of air. Needles
should be of the rust-proof variety and for use in podiatry, they
should be one-half or one inch long and have a twenty or twenty-two
gauge lumen.
After the syringe has been sterilized, it should be adjusted and the
fluid drawn into it after the needle is attached to the barrel. The
entire instrument is then turned, needle up, and the air that may be in
the barrel is expelled by pressure on the piston. When this is done,
the syringe is ready for use.
If the needle is sterile, the only preparation necessary for the skin
is to paint it with tincture of iodine, and then the injection of the
anesthetic may be commenced. The area to be anesthetized is determined,
and then at the most proximal portion, the skin is grasped between the
thumb and forefinger of the left hand. The syringe should be held in
the right hand with the barrel between the first and middle fingers,
and the thumb on the piston. When the skin has been blanched by the
pressure of the fingers of the left hand, the point of the needle,
lumen downward, is thrust into the skin with a quick movement and
immediately after, pressure is brought to bear upon the piston. As the
fluid enters the tissues, it produces a blanched area which is called
a wheal. As the wheal is formed, the needle is gradually moved forward
in the derma until it is inserted as far as the base. It is then
withdrawn, and a second injection is commenced, a little back of the
distal end of the wheal. This second injection, being started in a part
already anesthetized, will cause no pain. So the needle is gradually
moved forward in the derma until the desired area has been covered.
When the deeper tissues are to be anesthetized, the needle may be
directed at an angle to the surface, pressure being borne on the piston
of the syringe as the needle gradually moves deeper into the flesh. It
must be remembered that if the needle is re-inserted into an area that
is already deadened, there will be no pain. The fluid should be ejected
from the syringe slowly, which insures an even distribution of the
drug, as well as comfort to the patient, while the anesthetic is being
administered. Most drugs cause a burning sensation if injected too
rapidly.
The most common lesion for which local anesthetics are used in podiatry
is the ingrown toe nail, and to get good results in these cases,
the technic must be followed in detail. After the derma has been
anesthetized over the region of the nail root and groove, one deep
injection should be made at the root, and vertically to the skin. This
will insure loss of sensation when the root is cut and when the matrix
at this point is curetted.
To prevent the absorption of toxic drugs into the system, some means
should be devised to cut off the circulation during the operation. This
is accomplished by the tourniquet, which is usually made of flexible,
solid rubber, about one-sixteenth or one-eighth inch in diameter and
about a foot long. When this band is tied around the base of the toe,
and pulled tight, it cuts off the circulation. Tourniquets cannot be
used when operating upon the foot proper, and in these cases it is
necessary to be guarded in the use of toxic drugs.
After the use of cocaine[4] or novocaine there is a reaction, and
occasionally the pains produced by this reaction are severe. These
pains may be alleviated to some extent by the use of wet dressings,
but they last only for a short time so that it is often unnecessary
to treat them. The patient should be warned of the reaction. The
local anemia produced by the injection of these drugs is subsequently
followed by hyperemia, and it is therefore necessary to guard against
hemorrhage in cases in which free incisions have been made. Wounds
should be packed, and proper bandages should be applied to prevent any
such possibilities.
CHAPTER X
HELOMA
=Derivation.= The word has its origin in the Greek “_helos_,” meaning
corn; (plural: _helomata_).
[Illustration: BUILDING NAILS (HELOS) USED IN PRE-HISTORIC TIMES]
In the accompanying cut will be found a photograph of two building
nails bearing the name and time of the reign of King Gudea in Ur,
Chaldea, about 2500 B.C. Plaster casts of the above were presented
to The First Institute of Podiatry by Fridtjov Anderson, Colonel in
the Norwegian Artillery. These nails were called helos and because of
their semblance to the foot excrescences, commonly called corns, the
latter were therefore named helomata.
=Synonyms.= Corn, clavus, horn.
=Definition.= An heloma is a circumscribed, conical, deep-seated
overgrowth of the epidermis, the apex of which presses down upon the
derma. Corns usually occur about the toes, but may appear upon any part
of the body subject to friction or pressure. They range in size from a
pinhead to a ten cent piece.
According to their appearance, texture or composition, helomata are
classified as follows:
Heloma durum, or hard corn.
Heloma molle, or soft corn.
Heloma vasculare, or vascular corn.
Heloma miliare, or seed corn.
HELOMA DURUM
=Heloma durum= is a hard circumscribed overgrowth of the epidermis and
may occur as above stated, but is usually found on the outer side of
the fifth toe, the dorsum of the second, third and fourth toes, and on
the plantar surface of the interphalangeal joint of the great toe.
=Symptoms.= The symptoms of an heloma durum may be classified as
subjective and objective. The chief subjective symptom is pain in
varying degrees. The formation of the growth produces a pressure upon
the nerves which, in turn, gives rise to pain varying from a dull and
mild sensation to a sharp and intense excitation. These pains are
increased when the part affected is further irritated by ill-fitting
shoes, by friction or by other pressure.
It is a well known fact that the pain in a corn is increased when the
weather is about to change. Helomata, which at other times cause no
inconvenience, will prove a source of annoyance at this time. This
is due to certain physiologic changes that take place in the body as
follows: the atmosphere preceding a storm becomes more and more charged
with moisture. As this increases, the function of the skin, namely the
elimination of liquid waste, is gradually diminished. This function is
taken up and performed by the kidneys, and as the air becomes fully
charged with moisture, the entire work of elimination is carried on by
these latter organs. This physiologic change requires a readjustment of
the blood supply and the nerves which control it, so as to bring about
a proper equilibrium. In this latter procedure the little nerve fibres
are unfavorably influenced, and pain results. The gradually increased
uncomfortableness that is experienced is due to gradual increase in the
humidity and when precipitation takes place and the air is freed from
this atmospheric pressure, relief is afforded.
The patient will complain of pain while shoes and stockings are worn,
but will feel relieved when they are removed, except in cases where
inflammatory processes have commenced. The pains at these times are of
the throbbing, pulsating variety, such as accompany all inflammations.
A clinical examination of an heloma durum shows a horny mass of
epidermic cells crowded together with no regular formation within
the growth. There is a sharp line of demarcation between it and the
surrounding tissues and it is also distinguished by its darker,
yellowish color in contradistinction to the healthy pink of the normal
skin. Within the growth, and usually at its centre, may be seen a
darker, more compact mass, which penetrates deeper into the tissues.
This is the radix or nucleus, incorrectly termed the root, or the
eye, of the corn. The skin immediately surrounding the heloma usually
presents a red line, due to the somewhat lessened irritation that
originally produced the corn. The color is due to congestion in the
derma.
=Etiology.= Helomata dura are commonly caused by direct intermittent
friction or pressure of ill-fitting shoes. The shoes may be too tight,
thereby causing pressure, or they may be too loose, thereby causing
friction. Helomata that appear on the plantar surface of the foot may
be caused either by some roughness in the finish of the shoe or by
soles which are too thin, or by downward displacement of the heads
of the metatarsal bones beneath, caused by wearing shoes that are not
anatomically correct.
Imperfections in the stockings, such as knots in the worsted or poor
workmanship in darning, are also factors in producing helomata. Any
concentrated or undue local pressure is capable of causing this
overgrowth, provided, however, that the pressure is not primarily
of sufficient intensity to set up such an amount of congestion and
consequent inflammation as to lead at once to an ulceration of the part.
The same principle of intermittent friction and pressure, with
counter-pressure, as a cause for helomata holds good on any part of the
body surface.
=Pathology.= The pathologic changes accompanying the development of an
heloma are mostly morphologic. The intermittent friction and pressure
produce first an irritation or excitation of the cutaneous nerves; this
causes an increased blood supply to the part and congestion takes place
in the derma immediately beneath.
Were this pressure or friction to cease at this time, nature would
restore the tissues to their normal condition in a very short time;
but, as this pressure or friction is continued from day to day, the
habitual congestion produces a chronic enlargement or hypertrophy of
the papillæ of the derma.
The epidermic cells originate from the material supplied by the blood
plasma, which is conveyed through the walls of the capillaries to
the surface of the basement membrane by endosomis, where it forms
into granules which contain nuclei of unusual size. These granules,
the first organic shape of the future cells, gradually develop into
nucleated cells.
Bearing in mind the development of the cells in the normal skin,
with an increased blood supply, there will naturally be a more rapid
proliferation or development of cells taking place over the enlarged
papillæ than over the surrounding normal ones. This excessive
development of cells causes an abnormal upward crowding of the
preceding cells, with the result that the horny layer gradually becomes
thickened. With this thickened layer acting as a counter-pressure from
above, cornification of the tender cells takes place more rapidly with
each succeeding new layer that is added to the under portion of that
already formed. The growth at this time takes place at the interior and
lateral portions of the heloma, principally the former.
This process in due time causes the epidermis to become transformed
into a dense homogeneous mass of cells which is called a _callosity_.
The size of the callosity is determined by the area of the papillæ
affected.
The etiologic factors which cause the enlargement of the papillæ
and the overgrowth of the epidermic cells continue, and that part
of the growth which was first formed and is most usually central,
becomes more dense than the surrounding callosity. This is due to
the greater irritation to which it is subjected, and eventually this
extends downward and penetrates the derma. The pressure of this new
development, known as a “radix,” against the papillæ, causes these
organisms to undergo progressive atrophy with the result that they are
at times completely absorbed. Thus, we have the common heloma durum.
The heloma now receives its nourishment from the lateral portions,
which still continue to maintain their increased vascularity.
It often happens that an heloma is subjected to unusual pressure during
its formation, which causes serous effusion or even subcutaneous
hemorrhage in minute quantities. This effusion is absorbed by the soft
cells which are in the process of transition into horny tissue. These
cells take on a laminated appearance which present different tints,
from a light yellow to a dark red.
The nerve filaments of the skin are also affected during the
development of an heloma, and when this process is marked, the
condition known as neuro-fibrous heloma is the result. These little
neuromata very often become quite enlarged. The favorite location
for this condition is the inner plantar edge of the great toe, and
sometimes the outer plantar edge of the metatarsophalangeal joint of
the fifth toe.
These helomata consist of two or three little irregularly shaped
structures extending downward into the derma and in juxtaposition to
each other, the septum dividing these structures being made up of one
or more rows of enlarged papillæ which have become highly vitalized
through the enlargement of the nerve fibres contained in them. The
condition is very painful and great care must be exercised when
operating upon them. The most logical reason for their appearance
upon the plantar edges seems to be the fact that the long papillæ of
the plantar surface leave off abruptly and are joined by the shorter
ones of the dorsum. The line of junction is undoubtedly subjected to
a greater degree of irritation than where the size of the papillæ is
uniform.
=Diagnosis.= A typical heloma durum is a mass of epidermic cells, round
in shape and varying in size. The color is usually yellow, but in cases
where serous or bloody infiltration has taken place, the color may
increase to red or even to dark purple.
Heloma durum may be mistaken for heloma vasculare or verruca, on
account of the dark blood stains which are often in evidence, but when
the top layers of the heloma are removed, the dark spots which were
mistaken for blood vessels are not found in the growth proper, but are
deep in the structure resting against the derma. When these spots,
which are clots, are cut with the knife, no bleeding occurs; whereas,
if the condition were one of heloma vasculare or verruca, hemorrhage
would be produced.
Lesions of several skin diseases, such as eczema and psoriasis, very
often produce scales or crusts on the feet which might be mistaken for
helomata, for when the fingers are passed over them they feel as if
they were an overgrowth of the skin. These scales or crusts, however,
are usually loosened at the edges and the color is quite different,
being red or white. Other indications of the presence of a skin
affection will usually be found on other parts of the foot.
The radix, or nucleus, of the heloma is a characteristic which
differentiates it from the ordinary callosity. The radix is a dark
solid mass of epidermic cells which has an almost transparent
appearance. When cutting an heloma, the radix may be felt by the
tension produced as the knife passes through it.
Helomata dura found on the plantar surface of the foot over the heads
of the metatarsal bones are not readily distinguished, due to the fact
that they are covered by a layer of callous, which, when removed,
exposes the nuclei to view.
[Illustration: HELOMA DURUM ON PLANTAR SURFACE]
=Prognosis.= The prognosis of heloma durum is uncertain. There are many
cases on record which have disappeared after the first treatment and,
on the other hand, some cases regularly recur notwithstanding many
years of regular attention. This is due to two conditions: first, the
cause of the heloma, namely, the continued wearing of the shoe, and,
second, the papillæ beneath the growth remain enlarged and continue
their function of excessive cell proliferation. The latter reason
is more important than the first, for, even in cases where proper
footgear is provided and no friction or pressure is permitted, the
heloma may continue to grow. The only way to account for the total
disappearance of some helomata, after treatment, is, that when the
growth is removed, the size of the papillæ diminishes and normal
function is restored. The situation of heloma durum is very important
in considering the ultimate cure of the growth. Those on the outer
aspect of the little toe rarely get well, due to the prominent position
of that digit, while those on the plantar surface over the heads of
the metatarsals are often completely cured after the proper treatment
has been applied. When the heads of the metatarsal bones have been
properly adjusted, the helomata produced by their downward displacement
gradually disappear.
=Treatment.= The treatment of heloma durum is divided into three
classes, viz.: preventive, palliative and operative.
=Preventive treatment= consists in securing freedom from friction of or
pressure on the parts affected. Footgear of proper size and shape is
essential. The shoes should be neither too tight nor too loose; they
should fit snugly in the heel, and the toe box and front of the shoe
should be broad enough to allow of freedom for the toes. The quality
and kind of leather used for the shoe should also be considered.
This should be soft and well seasoned, vici kid and calf skin being
preferred. Patent leather and colt skin are undesirable, in that
they are hard and almost air tight. Shoes made to measure on a last
constructed from a plaster of Paris cast of the foot, are the best.
In making a shoe, consideration should be given to other deformities,
such as flat foot, metatarsalgia, etc., and means for correcting these
ailments should be taken.
The stocking should be large enough to prevent pressure on either
lateral side of the foot. There are stockings on the market which are
cut for each foot and are known as right and left stockings. These are
very desirable, as they prevent distortion of the toes, which is often
produced by the regular stocking cut to a point at the third toe. The
material is of little consequence, except that wool or cotton absorbs
moisture excreted by the glands better than silk.
=Palliative treatment= includes the application of palliative agents,
among which silver nitrate and salicylic acid are most serviceable.
These remedies cause desiccation and shrinkage of the horny growth,
which is thus made to shell out from the bed in which it lies. This
method of treating an heloma durum is long and tedious, as many
applications of the drugs are required to obtain a result. Great
care must be exercised to prevent the applications from touching the
surrounding normal skin. The virtue of so-called corn cures, which are
very plentiful and are given artistic names, all depend upon some drug
or chemical, chief among which is salicylic acid. The danger to the
layman is readily seen, for when these agents are applied carelessly
or in large quantities, the action is too severe, and ulceration and
infection is the result.
When the practitioner finds it necessary to resort to palliative
measures in the treatment of an heloma durum the following procedure
is advised: the tissues surrounding the horny growth are protected by
painting with several layers of collodion or glycerine jelly (Unna). A
piece of salicylic acid plaster is cut to the size of the heloma and
placed over it and a proper protection applied. Or, a shield can be
fitted around the part and in the aperture is placed a 25% salicylic
ointment, and the entire dressing is covered with adhesive plaster.
This dressing is allowed to remain in contact with the part for two
or three days, when the dressing is removed and the white, macerated
tissues are scraped or cut away. The treatment is again applied and
repeated as often as necessary. (See chapter, _Shields and Shielding_.)
=Operative treatment= may be divided into two classes, the radical and
the non-radical. The _radical_ method is painful, but with the use of
local anesthetics, good results are obtained without discomfort to
the patient. Alypin, 1 : 2%, quinine and urea hydrochloride, 2%, or
novocaine, 1% (the latter being preferred by the writer) may be used
to produce local anesthesia[5]. The parts are thoroughly cleansed and
made aseptic by washing with the tincture of green soap, followed by
alcohol, 60%, and finally painting the entire surface, including the
surrounding parts with tincture of iodine. The hypodermic needle and
syringe and all the instruments to be used in the operation are boiled
in water for at least ten minutes. A spot is selected for the injection
of the anesthetic, and ethyl chloride is sprayed on it, to make the
primary injection of the needle painless. The needle is forced into the
derma and pressure brought to bear on the piston of the syringe, as it
moves forward into the tissues. By following the wheal thus produced,
the entire area surrounding the heloma can be anesthetized.
When the anesthesia is complete, two semi-elliptic incisions, meeting
at their extremities, are made through the skin, care being taken
that they penetrate the subcutaneous tissue. These incisions should
completely envelop the growth. The tissues between the incisions are
seized with an artery forceps, and the entire wedge, including the
derma and subcutaneous tissue, is dissected out. This produces free
oozing, and it may be necessary to twist a small vessel. Hemorrhage is
never severe. The edges of the wound are brought together (apposition
should be perfect) by one or two fine sutures and primary union takes
place in a few days, or, if the wound is not large, the part may be
dressed and allowed to heal by granulation. Subsequent dressings should
include shields for the prevention of friction or pressure.
Dr. Robert T. Morris, of New York City, recommends skin grafting with
this operation, in order to prevent the formation of scar tissue, a
very desirable consideration. After the tissue has been dissected out,
some skin is taken from the fleshy part of the leg and is attached over
the wound. This eliminates drawing the edges of the wound together,
which procedure often causes harmful after-effects.
The _non-radical operative_ treatment of heloma durum is the most
popular and practical method employed by chiropodists today. The growth
is removed down to the true skin, care being taken that this layer is
not punctured and bleeding thus produced.
There are two general methods of procedure for the surgical treatment
of callositas and helomata in vogue today. These are known as the
paring or shaving method and the dissection or excision method. This
nomenclature is derived from the operations themselves.
As the term implies, the paring method consists of removing the
callouses with the chisel, knife or scalpel by shaving away the growth
with a series of knife strokes or cuts, and the subsequent removal
of the cone body or radix with the point of the same or a similar
instrument.
=Technic of the Shaving Method.= The part is thoroughly cleansed with
a standard antiseptic, such as phenol, 5%, lysol, 1%, or cresol, 1%,
and this is followed by alcohol, 60%, which is allowed to remain in
contact with the heloma for a few minutes. The instrument employed
should be sterilized by boiling in water for at least fifteen minutes
or by placing it in phenol, 95%, until the liquid clings to the blade,
followed by alcohol, 95%.
After thorough asepsis has been obtained, the tissues adjoining the
area to be removed are held firmly between the thumb and index finger
of the left hand and the knife is grasped firmly with the fingers of
the right hand.
By holding the tissues of the part firmly so that they may not move,
the pain to the patient and the danger of invading the vascular tissues
is minimized. A knife, no matter how sharp, is bound to pull the
tissues overlying a tender and inflamed part unless these tissues are
in some way prevented from moving.
After the overlying callouses have been thoroughly pared away, and
the part is found to be soft and flexible, the nuclei are removed.
In removing these hard bodies the operator who shaves or pares,
practically becomes a dissector. With a sharp pointed knife the heloma
is loosened from the surrounding soft parts until entirely freed,
when it is lifted out. Should there be two or more helomata under one
callous, the same procedure is adopted for each individual growth until
all are removed and the whole area is found flexible.
The stroke of the knife in the shaving method is usually toward the
operator, his fingers and thumbs being so arranged as to limit the
distance which the blade may travel and so prevent cutting the patient
or himself.
In shaving an heloma on the dorsum of the intermediate toes, the index
finger of the left hand is placed anterior to the hardened area and the
thumb, posterior. The knife is then held as a penholder and the strokes
are made toward the operator, the toe being moved or rotated to bring
all the surfaces of the growth under the blade of the knife.
On the plantar surface the operator, at times, is forced to work away
from himself, but in most cases the blade is directed toward himself.
For operating on helomata between the toes, the knife is held as a
penholder and the blade is directed toward the toe or web. Many of the
practitioners who “shave” use a distinct dissection method for the
removal of helomata in this location. They employ what is known as a
“spoon”--a shallow flattened curette--and starting from the outer edge
of the calloused area, work under the hardened layers until the entire
growth is loosened, whereupon it is deftly removed.
The stroke of the chisel in the shaving method is usually away from
the operator. This is in contradistinction to the stroke of the knife
or scalpel. When operating on the dorsum of the toes, however, most
operators using the chisel direct the blade toward themselves, unless,
as is common, the operator moves around in front of the patient, when
the cutting is done away from the operator.
=Technic of the Dissection Method.= One of the oldest, yet one of the
most popular methods of operation is that known as dissection. As
will be understood by the term, this method is a procedure whereby the
growth is excised by the helotomon, as a whole, from the underlying
tissues. This is in contradistinction to the paring or shaving method.
Two of the best known practitioners who use this method of procedure
are E. C. Rice, M.D., of Washington, D. C., and Charles F. Stevens, of
Elmira, N. Y. Dr. E. C. Rice has this to say on the subject:
“The limited knowledge of the chiropodists of earlier years did not
apply to their handling of instruments, which was professionally
scientific to the highest degree. The dissecting method was the method
of operating in the early days.
“In the late fifties a practitioner by the name of Josiah Briggs
taught many young men, among them Elliott W. Johnson, and the writer’s
father, W. E. Rice. A Scotchman also instructed Nehemiah Kenison.
They in turn taught others the dissection method. There will always
be two professional methods of operating on helomata, the shaving
(exfoliating) and the dissecting (excision) methods, and practitioners
should understand both.
“Those who have a light touch, if determined to learn, can become
skillful in the art of dissecting, and, when acquired, their life’s
work will become a daily fascination. The procedure calls for
skill that compares with that employed by the eye, nose and throat
specialists and is appreciated by the most eminent surgeons.
“The word ‘dissect’ implies a separation, and this method permits the
operator to separate the heloma from the normal tissue in one piece
so that classification is made simple. In removing the growth in its
entirety, it is possible to observe the various forms the nuclei take,
and the classification the writer would make is as follows: granular,
grain-like in appearance, sometimes called ‘surface corn’; crescent,
forming a semi-circle about the joint; wedge, having a wedge-shaped
nucleus, commonly found on the plantar surface; cone, from its shape;
thumb tack, also named from its shape; multiple nuclei, resembling
any of the above named and having numerous central points; soft, the
gristly tissue between the toes; elevated, protruding, horn shaped;
circular, because of the form of the nucleus.
“The instruments used in this method of operating are the chisel
(helotomon--Dr. F. Oefele, editor,) and the iris mouse-toothed forceps.
“The original chiropodist’s instrument in this country was a cross
between the surgeon’s scalpel and a chisel. The blade was shaped much
like the human foot and was on a handle such as is used on the standard
razor. From this first instrument of chiropody was evolved the only
distinctive instrument of our profession, the chisel, which has been
successfully used for more than half a century.
“It is distinctly a chiropodist’s instrument, as much as the plane
is the tool of the carpenter. With this chisel the dissecting method
is made possible, for its cutting edge, as its name suggests, is on
the end of the instrument, and permits of the most delicate work. The
chisel should be five and one-half inches long and should have a rough
hexagon handle. The round or oval handles do not permit perfect finger
control. The blade or cutting edge may be oblique, straight or oval, as
the operator desires.
“The technic of the dissecting method of operating is as follows:
“The chisel is held in the right hand and the forceps in the left. Hold
each as you would a correctly held penholder; to support and to steady
the hands, let them rest gently on the fourth and fifth fingers; when
operating between the toes, the supporting fingers rest upon and press
aside the toes so as to give plenty of room for operating.
“The tissues at the periphery of the heloma are separated; with the
forceps grasp the free edge and raise sufficiently to see the line of
demarcation and use enough traction on the forceps to overcome the
pressure of the chisel, not enough, however, to produce the sensation
of pulling.
“When properly performed, the gentle lifting of the tissue prevents the
nerve being pressed upon or pinched between the blade of the instrument
and the underlying bone. The line of demarcation is made by the union
of the light and dark shades of tissue, the normal being the light and
the darker shade belonging to the heloma.
[Illustration: ILLUSTRATING METHOD OF SPREADING TOES APART BY USING
FOURTH FINGER OF EACH HAND, MAKING OPERATION EASY]
“Those who use the oval chisel find they can do more work and have
fewer hemorrhages, and only occasionally do they find it necessary to
use the nucleus dissector, which is required to remove an heloma of
the thumb tack variety, as its shaft may extend to a depth of a fourth
or a third of an inch. In dissecting this type of heloma, when the
head of the same has been separated back to its shaft, the traction on
the forceps is increased, the tissue being gently lifted and turned
back. This tends to present the shaft toward the blade, and as cutting
proceeds the shaft seems to be lifted up and out of the soft tissue
into which it is embedded.
“To beginners, the writer would suggest the oval-shaped chisel and
would advise practising first on the plantar surface.”
C. F. Stevens contributes the following:
“Speaking generally and taking the average heloma as an example, my
method of procedure would be somewhat as follows:
“These growths are hardly ever deep, and are removed by the following
process more easily than to chisel or pare. After the usual antiseptic
precautions as to the operator’s hands, instruments and the patient’s
foot have been taken, the operator grasps a sharp, pointed, slim
instrument.
“Holding this knife with the right hand and with a small forceps in the
left, he grasps the free part of the growth with the forceps, carefully
raising this part to determine if possible how much is free and how
much is attached to the deeper tissues.
[Illustration: PROPER USE OF FINGERS ELIMINATES NECESSITY OF TOE
SPREADERS]
“With a sharp blade he makes a series of slight strokes, cutting but
little at a time, on a line between the growth and the skin (the growth
being darker than the skin), thus separating the excess deposit of
horny cuticle from the skin, following every curve, deep part or point,
until all is separated in the one mass. In this manner he is enabled to
remove all in one piece. Dressings vary, according to the prominence of
the part and the shoe worn.
“Since the writer was taught this method of procedure he has found it
to be much easier to separate such a horny growth from its bed, than to
try to pare it off in bits or shave it as the patient himself tries to
do. Helomata being hard, very naturally resist the cutting of a knife,
and the blade, therefore, when trying to pierce the hard mass, pulls on
the sensitive tissues beneath, thus causing pain. Following the line
between the normal and the abnormal tissues in operating, much softer
integument is encountered; therefore, the cutting is easier and can be
done with practically no pain.
“The cautious, careful operator will seldom invade the healthy tissues
beneath sufficiently to cause capillary hemorrhage. A paring or shaving
process could, of course, first be employed to remove the indurated
callous, then proceed to carefully separate the deep parts as described
in the case of heloma. Simply raising gently with the thumb forceps
and cutting a very little at each stroke with a sharp pointed blade,
following each wave or indentation indicated, as the work progresses,
until each piece or mass is separated and removed, will be found a
preferable procedure. However, we have found it as simple and easy to
dissect the mass as a whole as to operate by paring and then removing
the deeper parts.
“In case of a deep-seated hard corn where the toe is red, inflamed and
very sensitive, the first described method (as in heloma) is usually
best. Often upon reaching the lowermost layers, one finds a quantity
of pus. When this escapes, as it does, the pressure on the inflamed
tissues is lessened, and the patient will allow the operator to proceed
faster.
“With a deep-seated heloma on the sole of the foot, the same method is
followed, no matter how deep or serrated. The operator (after one or
two small cuts) gently raises the edge with the forceps, while with the
same style of blade he cuts down and around the growth, until the whole
piece with its radix is lifted out.
“In connection with this the writer hears some one say, ‘even though
you do remove the growth scientifically and without pain, severe pain
will follow in an attempt to walk.’
“Of course, comfort depends in many instances on the dressing. The
writer is not a great believer in heavy shielding and the method of
dressing he employs is as follows: take a pledget of cotton which, when
rolled, is about as large as the heloma just removed; place thereon a
small amount of sedative in ointment form; place this in the cavity
left by the removal of the growth, then cover all with a goodly sized
piece of adhesive plaster. Instruct the patient to wear this for
twenty-four hours, when he may remove the plaster. By this dressing the
tissues that had been held up by the large heloma, are still held up
by the rolled pledget of cotton, at the same time the cotton gradually
flattens down with the patient’s weight. Thus the tissues are allowed
to resume their normal position slowly and easily.
“When the adhesive plaster is removed, the cotton dressing comes with
it. The tissues adjust themselves in from twelve to twenty hours and
thus an equilibrium is painlessly established.
“Several years ago the writer chanced on to this method of dressing
and since then he has used it and found it to be very efficacious in a
large majority of cases; he has termed it the ‘filling dressing.’
“In operations on heloma molle the same surgical procedure is employed.
It matters not whether the growth be on the side of the toe, or deep
down between the toes on the web. The sharp, fine-pointed, narrow
blade enables one to operate in a closely contracted space, and when
used with short little cuts the blade reaches down, around and under
the growth, thus loosening it completely and leaving its usually deep
seat, clear and free from any parts which might remain, if chiseling or
gouging were employed.”
(The authors of this work all operate with the knife or scalpel and
have found that form of instrument very satisfactory. The beginner
is advised to study and learn both methods so that he may be able to
use both at any time. The fact that there are two methods does not
mean that one is better than the other. There are many successful
practitioners of both classes.)
Some persons have a great amount of dorsi-flexion of the toes, due to
hammer toe or hallux flexus, and they usually develop an heloma on the
distal end of the toe, under the nail. This is treated by cutting away
the nail over the growth, and when the heloma is exposed to view it is
treated in the same way as other helomata dura.
The subsequent dressings for helomata depend upon the state of the
tissues beneath. Care should be exercised in operating so as not to
cut too close to the normal skin, otherwise the parts become extremely
sensitive.
The epidermis is a storehouse for bacteria, and when an heloma is
removed, there is always a possibility that some of these bacteria may
enter the body through some slight and invisible abrasion which does
not necessarily bleed. It is, therefore, necessary to take precautions
against this danger, and this is best done by painting all surfaces
operated upon with a 4% solution of tincture of iodine (this may be
made by diluting the official tincture with an equal amount of grain
alcohol). This should be followed by painting these same surfaces with
icthyolated collodion or nafalan collodion.
If the toe is inflamed it is treated with an agent that has the power
to reduce inflammation. In severe inflammations, a wet dressing
of Burow’s solution may be used to good advantage. The principal
ingredient of this solution is aluminum acetate, which is astringent
in its action, and a wet dressing applied for twenty-four hours
will usually reduce the condition. In milder cases of inflammation,
ointments of ichthyol, 10 or 15%, may be applied. This means of
medication is very desirable whenever the application of a shield is
indicated, because the aperture of the shield is a suitable place for
ointment dressings.
When an heloma is found to be infected, the growth should be removed
and the pus present evacuated. This should be followed by the
application of hydrogen peroxide and the parts should then be irrigated
with bichloride of mercury solution (¹⁄₄₀₀₀). The wound may now be
treated with a wet dressing of Burow’s solution or, in severe cases in
which there is an indication of the presence of cellulitis, bichloride
of mercury solution (¹⁄₅₀₀₀) for twenty-four to forty-eight hours,
should be similarly applied.
Subsequent dressings to stimulate granulation and promote healing may
be applied, balsam of Peru or silver nitrate ointment or colloidal
iodine being very efficacious.
The latest medication for infected areas, either great or small,
and one of the many discoveries in surgical treatment since the
beginning of the present war, is the Dakin solution. The worth of the
application of this solution is based upon the helpful influence of
free chlorine in small quantities, to tissues that have been mutilated
either by injury or infection. Chlorazene tablets, purchasable in all
drug stores, contain the elements desired for this treatment. Liquid
chlorine ampules (J & J) also make an accurate Dakin solution.
[Illustration: INFECTED HELOMA]
If, upon examination, an infection shows that the deeper tissues, such
as the periosteum or the bone, are involved, the patient should be sent
to the surgeon, whose function it is to treat such cases, who will make
incisions into the soft tissues so as to establish free drainage. The
wound thus produced is packed with sterile gauze, and often with the
aid of wet dressings, and nothing more, the wound is allowed to drain
and heal.
The protection of the parts after an heloma has been removed, so as
to insure comfort to the patient, is an all important part of the
treatment of this ailment and a special chapter has been devoted
to this feature of chiropody practice. (See Chapter _Shields and
Shielding_.) There are certain types of helomata dura that are never
relieved of pain, even after operation, unless a well-fitted shield has
been applied.
HELOMA MOLLE
=Definition.= Heloma molle is a soft, white, macerated growth found
between the toes, principally in the web of the fourth interosseous
space and on the lateral sides of the interphalangeal joints of the
toes.
=Symptoms.= The pain accompanying heloma molle varies with the degree
of pressure brought to bear upon the toes. Where the heloma is situated
in the web of the fourth and fifth toes, there is a sensation as if
there were some foreign body, such as a pebble, between the toes, and
as the growth develops the pain becomes gradually worse. The pain of an
heloma molle, in other parts, is similar to the pain of heloma durum,
and usually ceases when the foot is not encased in a shoe.
Upon examination, an heloma molle presents a white soft mass, having
the consistency of rubber. There is no sharp line of demarcation
between the lesion and the healthy skin. This is due to the blanching
of all the tissues that come in contact with the excretions. In some
instances there is a yellow ridge surrounding the neoplasm. The growth
is superficial, due to its anatomic position. There is very little soft
tissue between the epidermis and the lateral sides of the extremities
of the phalanges, and therefore there is no possibility of the growth
becoming deep-seated, as in heloma durum. The radix, or nucleus, when
present, is of a dirty white color.
Helomata mollia found in the web of the fourth and fifth toes, have
well defined nuclei which penetrate into the interosseous space between
the metatarsal bones. These are easily distinguished since, as the
surrounding callous is removed, they appear as a dirty white spot in an
area of healthy pink skin.
=Etiology.= Helomata mollia are caused by shoes, the same as other
types of helomata, but in this case the footgear acts as a secondary
cause. Normally the phalanges are placed so that the base of one bone
is opposite the head of another. When lateral pressure is brought to
bear upon the toes, these bones press upon each other and thus produce
an overgrowth of skin cells.
The sweat glands continue to functionate, but the parts being pressed
together, do not allow the perspiration to evaporate; hence, there is
an accumulation of moisture which acts upon the skin, producing a soft,
white, macerated mass, with a rubber-like texture.
In the case of helomata mollia found in the web of the fourth and fifth
toes, there is an outward rotation of the head of the fourth metatarsal
bone, due to the lateral pressure on this region, causing the bone to
drop and rotate outward; this in turn presses upon the base of the
fifth proximal phalanx.
=Pathology.= The pathology of heloma molle is identical with that
of heloma durum, except that the nucleus is rarely deep-seated. The
epidermis composing heloma molle has no distinct cell formation,
because of the macerated condition of the mass, but occasionally
the nucleus of such a lesion, found in the web of the fourth and
fifth toes, shows some of the original cell formation. Inflammation,
terminating in suppuration, is very often encountered in this
condition. Because of uncleanliness of the parts, bacteria thrive in
this locality and the acidity of the moisture very often produces a
fissure or abrasion in the tissues which may lead to infection and
subsequent suppuration.
=Diagnosis.= The typical heloma molle is a mass of epidermic cells
rarely larger than half the size of a dime. The color is white, with a
dark grey centre, denoting the radix.
Very often an ordinary exfoliation of the epidermis between the toes
may take on the appearance of an heloma molle, but careful examination
will show that there is no overgrowth of epidermis. This exfoliation
is easily loosened with a pair of forceps.
Fissured toe webs, accompanied by exudation and exfoliation of skin,
may be mistaken for heloma molle, and treatment inaugurated for the
latter condition will produce bad results, particularly if chemicals
are used.
There need be no doubt about making a positive diagnosis if the color
and texture of the growth be borne in mind. The finger passed over the
affected surface will give the sensation of increased tissue.
[Illustration: HELOMA MOLLE]
=Prognosis.= The possibilities of the ultimate disappearance of
helomata mollia is good. If the proper shoes are worn and the proper
treatment be installed, the growths will gradually become smaller and
will finally disappear.
The helomata that appear between the toes on the interphalangeal joints
are most easily cured, by simply keeping the adjacent sides of the toes
separated. Those that appear on the outer lateral side of the great toe
do not respond to treatment as readily as the other types, for there
is more soft tissue over this joint and usually the great toe is in a
fixed position and does not easily straighten.
Helomata mollia that appear in the web of the fourth and fifth toes can
also be permanently cured, but it is necessary to raise the head of
the offending metatarsal bone, as well as to separate the toes.
Bearing in mind the etiology of heloma molle, and installing treatment
which will correct or remove these causes, time and conscientious
treatment will ordinarily insure a favorable outcome.
=Treatment.= Treatment of helomata mollia is divided into two classes:
the non-radical surgical and the therapeutic. The latter method is the
most popular, as it is very often impossible to use the knife. The
texture of the skin, and the anatomic position of the growth often make
it impossible to use an instrument with a cutting edge with a view to
obtaining good results.
The _non-radical surgical_ method consists of removing the corn in
much the same way that an heloma durum is removed. The long cutting
edges of knives and chisels are not well adapted for work between the
toes, and for this purpose the “golf stick” and the “soft corn spoon”
have been devised and are used extensively. The “golf stick” is an
instrument which, as its name indicates, resembles the stick used by
the golfer. Its cutting edge is almost at right angles to the handle
and is about three-eighths of an inch long. This makes a very desirable
instrument for removing helomata mollia on the lateral sides of the
interphalangeal joints. The end of the instrument is rounded so as
to allow for the removal of nuclei, if present. The cutting edge of
the “soft corn spoon” extends almost around the entire instrument,
and admits of a circular movement such as is employed in dissecting
helomata dura. This instrument is used for removing soft corns that
appear in the web of the toes, and is very efficient, inasmuch as by
its use the operator is enabled to remove the growth without cutting
into the tissues, as is often done with a knife or a chisel having a
long straight edge.
The _therapeutic_ method of treating heloma molle depends upon the
caustic action of several drugs, among which may be mentioned salicylic
acid, trichloracetic acid and silver nitrate. The two latter are used
only occasionally, as they are powerful caustics, and unless applied
with great caution they may produce harmful results.
Salicylic acid finds great favor among practitioners of podiatry, and
the usual technic is as follows: after asepsis has been practised and
the growth cannot be removed by the use of the knife, an ointment of
salicylic acid, 15%, is applied over the growth, care being taken that
the medication does not come in contact with the surrounding normal
tissues. This is covered with a protective cocoon dressing, or the
ointment may be applied into the aperture of the shield, if one is
used. The dressing is allowed to remain in contact with the part for
from four to seven days, depending upon the thickness of the skin. When
the dressing is removed, the entire mass will be found, as a rule, to
be loosened from the tissues beneath. If all of the growth is not thus
loosed, the treatment is repeated and the patient is instructed to
return in the prescribed length of time.
Shielding plays an important part in the treatment of heloma molle. For
the type that forms on the lateral sides of the interphalangeal joints,
a shield of the oval type with the aperture over the affected part, is
most efficient, while for those that appear in the web of the toes, an
oval shield with a semi-circular opening on the proximal end, which
sets between the toes and protects the growth, is most desirable. In
connection with a shield to protect the growth and separate the toes,
it is necessary to raise the head of the affected metatarsal bone,
which is the cause of this type of heloma molle. For this purpose,
Alfred Ahrens, of New York City, has devised a dressing which he terms
the “duck shield,” because of its resemblance to that animal. This
shield has a dual function. It separates the toes and then passes down
to the plantar surface of the foot over the metatarsal bone, and acts
as a pad to raise the bone. The continuous application of this device
to helomata mollia of this variety will produce good results.
HELOMA VASCULARE
=Definition.= Heloma vasculare, or vascular corn, is an overgrowth of
the epidermis in which enlarged and elongated blood vessels are found.
=Symptoms.= The growths usually appear on the plantar surface of the
foot, but occasionally they may develop in old callouses and helomata
situated on the dorsal surface of the fifth toe. Pain is more severe
than in other forms of helomata, the patient complaining of a burning
sensation when not in a standing position. This form of growth is
similar in appearance to heloma durum, having in addition small dark
red spots scattered throughout it, which bleed upon being cut. These
spots are not blood clots, such as are found in helomata dura as the
result of injury, but are distinct blood vessels. The composition of
the tissues is very dense, particularly when the growth is situated
over the head of a bone, as is ordinarily the case when it appears
on the plantar surface. The color of the entire mass is somewhat
darker than in heloma durum, being grayish, or sometimes brownish, in
appearance.
=Etiology.= As previously stated, helomata of all types are due to
intermittent friction and pressure. The blood vessels that are found
in this particular form are forced into the epidermis owing to lateral
pressure of the shoes, or to the pinching of tight stockings. Why the
blood vessels should be forced up into the epidermis is most peculiar,
but helomata vasculare appear where the normal papillæ are longest,
and this increased length of the vessels tends to force them up into
the dead skin. Athletes, particularly runners and jumpers, are most
commonly afflicted.
=Pathology.= Heloma vasculare consists of an overgrowth of epidermic
cells in which are found the elongated vessels. There is an increase
in epithelial tissue, but there is no increase in the quantity of the
connective tissue and blood vessels, as in verruca. The blood vessels
leave the papillary layer of the derma and enter directly into the
epidermis, without any elevation of the surrounding connective tissue.
On some occasions a nerve ending is found embedded in the callous mass.
This adds considerably to the pain, but is not the true neuro-fibrous
corn described under heloma durum, which has no accompanying blood
vessels. The area surrounding an heloma vasculare is usually inflamed,
but the inflammation rarely terminates in suppuration.
=Diagnosis.= The true heloma vasculare may be easily distinguished from
verruca when the two conditions appear on the dorsal surface or any
surface not subjected to extreme pressure, in that the latter is an
overgrowth of all the layers of the skin, including the derma, and has
a characteristic cauliflower appearance. However, when verrucæ appear
on the plantar surface, they lose their cauliflower appearance and
become flattened; they then resemble heloma vasculare, except that they
are somewhat darker.
The blood vessels in heloma vasculare are not so numerous as in
verruca, but this diagnostic point may not always manifest itself to
the naked eye. A differential diagnosis between these two conditions is
of no great importance, as the treatment is practically identical.
Heloma vasculare may be readily distinguished from heloma durum by
the small red spots found therein which bleed when cut. Very often an
heloma durum has a dark red spot at the base of the mass, due to the
rupture of a small vessel and consequent clotting of the blood. This
dark red spot does not bleed when the knife is passed through it,
denoting the absence of blood vessels.
=Prognosis.= Heloma vasculare will always respond when the treatment is
thorough. There may be a recurrence of heloma durum over the spot where
the original growth was located, but the vascular condition, when once
eradicated, should not return.
=Treatment.= The treatment of heloma vasculare may be divided into
three classes, viz.: surgical, medicinal and mechanical.
The technic of the _surgical_ method is as follows: the part is
cleansed with tincture of green soap, followed by the application of
tincture of iodine, 4%. The instruments having been sterilized, the
part is anesthetized by the hypodermic method and a semi-elliptic
incision is made a little to the outside of one-half the growth. The
flap thus produced is seized with an artery forceps. The forceps are
then raised and the rest of the growth is dissected out with a sharp
knife or with a heavy pointed scissors. When the entire growth has thus
been eradicated, a few layers of gauze should be placed over the part
to produce pressure. A bandage should be applied over all to hold the
dressing in place. This may be removed in three or four days, provided
no inflammation is present, and the subsequent dressing should contain
balsam of Peru or some other stimulant.
The _medicinal_ or _chemical_ treatment of heloma vasculare consists
of the gradual destruction of the growth by means of chemicals, chief
among which are nitric acid, potassium hydroxide and salicylic acid.
If nitric acid is employed, the callous is removed so as to produce a
slight oozing of blood, and a drop of the acid is allowed to fall in
the centre of the mass. This is allowed to remain in contact with the
part for two days, when the eschar produced is removed, and the acid
is again applied. This treatment is continued as long as necessary
to completely destroy the growth; when a slight exudation of pus is
noticed, the application of the acid should cease. The subsequent ulcer
thus produced is treated in the same manner as any other ulcer (see
chapter _Ulcers_).
The salicylic acid method of treating heloma vasculare varies greatly
depending upon the strength of the acid employed. If a weaker
percentage is used, the treatment is practically the same as that with
nitric acid. Several applications are necessary to completely remove
the entire excrescence. The weaker solutions of this drug are the 10
to 15% ointments. The stronger ointments contain from 50 to 60% of
the acid. The treatment with the 60% salicylic acid is preceded by
cleansing the parts and removing the superfluous callous. The acid
is then applied and the part protected. The dressing is allowed to
remain in contact with the part for from ten days to two weeks, and
when removed, the entire mass may be easily scooped out. When the
stronger acid is used, it is often necessary to warn the patient that
if there should be any throbbing pain experienced, he must return for
treatment at once. This pain is due to the rapid action of the drug,
and to a mechanical inflammation which ensues. Examination will usually
reveal a newly formed ulcer, which must be cleansed and treated in the
usual manner. The salicylic ointment method is finding great favor,
particularly on account of the few treatments necessary. Those inclined
to nervousness and imaginary fears, regarding chiropodical or any other
operations, are also usually highly pleased with this non-surgical
method of treatment because the use of the knife is avoided and cure is
not long delayed.
In treating these cases medically, it is well to remember that the
chemicals employed have a destructive action on the healthy tissue
beneath the heloma as well as upon the heloma itself, and caution
should be exercised in applying them. The case should be carefully
watched and at no time should the operator allow the patient to remain
away from the office for a greater length of time than above specified.
It is also well to remember to warn the patient of the dull throbbing
so characteristic of inflammation, which gradually increases as the
pains become worse. These pains are due to a chemic inflammation
produced by the action of the drug upon the normal tissue beneath the
growth, and are always an indication to discontinue treatment, remove
what is left of the destroyed tissue, and direct treatment to the
healing of the parts.
The _mechanical_ treatment of heloma vasculare consists of the removal
of the growth by means of electricity. The fulguration spark and
electrolysis are the two methods employed.
The fulguration spark is a concentrated violet ray, or high frequency
current. The current is concentrated by passing it from the coil
through a narrow glass electrode, at the far end of which is inserted
a small piece of platinum or copper wire. As the current passes
through the tube and the charged wire is brought in apposition to
the excrescence, instead of the usual blue spark that is produced by
the high frequency current in an ordinary vacuum electrode, there is
a yellow spark produced which is quite painful to the body tissues.
This spark has a caustic action, and after penetrating the superficial
layers it enters into the deeper structures and there causes a
destruction of the tissues.
Two, or at the most three, applications of this current, each of
thirty seconds duration, will suffice for helomata vasculare which are
situated on the dorsum of the foot. On the plantar surface, however,
the tissues are more dense and many more treatments are required. It is
on account of this density of the tissues that fulguration or any other
form of electricity for the treatment of plantar growths is inadvisable.
Electrolysis consists of inserting a needle or other sharply pointed
instrument to which the negative pole of a galvanic cell has been
attached, beneath and around the growth. The positive pole is attached
to a spot near where the condition is found, usually the calf of the
leg. As the current is passing through the foot, the water in the
tissues undergoes electrolysis, and after a time, as the hydrogen goes
to the negative pole, bubbles of this gas are noticed around the free
surface of the needles. This is an evidence that the decomposition has
gone on sufficiently and the needle may be withdrawn. If the growth is
a large one, the needle should be re-inserted at right angles to the
original insertion, and the process repeated. If this is done properly,
after two or three days, the entire mass will separate from the
surrounding tissues. The greatest care must be observed in practising
asepsis, as the electrolysis method is not an antiseptic one. The
needle must be thoroughly boiled, and the part cleansed in the same
manner as if a surgical operation were to be performed. This method, as
well as the previous one, is not practical for helomata vasculare that
appear on the plantar surface of the foot.
The carbon dioxide pencil may also be used in the treatment of this
condition. This method, however, is not advised, as the parts become
frozen from the contact and the pain of reaction is severe.
As previously stated, the treatment of heloma vasculare is almost
identical with that of verruca and the reader is advised to consult the
chapter on verruca for further knowledge along this line of treatment.
HELOMA MILIARE
=Definition.= Heloma miliare, or heloma disseminatum, or seed corn,
is a small excrescence usually found in large numbers on the plantar
surface of the foot, around the heel, or over the dorsal and inner
lateral surface of the great toe joint. The growth is about the size of
a millet seed.
=Symptoms.= This form of heloma does not produce the extreme pains
caused by the other types of this growth, and only when they develop in
great numbers do they become annoying. The patient then complains of
an uncomfortable feeling, as if there were a foreign body in the shoe
or stocking. Upon examination, several small helomata are seen, which
appear to be all nuclei.
=Etiology.= Wrinkles produced by wearing loose stockings are a factor
in producing helomata miliare; nails which protrude from the plantar
surface of the shoe are also a fruitful cause of this condition. The
wrinkling of the stockings produces an uneven surface over the length
of the wrinkle and the weave of the material, usually wool, causes
these helomata to develop. The nails found in shoes are usually caused
by imperfect repairing. They do not extend out more than just the
smallest fraction; in fact they protrude just enough to allow the
patient to go along for several days or weeks without noticing that
something is wrong.
=Pathology.= Hypertrophy of the epidermis takes place at the nucleus
only, but the area immediately surrounding the heloma miliare feels
hard and congested to the touch. Hypertrophy of the papillæ occurs, but
only a small number are involved. There is no disturbance in the skin
between the individual growths, each of the neoplasms having a distinct
etiologic factor in its production.
=Diagnosis.= The heloma miliare is characteristic and cannot be
mistaken for any other condition. As stated, the growth is rarely
larger than a millet seed and appears to be all nucleus. There is an
area of normal skin between these helomata, when they occur in numbers.
=Prognosis.= Careful operating and intelligent after-care will produce
a cure in from four to five treatments. There are cases on record that
have entirely disappeared after one treatment, but these are rare. The
footgear, both shoes and stockings, should be examined and if found
faulty should be corrected. This aids in a rapid cure and will, as
well, prove a preventive.
=Treatment.= The removal of these helomata may be accomplished with the
knife, but the ordinary scalpel is useless. It is necessary to have a
very finely pointed small knife, and the procedure is the same as that
followed in the treatment of the nucleus of heloma durum, except that
more care must be practised, because of the smallness of the growth.
The helomata miliare occur in groups containing as many as twenty or
even thirty distinct minute growths, and it is necessary to take as
much care with each one of them as with the first one removed. This is
trying both to the patient and to the operator, but as it is essential
to the successful cure to have the growths removed individually and
carefully, patience is necessary. The after dressings may consist of
ichthyol ointment, 15%, applied on a piece of lint, or balsam of Peru
painted on after the helomata have been removed, and covered by a lint
or cocoon dressing. Some practitioners apply tincture of iodine to the
part without further dressing.
The therapeutic method of treatment consists of applying salicylic
acid plaster, cut so as to fit over the affected area, and allowing
this to remain in contact with the part for several days. This softens
the tissues, so that the small growths may be easily removed, but
care must be taken, as the acid will destroy the healthy tissue
between the helomata unless each growth is isolated in treatment.
The disintegrating process must not be allowed to continue to the
extent that it does in the treatment of heloma molle or in the other
conditions in which salicylic acid is employed. It is then often
necessary to use the knife to remove the remaining tissue.
Recurrence is the rule in helomata miliare, but after persistent
treatment the condition usually disappears. It must be borne in mind,
however, that the footgear of the patient must be carefully examined
and necessary corrections made. This, in itself, without the thorough
treatment prescribed above, will often result in a cure of the most
annoying cases of heloma miliare.
CHAPTER XI
CALLOSITAS
=Derivation.= The word callositas is derived from the Latin “callus,”
meaning horn.
=Synonyms.= Callus, callosity, callous, tyloma, tylosis.
=Definition.= Callositas, or callouses, are a thickening of the
epidermis, usually found on the plantar surface of the foot. They
also occur on the dorsum of the toes, and are found on the hands of
mechanics who continuously use hand tools involving pressure on the
parts. Coachmen develop callouses between their fingers on account
of the manner in which they hold the reins while driving. In rare
instances, women have been known to have callouses on their hips, due
to the pressure of the steel in their corsets, and cavalry men who sit
in the saddle for long periods develop callous on the parts exposed to
irritation.
=Symptoms.= Callosities are composed of variously sized areas of
yellowish or grayish, horny excrescences of epidermic cells. They
are hard, dry and horn-like, thicker in the centre of the growth and
gradually becoming thinner at the periphery. There is no sharp line
of demarcation between a callous and the surrounding skin, such as is
found in helomata, but the thickened cuticle gradually blends with the
surrounding skin.
=Etiology.= A callosity is the result of an irritation of some form
and is nature’s way of protecting the delicate structures beneath the
skin from the direct pressure or friction to the parts. The outer
layers of the skin become thickened and act as a buffer, which absorbs
shock and prevents inflammation and tissue destruction. When found on
the soles of the feet, callouses are due to standing or walking in
improper footgear. The ball of the great toe is a very common site for
callosities; also the region over the heads of the metatarsal bones,
due to high heels which force one to walk directly on these parts
without equal weight distribution, is subject to them.
Callosities may occur as the result of chronic skin lesions such as
eczema, psoriasis, lichen planus and ichthyosis and after the prolonged
use of arsenic.
Callosities occurring on the dorsum of the toes are caused by the
pressure of the skin against the top of the shoe. The parts beneath
the callous at this point usually show the presence of bursitis, which
causes a swelling and subsequent pressure on the skin.
=Pathology.= The changes that take place in the formation of
callosities are the same as those which arise in heloma, except that
the deeper layers of the epidermis and the true skin are not affected
unless accidentally infected or injured.
There is no inflammation present except in cases of infection or
injury. The upper layers of the epidermis are the only ones involved,
and the condition is really a physiologic rather than a pathologic one.
It is more of a protection than a true hypertrophy. The overgrowth may
continue to a greater extent, and then even helomata may develop.
=Diagnosis.= The callosity is yellow to grey in color and is composed
of a horn-like mass of epidermic cells. It is easily distinguished
from an heloma in that there is no nucleus present, and the part is
not severely painful on pressure. It may be mistaken for some of the
chronic skin lesions, previously mentioned, but the skin eruption
presents a scale or crust which readily peels off, en masse, leaving
the bare rete Malpighii exposed. The callosity comes off in layers and,
as the deeper structures are reached, a healthy pink color is noticed.
=Prognosis.= A change in occupation or a change of footgear often
results in the disappearance of this condition. Unless the direct
cause is removed there will be a recurrence, which is an indication
that the part again needs protection and care. Persons who have been
accustomed to standing or walking for protracted periods of time,
such as policemen, floor walkers, etc., soon lose the callouses they
developed, after they change their occupation.
=Treatment.= If the growth becomes thick enough to cause discomfort, it
may be easily removed, by softening it and then scraping or paring it.
The foot may be soaked in an alkaline foot bath composed of one-half
ounce of sodium bicarbonate to two quarts of hot water, or painting the
part with a dilute solution of potassium hydroxide (caustic potash),
5%, several applications every few minutes, the softened area being
scraped away after each application. Salicylic acid plaster, 25%,
placed over the affected area and allowed to remain in contact for
forty-eight hours, will usually loosen the redundant mass. If the
callosity appears over the head of the first or fourth metatarsal bone,
mechanical adjustment should be made, whereby the pressure in walking
is thrown upon the entire surface of the anterior part of the foot.
Pads of felt or buckskin, properly skived and fitted, will accomplish
this result.
Care must be taken that too much of the induration is not removed when
treating this condition. As previously stated, the calloused mass acts
as a protective for the parts beneath and is nature’s way of preventing
serious trouble, and if too much is removed, pain will be experienced
when the foot is used in walking. If this should occur, the part should
be painted with tincture of iodine, 4%, and covered with moleskin or
adhesive plaster. If an abrasion has been made, it is important to
dress the part with an antiseptic, followed by a stimulating agent, all
of this to be covered with a cocoon dressing or a lint shield.
Where callosities are caused by a displacement of the anterior
metatarsal arch, or by any of its bony constituents, the bony lesion
must be corrected before the callosities will respond to treatment.
CHAPTER XII
VERRUCA
Verruca, sometimes called papilloma, is an innocent or benign tumor,
containing many blood vessels, and is an overgrowth of all the layers
of the skin including the derma. It is usually found on the hands and
feet, but other parts of the body may become affected, particularly the
face.
Verruca, like other innocent or benign tumors, does not penetrate into
the surrounding tissues, and is encapsulated. Those found on the foot
are divided into two classes, (1) the verruca arida, or dry wart, and
(2) the verruca humida, or moist wart.
The common wart found on the hands and fingers, is a form of verruca
arida and is called verruca vulgaris. There are many other names used
to designate verruca, but these are only indicative of the location,
shape or consistency of the growth, which, as stated, is either of the
arida or humida variety, and additional nomenclature tends to confuse
the student. Among these are the verruca plantaris, verruca calcis,
verruca metatarsalis, verruca lobosa, verruca fibrosa, verruca digita,
etc.
=Synonyms.= Papilloma, Wart. Fr. verrue.
=Derivation.= Verruca is derived from the Latin, meaning wart.
=Etiology.= There is no general agreement among pathologists as to the
cause of verruca. The older theory held that verruca was due to want
of normal power within the integument. Some claim it to be due to a
microorganism, while others assert that it is caused by irritation or
injury. The latter reason seems to be the most reasonable one, since
the patients who have been questioned thoroughly, all seem to give a
history of trauma or of some chronic irritation.
Some verrucæ seem to occur spontaneously and it becomes difficult to
draw a line between those that grow in this manner and those that
develop from an injury or from a chronic irritation. Predisposition
seems to play an important part in the etiology of verruca, but
irritation is surely a factor in most if not in all cases. This
predisposition may lie in the peculiar structure of the tissues, which
is of course, difficult to determine.
[Illustration: VERRUCA HUMIDA OR CALCIS]
The fall and early winter, seem to be the time at which most cases
appear, and their history seems to indicate that either there has
been an injury or an irritation, such for instance as is produced in
walking barefooted on the beaches, which occurred during the previous
summer. Those who walk distances over rough roads in the mountains, or
who wear thin-soled shoes and sneakers or hob-nail shoes, or who have
stepped on a sharp stone, are most likely to develop verrucæ.
Verruca is found on the hands of young persons, and on the feet of
adults, but only occasionally is this growth seen on the feet of
children. This is undoubtedly due to the fact that young people use
the hands in playing to a great extent, and in that way are subjected
to irritation, whereas the shoes of adults, and the rigidity of the
tissues in older persons cause the development of verrucæ on the feet.
Observation has shown that those of athletic bent, such as golfers,
tennis players, base ball players, etc., are affected to a greater
extent than those who follow a sedentary occupation.
=Pathology.= Verrucæ of all types are overgrowths of the derma covered
with a somewhat hypertrophied epidermis, which is more granular and
rougher than the normal skin. The wart may be only a simple, smooth,
hemi-spherical elevation, or it may have a rough cauliflower-like
appearance, sessile or pedunculated. These latter may be dry or moist
and may be elevated above the level of the skin or flattened to the
level of the normal surrounding tissue. The size varies from minute
points to growths as large as a nut. They are somewhat pigmented and
bleed easily.
Verruca may occur singly, as it usually does on the foot, or it
may occur in groups, and there may be several such groups in
widely scattered parts of the body. The most common sites are the
hands, feet, neck, back and face. Warts also occur on the mucous
membrane, particularly in the bladder, larynx, nasal chamber and the
gastro-intestinal tract, in which locations they are commonly termed
papilloma.
The structural essentials of verrucæ are the centre or ground
work containing blood vessels and an epithelial covering. In the
skin, the growth resembles the normal papillæ, all of these latter
however, being greatly enlarged. There is hypertrophy of all the
connective tissue cells, and in the growths that have a cauliflower
appearance, a vertical section shows a branching arrangement. Each of
the branches has a connective tissue frame work with an epithelial
covering. The epithelium is of the striated-squamous type and shows
a decided tendency to hornification. Distinct concentric whorls of
horny epithelium, such as are seen in epithelioma of the skin, may be
found in verruca. The amount of connective tissue ground work varies,
in some cases being excessive, while in others the growth appears to
consist entirely of proliferated epithelium. In these latter cases the
resemblance to epithelioma is rather marked, but a distinction can be
made by observing that the tumor grows outward while the malignant
tumor grows into the deeper structures and there is always some
connective tissue stroma present. This is important for the podiatrist
to remember as it may often be necessary to distinguish between the
benign and the malignant tumors of this type.
VARIETIES OF VERRUCA
Verrucæ of the hands and feet vary to a greater or lesser extent
depending upon the location of the lesion. The shape of the growth
differs with the amount of pressure brought to bear upon it, those of
the hands being better defined than those of the feet.
=The Verruca Vulgaris=, or common wart of the hand, is found on the
palmar and dorsal surfaces, more usually in children than in adults.
They often appear in large numbers, and very often the forearms and
elbows are affected. The lesion is an elevated, rounded, conical
hypertrophy having an uneven top and resembling a cauliflower. The
growth develops slowly, and in its beginning has the same color as the
surrounding skin. Later in its formation it becomes darker and takes on
a cracked, rough cauliflower-like shape. There is no pain manifested,
but the growth bleeds easily upon being injured, due to its great
vascularity.
=The Verruca Arida=, or dry wart of the foot, usually appears upon the
plantar surface, over the metatarsals and on the ends of the toes. It
is in reality a modification of the verruca vulgaris, which has been
subjected to pressure. There is a distinct callous formation covering
and surrounding the growth, and the entire mass has a flattened shape.
At the ends of the toes on the dorsal surfaces and along the nail
grooves, verrucæ which have a slight elevation often appear and are of
the arida type.
=The Verruca Humida=, or moist wart, is found on the foot, usually on
the heel and between the toes. It has a spongy, soft appearance, with a
sharp line of demarcation separating it from the surrounding tissues;
the centre of the growth is white and has a crater-like shape. It is
sometimes covered by a layer of callous, which is spongy and blanched,
much the same as that of an heloma molle. The sudoriferous excretions
in those suffering with hyperidrosis or bromidrosis are the cause of
the color and texture of these lesions.
=Diagnosis.= Verruca is an overgrowth of all the layers of the skin,
and when it appears on places where it is not subjected to pressure of
any great magnitude, its diagnosis is a simple matter. When, however,
it appears on the foot, its true character is lost, and it may be
confused with other lesions, notably epithelioma, syphilitic lesions
and heloma vasculare.
The malignant epithelioma is occasionally seen as a warty growth, but
it generally has adherent scabs, ulcerates superficially, and has a
disagreeable odor. The surrounding tissues are infiltrated and severe
and persistent pain is common. Innocent tumors of this type, after a
long period, may become malignant; increase in the size of the growth,
implication of neighboring glands, infiltration of adjacent tissues,
plus the other symptoms of epithelioma, should be sufficient to arouse
suspicion as they are indicative of the more serious developments.
Some lesions of syphilis taking on a papillary character, may be
mistaken for verruca, but other indications of a specific condition
are usually present so that when confusion as to diagnosis arises,
the lesion may be readily distinguished if it be a luetic one. The
smaller tertiary ulcers of syphilis that appear on the plantar surface
of the foot often have cracked, uneven overgrowths around and on them,
which upon superficial examination may be mistaken for verruca, but a
negative Wassermann test (see Miscellaneous Foot Lesions--_Syphilis_)
will make it possible for the practitioner to eliminate syphilis as a
factor.
Venereal warts occur on the genitals only and need not be considered in
this chapter.
Verruca and heloma vasculare are often confused, but inasmuch as the
treatment is identical in both these lesions, an error in diagnosis
is of no particular consequence. In heloma vasculare the affected
papillæ, which are found in the hornified skin, are few in number and
are confined to a limited area, whereas in verruca all the papillæ are
affected and the entire growth is vascular.
[Illustration: EPITHELIOMA]
=Prognosis.= Some verrucæ disappear spontaneously, but those appearing
upon the foot are persistent and painful, and require regular treatment
to effect a cure. The growth will get well with proper attention
and only when it changes its nature and becomes malignant, is the
prognosis unfavorable.
=Treatment.= The treatment of verruca is more varied than the treatment
of any other chiropodical lesion, and the practitioners using these
different methods all seem to favor the one particular form with which
they have had the most experience and the best results.
Treatment is generally effective, the percentage of failures being very
small, notwithstanding the statement of those who expect immediate
results, and not receiving them, claim failure on the part of the
practitioner.
The various treatments are as follows:
[Illustration: MULTIPLE VERRUCA]
Potential Cautery--including the following chemicals: Nitric Acid,
Acetic Acid, Monochloracetic Acid, Trichloracetic Acid, Salicylic Acid,
Silver Nitrate, Potassium Hydroxide, Sodium Hydroxide and Pyrogallic
Acid.
Excision.
Fulguration.
Electrolysis.
Direct Cautery.
Carbon Dioxide Pencil.
=Potential Cautery.= The treatment of verruca by the use of chemical
agents which destroy the tissues to which they are applied, is
unquestionably the most popular method of treating this lesion and is
practised to a great extent by modern podiatrists. The tissues are
destroyed in one of two ways, depending upon the chemical selected. The
acid caustics destroy the tissues by oxidizing them, and the alkali
caustics destroy the tissues by dehydrating them. Therefore the kind
of tumor with which one has to deal is a factor in determining which
caustic is best suited for rapid and certain cure. A verruca which is
hard and dry will be easily destroyed by oxidation, whereas a verruca
that is soft and moist will be easiest of removal by dehydration.
The selection of a particular chemical for removing a certain type of
growth, is more or less a matter of individual choice on the part of
the operator, as any one of the recognized remedies will suffice if the
technic of its application be properly followed. A podiatrist who uses
nitric acid for verruca arida, may just as well use trichloracetic acid
and obtain equally good results.
Inasmuch as there are so many agents which one can use successfully,
the authors have asked several well known practitioners of podiatry to
state their technic in the treatment of verruca, and later on in this
chapter their views will be found quoted verbatim.
The method of procedure for the treatment of verruca by the use of acid
caustics generally is as follows:
The field of operation is rendered aseptic by means of a solution of
bichloride of mercury (¹⁄₂₀₀₀) or a solution of alcohol, 60%. A sharp
knife or chisel is employed to remove the callous that usually covers
the growth. As soon as bleeding is observed, which is an indication
that some of the capillaries of the tumor have been cut, a styptic,
such as Monsel’s solution or powdered alum, is applied and readily
controls the hemorrhage. The part is then thoroughly dried with sterile
gauze or cotton, and the caustic selected is applied to the part. If
an acid is used, a single drop is usually employed at each treatment.
The patient, as a result, will complain of a burning sensation in the
growth which persists from a few minutes to an hour, depending upon the
amount of the acid absorbed. If the growth is dense, the absorption is
lessened and more frequent treatments become necessary.
A properly fitted and skived shield of felt is then applied, with a
hole large enough to prevent pressure over the affected area. No other
medicament is required, nor is it necessary to cover the verruca. The
acid forms an eschar which seals the lesion and prevents bacterial
infection. The second treatment should take place forty-eight hours
after the first, and the same procedure should be practised, including
the asepsis. The treatments are continued every other day, daily, if
possible, until the entire growth has been destroyed.
Unless great care is exercised, as the destruction of the growth
continues and its size decreases, the acid coming in contact with the
underlying healthy tissues creates pain of a throbbing character and
later on pus is likely to form under the eschar. Some practitioners
believe that both the pain and the pus are necessary precursors of the
healing process, but neither is essential. They are both the usual
concomitants of the later stages of this treatment merely because, as
stated, it has been impossible to exercise the strict care desired.
When the growth has been destroyed, the eschar is entirely removed and
if pus is present it is drained. Hydrogen peroxide is a most efficient
agent for this purpose. The lesion is now treated much the same as any
other ulceration, that is to say, by stimulants, balsam of Peru or
ichthyol being the mediums usually preferred. The balsam of Peru used
for this purpose should be diluted with an equal quantity of castor
oil; the best method of applying ichthyol is in ointment form (25%)
with vaseline as a base.
The treatment of verruca by means of the alkali caustics is much the
same as with the acid caustics, except that the cauterization by the
latter method may continue so as to destroy the entire growth at one
treatment. This of course would prove even more painful than if done
intermittently, therefore it is far better to treat the patient at
several different times than to attempt anything quite so radical. The
parts must be protected during the treatment and the subsequent ulcer
invariably produced by this method, is treated the same as the ulcer
frequently resulting from acid applications and previously described.
_Nitric acid_ is extensively used in this condition in the pure state.
The treatment of the eschar produced varies.
S. Rutherford Levy, of San Francisco, California, uses the nitric acid
pure, and reports very favorable results. He removes the eschar after
each treatment.
Alfred C. Moran, of Pawtucket, R. I., also favors nitric acid, but
advises that the eschar be allowed to remain on the part until healing
takes place or until signs of suppuration manifest themselves. He
punctures the surface of the growth with a sharp instrument to assist
the diffusion of the acid.
Albert E. Smallwood, a well known and busy practitioner of podiatry, of
Pittsburgh, Pa., reports good results with the use of trichloracetic
acid (Merck) and his modus operandi follows:
“_Trichloracetic acid_ is a safe caustic and should be used full
strength. A tooth pick is wrapped with a small piece of cotton and
the latter is saturated with the acid. (The crystals of the acid are
permitted to stand exposed to the air for a few minutes when they will
deliquesce.) Apply the cotton thus prepared directly over the verruca,
allowing it (the cotton) to remain in situ; then cover the growth and
the cotton with a thin felt shield and fasten it with adhesive plaster.
To prevent the acid from coming in contact with the normal tissues,
the latter should be protected with oil or vaseline. Have the patient
return in two days for a second treatment, and if the pains were only
of short duration, the same procedure is repeated. The white eschar
produced is removed, care being taken that bleeding is avoided. It is
better to remove only a little of the eschar, as this saves suffering
in the interim of treatments.
“Treatment is continued every other day until the entire growth is
eradicated, which is usually indicated by the presence of pus. The
subsequent treatment is that for ulcerations in general.”
F. S. Sargent, of Providence, R. I., prefers _silver nitrate_ to any
other of the potential caustics. He uses the pulverized salt, applied
directly to the verruca, protecting the surrounding tissue with
adhesive plaster and using felt shields during the treatment. When the
part has suppurated he cleanses the wound, dusts with some antiseptic
powder such as aristol, and to stimulate granulations he applies balsam
of Peru, 50%, in castor oil.
One of the best known practitioners on the pacific coast, Helen C.
Sexton, has a very interesting technic for the destruction of verrucæ,
which is as follows:
“Place a small wad of cotton soaked with a 5% solution of _potassium
hydroxide_ over the growth and apply the surface electrode of the high
frequency current for five minutes, or until it is uncomfortable to
the patient. Then dissect out as much of the dead tissue as possible
and if bleeding should occur, do not attempt to check it for a few
minutes. The hemorrhage is then easily controlled by digital pressure.
A piece of moleskin, about the size of a fifty cent piece, with a hole
in its centre, the exact size of the verruca, is next applied, and in
the aperture a sixty per cent. salicylic acid ointment is placed. The
ointment is covered with fish skin and the entire dressing protected
with a well skived and properly adjusted felt shield. The patient is
instructed to return in one week unless pains develop, in which case he
should return immediately. The treatment is continued every week until
the growth is destroyed, and after the skin surface is again normal,
the patient is instructed to wear a protective, such as a piece of
moleskin, for at least one week. If a case does not respond to this
treatment in a period of three weeks, electrolysis is resorted to.”
James Parker Buntin, of Boston, Mass., calls the following his
“antiquated” treatment, but says he has had very good results with it
and with very little, if any discomfort to the patient:
“Take a small piece of caustic potash (_potassium hydroxide_) and
allow it to stand in the open air until it slacks. Then thicken it to
a paste with pulverized gum arabic, which will prevent it spreading to
the surrounding tissues when applied. Carefully remove the superficial
layers of the verruca and apply the paste and let it remain for ten
minutes. Soak the part in sharp vinegar or sweet oil, either of which
will neutralize the action of the caustic potash. This treatment is
continued every other day until the entire growth is removed.”
Oscar Klotzbach, of Cleveland, Ohio, is using _methylene blue_ for the
treatment of verruca, applying the drug (once a week), and protecting
the part with sterile dressings. This is a painless method.
Bertha DeWolfe, of Denver, Colo., is using _ethylate of soda_ for
verruca and reports gratifying results. The drug is dampened with
a drop of absolute alcohol and placed in the centre of a piece of
adhesive plaster, the size of a twenty-five cent piece, and then
applied so that the sodium ethylate comes in direct contact with the
warty growth. The treatment is repeated daily, at first, and then every
other day, until a cure is affected. The pain is slight, being limited
to one or two days of slight discomfort. If the ethylate of soda is
employed for verrucæ of the dorsum of the foot or of the fingers, it
should be diluted, varying from 15% to a saturated solution. The full
strength of the drug should be used on the plantar surface of the foot
only.
Anna Moyde Savage, of Syracuse, N. Y., who has had experience with many
treatments for verruca, has been using and recommends _pyrogallol_ for
this lesion. Her statement follows:
“Pyrogallol is a white, lustrous, bitter crystalline substance soluble
in water, alcohol and ether. It is used extensively in diseases of
the skin, and in all the cases of verruca in which it was used, a 30%
ointment in a vaseline base proved sufficiently strong to remove the
growth. Most of the cases respond to one treatment, and no case has
ever required more than five treatments to effect a cure.
“The treatments are given at intervals of from five to seven days, and
at no time is it necessary for the patients to remain in bed or refrain
from their usual occupations. A fairly thick pad of felt is applied
with an opening large enough to protect the verruca. In this opening
the 30% ointment of pyrogallic acid is applied, a cotton or gauze
dressing being placed over it, and then the entire dressing is securely
fastened with adhesive plaster. There is no pain or discomfort during
the treatment, and only when the pyrogallol has destroyed the tumor and
penetrates into the healthy tissues, is a drawing pain noticed. This
is mild and lasts but one day, and when the final dressing is removed,
the verruca is eradicated. The subsequent ulceration may be treated
with any stimulant, after aseptic precautions have been observed, some
iodine preparation for example. The pad should be worn until the entire
lesion is healed. No case so far treated with this method has shown any
signs of recurrence.”
_Salicylic Acid_ is used to a great extent for the destruction of
verrucæ, and is admirably adapted for this purpose, inasmuch as it is
painless and does not require frequent changes of dressings. A piece of
adhesive plaster is fitted to the part with a hole cut in it exposing
the verruca. A piece of felt of the required thickness is then applied
to the foot, which acts as a shield. In the holed-out portion of the
felt, a 60% salicylic acid ointment is applied directly over the
verruca. The adhesive plaster first applied prevents the acid spreading
to the surrounding normal structures. The entire dressing is protected
with adhesive plaster and the patient is instructed to return in a week
or ten days. By this time the therapeutic action of the acid will have
manifested itself, and a suppurative process will be noted at the base
of the growth. The patient complains of throbbing in the part and when
the dressing is removed, the part cleansed and a sharp knife inserted
into the growth, oozing of pus will occur. The entire mass can be then
removed, whereupon the abscess cavity should be thoroughly cleaned.
This can be done by means of peroxide of hydrogen. The pyogenic
membrane can be destroyed by the use of pure phenol followed by
alcohol, after which a stimulant, such as balsam of Peru or ichthyol,
should be applied. These latter dressings should be changed every other
day until the wound is healed. This method is particularly adaptable
for verrucæ around the nails.
=Excision.= The removal of verruca by surgical means is a very simple
procedure and, if properly done, should result in an absolute cure in
every case in which it is employed.
The part to be operated upon is rendered sterile by thoroughly
cleansing with soap and water, and subsequently painting it with
tincture of iodine. The instruments are boiled for at least fifteen
minutes in water containing a little sodium carbonate and the hands of
the operator are thoroughly cleaned and dipped in alcohol.
Local anesthesia is induced by the hypodermatic injection of any
approved anesthetic, preferably novocaine, 1%, and when the tissues
around and beneath the verruca are thoroughly anesthetized, the
operator makes a semi-elliptical incision a little outside of and
beneath the growth. The flap thus produced is grasped with an artery
forceps and raised. This affords room to dissect out the growth with a
scalpel or with a pair of heavy, pointed scissors.
The wound produced by the removal of the verruca should now be packed
with sterile gauze and a bandage applied to prevent infection. If
the gap is a large one it may be closed by taking one or two sutures
(interrupted) and drawing the edges of the wound together in this
manner.
To afford relief from the reaction of the anesthetic, and as a
precautionary measure against infection, a wet dressing of bichloride
of mercury (¹⁄₅₀₀₀) should be applied for from twenty-four to
forty-eight hours immediately following the operation. This, however,
is unnecessary if asepsis has been practised throughout the operation.
If no complications arise, the dressing should be left undisturbed
for four or five days, when the bandage can be softened and removed.
(Tearing a dry bandage from a granulating wound will destroy some of
the newly formed granulations). If sutures have been used, they should
now be removed, and a mild stimulant such as balsam of Peru, 50%, or
ichthyol, 10%, should be applied to stimulate further granulation.
Dressings should be changed every other day until the area is
completely healed, a process requiring from one to two weeks. With
proper shielding, the patient should be able to walk comfortably after
the first dressing has been removed.
=Fulguration.= The use of electricity in the treatment of disease has
greatly increased in recent years. This is particularly true of the
high frequency current, examples of which are the so-called violet ray
and the X-ray. This form of electricity is quite different from the
usual form encountered when using the faradic or galvanic currents,
and although its voltage is expressed in the thousands, it is quite
harmless when one knows just how to use it.
For the purposes of the podiatrist, a small coil generator with one
or two electrodes, will usually suffice. The fulguration electrode is
a glass rod through the centre of which passes a piece of fine copper
or platinum wire, terminating a little beyond the end of the tube.
This free end of the wire is protected by a small glass cup which fits
over the end of the tube. The tube itself is a vacuum. The rear of the
electrode is set in a brass cup, which fits into the handle of the
apparatus and makes direct contact with the wire conducting the current
from the generator.
For the destruction of verruca the part is cleansed with alcohol, and
the electrode is placed directly over and in close contact with the
growth. A small amount of current is then passed through the apparatus,
and a yellow spark will be noticed leaving the free end of the wire and
entering the verruca. If this is painful to the patient, the current
must be reduced. When the entire area has turned white, the current is
turned off. This takes from 20 to 40 seconds, depending upon the size
of the tumor.
The part should be dressed with a well skived shield, to afford
protection, and should then be covered with dry, sterile gauze. This
dressing is left unmolested for a few days. The growth during this time
dries up completely and when the dressing is removed the growth can
easily be separated. If all of the neoplasm has not been destroyed,
another application of the high frequency current should be made over
the remaining portion. When the entire growth has been thus removed,
the tissues are protected with a piece of moleskin for one or two weeks.
Rudolph Mertin, of Boston, Mass., has used the high frequency current
extensively in the treatment of verruca and he says that two or three
applications of from twenty to thirty seconds duration usually suffice
to effect an absolute cure for even a large sized growth of this
variety. He advises that, for nervous patients, the current be reduced
and if necessary the treatment be extended to six or even ten different
applications. This eliminates fright and nervousness.
=Electrolysis.= The use of the galvanic current in the treatment of
verruca is finding great favor among podiatrists, and is especially
adapted to verruca vulgaris of the hands. The current may be generated
in a few small wet or dry cells, and by passing it through a rheostat
with a milliamperemeter attached, it can easily be regulated and
controlled. There are many such machines on the market today, any one
of which will answer the purposes of the practitioner. Ordinary direct
lighting current, if properly reduced, is admirable.
James R. Bennie, of Philadelphia, Pa., who uses this method of
treating verruca exclusively, has developed a technic that is fully
described in the following:
“Eight years ago I began treating verruca with electricity and such
was the success that invariably followed the use of this agent, that I
quickly abandoned all other methods of treatment. I use the galvanic
current, and the growth is destroyed by electrolysis. This is the
quickest, the surest and the least painful method of treatment and is
equally successful in treating helomata vasculare and moles.
“Electrolysis is accomplished by the use of the negative or active
pole. Through the action of the negative current, caustic alkalies
are formed. The action of these alkalies, in conjunction with the
current itself, causes the growths to liquify and disintegrate. Any
galvanic current which will give from two to ten milliamperes during
the treatment, may be used. An essential point to remember is that the
negative pole is the operating pole whenever tissue is to be liquified
and disintegrated. The positive pole contracts and hardens the tissues.
“The procedure in the treatment of growths by electrolysis is simple,
but the greatest care should be observed in carrying out all antiseptic
precautions. Remove all calloused tissue on or about the growth.
Saturate the positive pole, which should be a copper plate covered with
felt, with an aqueous solution of common salt, then place the pole
on the skin as near the seat of operation as possible. The negative
pole should be a platinum needle or needles, as the case may demand. I
have used as many as twelve needles at one time. The needles should be
sharp, and platinum is the best metal for this work.
“With the field of operation properly prepared, transfix the growth
through its base with the platinum needle, taking care not to penetrate
too deeply into the true skin about the growth. The current is then
turned on and applied in the strength of from one to five milliamperes.
The application is continued until the verruca assumes a pearly hue.
A frothy substance will form in and about the needles; this is
hydrogen gas mixed with a serous exudate and is positive evidence that
disintegration is completed. If the growth is exceptionally large and
painful, local anesthesia may be induced by hypodermatic injection.
“The time required for each treatment varies with the character of the
verruca. The more vascular the verruca, the quicker its disintegration.
When the current is turned off and the needle removed, the part should
be antiseptically dressed, and should be protected with a shield of
felt or buckskin, properly fitted and fastened. At the expiration of
one week the patient is requested to return for further treatment, when
the dressing should be removed and the eschar cut away. If the verruca
is not completely destroyed, the treatment is repeated.
“The appearance of the part after the verruca has been completely
destroyed is not always the same; in some cases coagulation occurs;
again there may be present a small quantity of purulent fluid. When
the products of the destruction of the growth are removed, a healthy
granulating ulcer remains, which yields readily to antiseptic treatment.
“When a large number of verruca are present, try to determine which is
the original growth and treat it first. With the destruction of this
lesion, the others will frequently disappear without further treatment,
thus enabling the podiatrist to accomplish a brilliant result which
will greatly impress the patient. I have frequently observed this
singular result of the galvanic current and believe it to occur from
the fact that the verruca develop within a definite nerve area, and
that the current affects the enervation of this area and thus brings to
completion the cure.”
=Direct Cautery.= The destruction of verrucæ by means of heat is
practised to a greater or lesser extent by a few practitioners of
podiatry, but on the whole, other methods which are available are
superior to it. Any implement which can be heated sufficiently hot,
so that when applied it will burn the growth, may be used in this
treatment. A small piece of carbon, pointed at one end, and small
enough to be easily handled with the thumb forceps, is used by some
practitioners. The pointed end is placed in an alcohol or other flame
until the carbon is glowing. It is then applied directly to the
verruca, and allowed to remain there until the pain becomes unbearable.
One or two seconds should be the limit of each application. The carbon
is again heated, and the application is repeated.
For the convenience of the practitioner, an electric apparatus has
been devised, which, with the aid of a platinum electrode, affords
an opportunity to generate sufficient heat for this form of cautery.
The platinum electrode is attached by two wires to the coil, and
when the contact is made the fine metal end soon becomes red hot.
The temperature is easily controlled by a little switch on the side
of the handle of the electrode. The platinum point is brought in
direct contact with the part to be destroyed, and after several short
applications, this is easily accomplished.
This method has several disadvantages, because the pain during the
operation is intense, and the smell of the burning tissue is very
disagreeable to both the patient and the operator. Further, the sight
of the red hot metal being applied to the foot usually frightens the
patient, so that, all in all, other methods are desirable.
=Carbon Dioxide Pencil.= For the treatment of verruca by this method,
the apparatus necessary is a small tank of liquified carbon dioxide
gas, and some small cylindric receptacle in which the gas can be
condensed into the solid form. A glove finger is very good for this
purpose. The gas is allowed to escape into the glove finger, where it
solidifies, forming carbon dioxide snow, or what is commonly called the
carbon dioxide pencil. The temperature of this snow or pencil is very
low, being much below the freezing point of water.
The pencil is applied directly over the verruca and is allowed to
remain for a few minutes, until the entire tissue has been devitalized.
The extreme cold causes the blood supply directly beneath and around
the growth to cease, much the same as exposure causes local anemia in
chilblains and frost bite. The tissues around the part become blanched
and the growth separates from the normal structures in a few days.
There is usually a slough which will respond to treatment.
Great care should be exercised, so that the application is not
prolonged, as this will destroy normal tissue, and cause deeper
ulcers which do not readily heal. This method is painless during the
operation, but the pains of reaction are marked, varying with the
duration of the application, and with the resistance of the individual.
Wm. Golus considers this method of treatment extremely harsh. Monroe
Redell and Irvin Mayer are similarly minded. All of these practitioners
state that they give the preference to any and all other procedures
whenever called upon to treat verruca--they will not use the carbon
dioxide pencil because they fear the after-effects.
CHAPTER XIII
CALLOUSED NAIL GROOVE
The formation of hardened, or calloused skin in the nail groove is,
unhappily, a very common occurrence. In our present day of high-heeled
and pointed shoes the nail grooves of all the nails, but particularly
those of the great toe, are subject to a great amount of pressure and
friction. This irritation develops conditions in these structures,
ranging from a transient inflammation to the formation of distinct
helomata, or the general callousing of the whole surface of the groove,
both under and beside the nail.
In many cases where an heloma has developed in the inner lateral nail
groove of the great toe, the condition is judged and treated as an
ingrown nail.
Why this error in diagnosis should occur is hard to reason out, for,
while the subjective symptoms of the two conditions may be and usually
are similar, the objective symptoms are so entirely different that the
only accountable reason for a mistaken diagnosis is carelessness or
ignorance on the part of the practitioner. The true ingrown nail is not
a particularly common occurrence and, as has been previously explained,
a nail to be classified as ingrowing, must present an edge that has
invaded and is imbedded in the softer tissues of the adjacent nail
fold. In calloused nail groove, nothing of this nature has occurred and
it is the maltreatment of cases of this kind that usually leads to true
cases of ingrown nail.
=Definition.= A calloused nail groove is a condition in which a
localized heloma (sometimes several disseminated helomata), or a
general calloused condition has developed in a lateral nail groove.
=Symptoms.= _Subjective symptoms_: excruciating pain on the slightest
pressure, heat, and throbbing in severe and neglected cases.
_Objective symptoms_: swelling, usually localized in the nail fold
involved; redness and general inflammatory condition; upon close
examination the heloma or the callous is easily demonstrated in the
fold by reason of its unyielding qualities.
=Etiology.= This condition may be caused by irritation of the tender
tissues of the nail fold brought on by persons who persist and delight
in “digging” about the edges of the nail with some instrument. In most
instances, however, a short or narrow shoe or stocking will cause
sufficient pressure of the edge of the nail upon the tissues of the
groove to cause nature to provide a protection which tends to prevent
the nail from piercing these softer tissues; the protection appears in
the form of callous. This callous will appear as a hard development
throughout the whole nail groove, and we find those tissues to be
unyielding and to have lost nearly if not all of the pinkish tint
which the great amount of vascularity underneath normally gives to the
tissues about the nail. The color is yellowish or sometimes greyish
white. Where a distinct heloma is present, it may be found covered by a
thin sheet of callous which covers some part of the groove, or it may
be distinctly independent and isolated from any such development. When
this latter condition is met, the heloma will usually be found to be
circumscribed, its edges regular and its shape circular. These latter
instances are not so common as the general callousing of the entire
groove. Where the helomata are found disseminated, they will usually
occur on the inside of the flap next the nail, although in some cases
they will be found under the edge of the nail itself. In these first
mentioned instances the pain will be greatest upon lateral pressure and
in the latter upon dorsal or plantar pressure.
=Treatment.= Various methods of treatment are employed for the
alleviation or cure of this painful ailment. They may be divided, for
discussion, into two general classes: surgical and medical.
=Surgical Treatment.= This method consists in removing the callous or
the heloma by means of a fine-pointed scalpel or a small curette. The
nail groove is first well softened by the application of small pledgets
of cotton saturated with warm water, or by the use of some epidermic
solvent such as liquor potassae, after which the parts are dried and
the operation is begun. With a sterile nail chisel sufficient of the
edge of the nail is cut away so that the heloma or the callous is
exposed. This not only gives the patient instant relief but also allows
room for the operation and the subsequent dressing.
With a pointed scalpel or bistoury, the growths are removed, much in
the same manner as helomata in any location might be treated. If the
calloused condition be general throughout the groove, a small curette
is used and the callous is loosened from the anterior end of the fold
and stripped backward toward the root of the nail.
The subsequent treatment consists in applying an ointment, such as
ammoniated mercury (5%), and packing the nail groove with sterile
gauze. Should the operator prefer a liquid, the gauze packing may be
saturated with bichloride of mercury, ¹⁄₅₀₀₀, or boric acid, saturated
solution; but it will be generally found that the ointment is more
effective in reducing the inflammatory symptoms present and also any
irritation which may have been caused during the operation.
Whilst this operation is being constantly performed and seems to be
generally in vogue, much more satisfactory results are obtainable from
local medical applications.
In the first place, in using a scalpel or curette in the nail fold,
the operator must be very skillful in order not to cause a hemorrhage
and subsequently a tender digit. In many instances, no matter how
skillful the operator, or how much care be exercised in the operation,
it will be found a practical impossibility to strip the callous from
a nail groove without capillary rupture. This latter, of course, is
undesirable and usually, no matter how the lesion is dressed, the
groove remains tender for days.
In some cases the small helomata found in the nail fold should at
once be at least partly removed, to give the patient relief. This may
be done with a fine-pointed scalpel and local treatment may then be
applied.
=Medical Treatment.= There are two methods of medical treatment
employed. One finds its efficacy in the use of salicylic acid as an
epidermic disintegrant, and the other in the application of liquor
potassae (potass. hydrox. 5%) as a cuticle solvent.
_Salicylic Acid._ After a sufficient portion of the nail has been
removed to give relief to the patient, the nail fold is thoroughly
cleansed and dried and the following ointment applied in the groove:
Acidi salicylici 8.00
Camphorae
Chloral aa 0.30
Ceratum 30.00
M. ft. unguentum
After a week or ten days has elapsed, the whole calloused area will be
found to be entirely disintegrated and may be easily removed with a
fine-pointed excavator. The groove is then packed with either gauze or
cotton, and an appropriate ointment or solution is applied to alleviate
the inflammatory condition.
The treatment with salicylic acid is easily combined with the surgical
treatment, if it be found necessary to remove a portion of the corneous
formation in order to afford relief to the patient.
In some cases it will be found efficacious, after the callous has been
removed by means of the salicylic ointment, to apply silver nitrate
(50%) to the groove. This will reduce the inflammatory conditions and
at the same time act as an astringent to the underlying capillaries and
as a sedative to the inflamed tissues. The alternate weekly use of the
ointment and the silver salt is advocated, and gratifying results are
usually obtained from this treatment in cases where it can be used.
_Liquor Potassae._ Potassium hydroxide solution is most generally used
in cases where the callous is general in the nail fold rather than
where there is simply a localized heloma.
An applicator is saturated in the solution and rubbed over the
calloused area until the mass is softened, when it may be easily
removed. While this mode of treatment is a popular one it has been
the experience of many practitioners that the liquor potassae
merely softens the calloused condition, failing to disintegrate it
entirely, and allows the parts to harden, directly the application is
discontinued. Joseph Renk, a well known New York practitioner, reports
the best of results from this treatment, when carefully used.
No doubt there are good features in both treatments and a wise
practitioner, utilizing both, will adopt that from which he obtains the
best results.
In no instance should the nail fold be packed tightly in these cases.
The operator should remember that if he removes a sliver of nail
one-sixteenth of an inch in width and then packs the resultant space
with a pledget of cotton, gauze or lamb’s wool one-eighth of an inch
in thickness, he will cause more pressure to be brought to bear on the
parts than there was originally present; this is, of course, to be
avoided under all circumstances.
On the other hand it must be remembered that sufficient packing should
be used to retain the normal line of the nail fold and to keep these
softer tissues in the proper place. Under no circumstances should they
be allowed to crowd up and over the nail, for if this does take place
we are merely setting the stage for a possible ingrown nail. Jack
Grossman, M.Cp., makes this a strong point in his talks to the students
of The First Institute of Podiatry.
CHAPTER XIV
ONYCHOCRYPTOSIS OR INGROWN TOE NAIL
=Definition.= Onychocryptosis, or ingrowing or ingrown toe nail,
is a condition in which the lateral edge of a nail has penetrated
through the epidermic layers and has become imbedded in the adjacent
or subjacent soft parts of the lateral nail groove. This abnormal
condition gives rise to a number of complications, viz: simple
inflammation, ulceration, circumscribed or diffused cellulitis
and the formation of proud flesh. These may occur singly or as is
commonly found, the last three in unison. The unclean condition of
people’s footgear, the general unsanitary conditions of the foot, or
maltreatment of ingrown nail in its incipiency, often give rise to
the still graver septic complications which ultimate in a general
septicemia.
A nail then to be classed as an ingrowing nail must be specifically
ingrowing. Mention is made of this fact, which many in their wisdom may
deem superfluous, because so many conditions of callous or helomata in
the nail groove are mistaken for ingrowing nail and their treatment
as such is not only useless, so far as a cure is concerned, but is
decidedly detrimental to the comfort of the patient and to the future
general condition of the nail involved.
=Etiology.= A large percentage, perhaps larger than most people
imagine, of ingrown nails arise from the injudicious cutting of the
part by an inexperienced person. Directly after an amateur operation
upon a painful nail, acute symptoms of ingrowing nail do not
necessarily develop--although it does happen in many cases; but the
etiology of a great number of acute and well defined cases of ingrown
nail, as stated, can be traced primarily to self-inflicted nail injury
at some previous time.
The changes taking place in the nail and in the tissues of the nail
groove after the removal of the lateral border of the nail, are
pronounced. Take, for example, the great toe nail, as this is the most
easily studied on account of its size and at the same time is the most
general seat of troubles of this nature.
The nails are placed on the dorsal surfaces of the toes as a means of
protection to the expanded extremities of the distal phalanges. Perhaps
the Divine Providence in moulding his masterpiece, man, foresaw the
advent of modern footgear and realizing its baneful effect upon the
human extremity, developed upon the great toe a heavy nail from which a
great deal of protection for the more tender tissues beneath might be
obtained. At any rate, the great toe nail today bears the brunt of the
pressure from our leather footgear and for that reason is probably the
seat of so many painful afflictions.
The free edge of the normal great toe nail is found to be more
flattened and expanded than the posterior portions of the nail nearer
its root. This flattened expansion holds the softer tissues of the end
of the toe and of the lateral border of the nail groove in place under
the nail and also prevents them, if allowed to remain untouched, from
crowding up or around the nail at any quarter. But allow the free edge
and the lateral border of the nail to be removed, and particularly
by inexperienced hands--and observe what takes place. These softer
tissues which were normally held in place by the free borders of the
nail, fill up the spaces left by the removal of the nail borders. Even
this condition, were the nail to remain stationary and cease to grow,
would not be conducive to great pain or inconvenience. But the nail is
being continually pushed forward by the formation of new cells at its
posterior extremity. This is embedded in the posterior nail fold, and
when the newly formed portion of the same width as originally found
arrives at the point where the softer tissues are crowded up and into
the space left by the removal of the borders of the nail, instead of
growing over them and forcing them back into their normal position, it
finds this impossible, and grows into them.
From the foregoing we are not to take it for granted that all cases
occur from injudicious cutting of the nail’s lateral borders. Short
and tight shoes and hose are in some cases the exciting causes of
ingrowing nails and, from observation, we are led to believe that
while the actual ingrowing nail is not hereditary, nevertheless the
predisposition toward nail inversion is manifest through an entire
family or even through a generation.
In the case of tight footgear or hosiery, the cause is the crowding
of the great toe against its neighbor, forcing the softer tissues of
the nail groove and flap to be crowded against the lateral edge of the
nail. In these cases the principal site of occurrence will naturally
be the outer sides of the great toe; in fact, in most cases, this
groove will be found to be the most general site of occurrence. The
soft tissues of the nail flap being crowded over and around the nail’s
lateral edge, there naturally follows an irritation in the groove,
caused by the nail rubbing upon these tissues which, in time no doubt
leads to ulceration of the parts with the accompanying inflammatory
symptoms.
Uric acid diathesis may in one sense be said to be the cause of some
cases of ingrown nail in that when patients so suffer, the nails
are prone to chip off at the edges leaving the latter ragged and
so allowing a chance for irritation from the saw-like projections,
ultimating in an ulcerated condition of the wounded parts.
=Complications.= Other than the general inflammatory conditions
brought about in connection with the ulceration caused by the edge of
the nail penetrating the softer tissues, proud flesh is probably the
complication most generally met with in these cases.
Proud flesh, thus produced, is due undoubtedly to the constant
irritation of the nail upon the exposed surfaces of ulcerated area.
It forms in many shapes and the mass developed depends largely upon
the length of time the condition is allowed to progress without proper
treatment. The excess growth is usually found covering the whole
exposed area, or only forming in a teat-like prominence with a small
circumscribed base and expanded extremity. The pain to the patient is
undoubtedly augmented by the presence of proud flesh and the discharge
from the ulcerated areas is thereby increased. Hemorrhage from the
movement of the toe in walking is prone to occur and the general
unwholesomeness of the part is thus exaggerated.
In some cases the production of these exuberant granulations takes
place under the body of the nail as well as in the groove or on the
flap and they are not clearly discernible until the imbedded portion of
the nail is removed, when they will be seen to crowd upward into view.
Any open wound upon the surfaces of the foot is very liable to septic
infection. Regardless of the cleanly care one may give his feet and
regardless of the washing of hose, infection will still take place,
and only naturally so. The feet are coming constantly in contact with
septic surfaces and the inside of a shoe presents large areas for the
resting place of countless microorganisms in that it combines the three
elements which are best suited for the growth of bacteria, viz: heat,
moisture and darkness.
Ingrown nails are even more prone to infection than is a lesion in
connection with an heloma or a fissured toe web, and in many instances
where cases have been allowed to run for some time before the surgeon
or podiatrist is called into consultation, infection has already
occurred.
In connection with septic cases, abscess cavities are often found
immediately in the nail groove, under the body of the nail itself or
with a suppurative sinus burrowing backward under the posterior nail
fold and involving the whole of the matrix in an acute suppurative
process. In exaggerated cases, the cellulitis may be diffused
throughout the whole digital region. However, these cases are rare, as
walking has become well-nigh impossible long before this takes place
and the patient will have been under scientific treatment before the
case has reached such proportions.
=Treatment.= From the standpoint of the podiatrist, there are two
distinct methods of operative technic in ingrown nail cases, the
radical and the palliative. They differ as to the exact technic of the
removal of the ingrown portion, but agree on practically all other
points.
In that but for the first part of the operation these two methods
are similar, they will be discussed separately as to that alone, and
the post-operative procedures and dressing of both will be combined
into one general discussion. Under each heading the treatment of the
surrounding tissues is mentioned, but the reader is referred to the
heading “Prophylaxis” for a thorough and comprehensive discussion of
the various procedures necessary to their proper care.
=Asepsis.= Proper aseptic precautions must be observed in all lesions
and particularly so with ingrown nail cases. As has already been
stated, conditions of this nature are prone to infection because the
surfaces and recesses or the nail groove present excellent lodgment for
bacteria, and this point should always be borne in mind.
The parts should first be thoroughly cleansed with ether. This removes
all greasy or oily matter from the field of operation and allows the
antiseptic solutions subsequently used to come in direct contact with
the affected surfaces.
Some effective antiseptic should then be used as a spray to prevent the
washing in of bacteria from the surrounding parts. There are a number
of solutions which are useful for this purpose; liq. zinci et alumini
compositus, N.F., and liq. zinci et ferri compositus, N.F., are both
highly recommended. Liq. cresolis compositus may also be used with
excellent results, although it carries the somewhat disagreeable odor
of the cresols. These solutions are all active in strengths ranging
from two to five per cent.
Iodine is unquestionably the best antiseptic that can be applied to the
field of operation, but as its discoloration of the tissues prevents
the operator from visually observing geographic points he may need for
further diagnosis, and as this drug also acts as a corrosive to metal
instruments, it is found advisable in many instances to refrain from
its use.
As a substitute for iodine, alcohol is the next most efficient
germicide. Sixty per cent. strength is recommended, as in that
proportion it has greater penetrative and antiseptic value than the
stronger solutions.
The alcohol, applied by means of a cotton wound applicator, is rubbed
into the parts, or a pledget of sterile cotton or gauze, saturated in
the solution, may be applied over the field and allowed to remain for
two or three minutes prior to operation.
When the operator has followed the foregoing, or a similar line of
procedure, the removal of the ingrown portion of nail may be begun.
For simplicity’s sake, the methods of treatment will be discussed,
beginning with the uncomplicated case, and the various complications
will be considered under separate headings.
UNCOMPLICATED CASES
=Removal of the Ingrown Portion.= Having obtained thorough asepsis of
the affected and surrounding areas, the operator by means of a small,
blunt sterile probe, should endeavor to locate the exact position and
size of the ingrown portion of nail, which should then be removed by
means of a sterile nail chisel.
=The Nail Chisel.= This instrument is a narrow steel blade set in a
long or short handle, as the operator desires, the operating end of
which is slightly oblique so that, upon direct pressure, the blade cuts
in a diagonal manner. This is for the purpose of minimizing the danger
of penetration into the nail bed. In the radical operation a broader
and heavier chisel is sometimes used so that the softer tissues may be
included in the incision.
=The Radical Method.= Proper antiseptic precautions having been
taken, the circulation is cut off at the base of the toe by the
application of a tourniquet. Under local anesthesia, induced preferably
by the hypodermatic injection of novocaine, 1%, the nail is split
longitudinally to the root with an ingrown nail chisel, care being
taken not to split the nail at or near its centre--a procedure
practised by some surgeons. When the nail has been cut through the
root, the free portion is grasped with an artery forceps and is lifted
out of the nail groove. It is often necessary to dissect the nail from
adhesions which have formed.
The proud flesh, should any be present, is now snipped off with a pair
of curved scissors and if necessary a portion of the enlarged nail flap
is also included in the cut. The soft tissues should be cut so that the
structure remaining appears normal in size.
The nail matrix is thoroughly curetted over its entire exposed area,
as is the nail bed along its whole surface to the distal end. This
procedure must be thorough to insure against recurrence. Bleeding is of
a capillary type and is easily controlled by digital pressure.
=The Palliative Method.= With a sterile nail clipper, a small cut is
made on the affected side in the free edge of the nail. The chisel is
then placed in this notch and gentle yet firm pressure is exerted so
that the instrument cuts through and splits the nail.
The cut made is in the shape of an arc, following as nearly as possible
the normal line of the lateral edge of the nail. The broadest part of
the arc is at the anterior or free edge of the nail, gradually reducing
the width of the piece to be removed until the lateral edge is reached.
In this way a clean sweeping cut is made which does not invade and
consequently does not irritate the tissues about the nail root.
The palliative method of operative technic in ingrown nail cases is
based on the theory that the condition is not one of a misdirected
growth of the nail, but rather a case of the soft tissues adjacent to
the nail crowding up, around and over the nail proper; and that the
nail body as it pushes continually forward, cannot force this mass back
into its normal position and, of necessity, must grow into it.
There is no lateral hypertrophy of the nail nor does it present any
misdirected growth.
[Illustration: ONYCHOCRYPTOSIS (SUPPURATING)]
Keeping this theory in mind, it would seem unnecessary and poor
surgery to remove the portions of the matrix of the nail from which
the affected side develops when in reality it is not the nail that is
at fault but rather the soft tissues adjacent to it; and the ingrowing
of the nail body is purely secondary to the displacement of these soft
tissues. As ever in surgery, however, it remains a matter of judgment
as to which operation should be done so as to obtain the best results.
When the palliative methods fail to be effective, the radical operation
is permissible--never the reverse.
The palliative method has for its object the removal of the portion of
nail whose irritant free border is embedded in the tissues and, this
accomplished, to treat these softer tissues in such a manner that they
will become normal as to position and all else. By such a manner and
method of treatment, sufficient space is obtained at its lateral edge
for the nail to grow to its full width and in time to become perfectly
normal as to appearance, function and feeling.
The straight nail chisel, in most instances, can be used, but where
the ingrown portion of nail is deeply embedded, a right or left curved
chisel can be substituted with greater success. The curve in this
variety of chisel aids the operator in lifting the nail out of its bed,
while at the same time the cutting process is not hindered.
=Dressing.= Following the removal of the offending portion of nail, the
operator should make sure that no nail slivers, previously existing
or of his own making, remain in the nail fold. Assured of this, the
parts should then be thoroughly irrigated either with alcohol, 60%, or
mercuric chloride, ¹⁄₄₀₀₀. Hydrogen peroxide may be used as an irrigant
where pus is present, but it should not be depended upon as a germicide
as its action is very transient and superficial. A final dressing is
then put in place.
There seems to be a wide diversity of opinion as to what constitutes
a proper dressing after the nail has been removed. Whatever else
individual experience may show to be useful, the dressing should be
one embodying antiseptic, astringent and healing properties. The
antiseptic, surely regardless of what other action is to be desired;
the astringent, so that inflammatory symptoms may be speedily combated
and the ulcerated areas contracted; and the healing so that granulation
may be the more speedily promoted.
Three forms of dressings may be classified: the wet; the dry; the
ointment.
=The Wet Dressing.= The nail groove is packed with a small piece of
sterile gauze. Care should be exercised that a thin fold of the gauze
be placed under the edge of the nail between it and the tissues into
which the ingrown portion of nail was embedded. A piece of sterile
gauze, of about three or four thicknesses and about two inches square,
is then placed over the affected fold of the nail, covering the
inflamed area and extending over the nail itself. This pledget is then
saturated with a solution of the operator’s choosing to meet the needs
of the case under treatment. Two solutions seem to be favored above all
others in this connection: mercuric chloride, ¹⁄₅₀₀₀, or weaker, and
liq. aluminum acetate. The latter solution is at most times preferable,
as it possesses antiseptic qualities (nearly, if not equal to corrosive
sublimate without exhibiting the toxic properties of the latter) and
produces an astringent and antiphlogistic action on the tissues. Strong
germicidal solutions such as the mercuric chloride are at times found
to be decidedly detrimental, in that they not alone cause maceration
and desquamation of the skin, but in some instances, if too strong,
they destroy the newly formed connective tissue granules.
The gauze square which covers the whole end of the toe, and which is
saturated with either solution just described, is held in place by a
roller bandage or by adhesive strips.
The usual method of applying these strips is to place one on each side
of the gauze square, adhering them over the end of the toe and to and
on the skin, and one over the centre of the dressing, carrying it over
the end and down to and on the plantar surface of the toe. A circular
strip is then carried around the toe, over the posterior end of the
dressing, thus binding down the ends of the three strips previously
applied.
No impervious covering such as gutta percha, oiled silk, etc., should
be used in this instance, or, in fact, in any condition where the skin
is broken. The warmth and moisture produced by such a covering is
congenial to the growth and development of hostile bacteria.
The wet dressing, then, should be left uncovered so that evaporation
may take place and a quantity of the solution used should be
prescribed for the patient, so that the dressing may be moistened with
it from time to time. The dressing without impervious covering is
antiseptic and heat reducing because of the evaporation and frequent
replenishment of the solution.
=The Dry Dressing.= Dry dressings in this sense consist in the
application either of plain, dry, sterile gauze packed in the nail
groove and unmoistened, or dusting the affected parts with some
antiseptic powder to maintain asepsis in the wound and to bring about
normal granulation.
Of these two forms of dry dressing, that constituted by the plain dry
gauze is productive of better results than are obtained by the dusting
powders. A lesion caused by the nail penetrating the soft tissues of
the nail fold, in the process of healing, necessarily discharges a
certain amount of waste material produced in the tissue repair. In
consequence, where a dusting powder is used, the serous discharge at
times combines with the particles of the powder to form a crust which,
in the confined areas of the nail groove, often becomes equally as
irritating as was the ingrown nail itself.
However, in some instances dusting powders may be used with impunity
and many practitioners favor and report success in their use.
Aristol (thymol iodide), dermatol (bismuth subgallate), bismuth
subnitrate and boric acid (powder), preferably the first two named,
may all be safely used in the treatment of ingrown nail cases. Aristol
depends upon the liberation of iodine for its antiseptic action while
the two bismuth salts, the subgallate and the subnitrate, combine
marked astringent properties with their antiseptic qualities.
After the powder is dusted into the affected groove, a thin layer of
sterile gauze is packed lightly under the lateral edge of the nail and
a cocoon dressing is placed over the whole.
This form of dressing is applied until resolution of the inflammatory
process and granulation of the wound has taken place.
=The Ointment Dressing.= All ointments are necessarily of fatty or
oily consistency and, in consequence, when applied over a surface
excreting a serous discharge, are liable to confine this discharge
to the affected areas rather than allow it to be absorbed by the
gauze dressing, and so drain the wound. For this reason the use of
ointments on discharging surfaces is not particularly recommended. Many
practitioners use them, however, and presumably with beneficial results.
Two classes of ointments may be used in this connection: antiseptic and
stimulating. Under these headings the following are suggested: sulphur,
10% (vaseline or lanolin base); ammoniated mercury (white precipitate),
5%; balsam of Peru, 10%; scarlet red (medicinal Biebrich), 4%.
The ointment is placed in the nail groove by means of a spatula, and
sterile gauze is packed lightly under the nail, holding the ointment in
place. This is covered with a cocoon dressing and is renewed until the
parts regain their normal condition.
COMPLICATED CASES
=Proud Flesh.= The development of unhealthy, exuberant granulations is
a common occurrence in connection with ingrown nail cases, especially
when they have been allowed to progress before proper treatment has
been inaugurated.
In all cases the primary steps in the treatment are essentially similar
to those described under “uncomplicated cases.” Proper asepsis and
antisepsis are at all times to be strictly observed, and any ingrown
portion of nail should in all cases be first removed before additional
treatment is administered.
The speedy and complete removal of the unhealthy granulations is at
all times essential. This may be accomplished either by excision, by
the actual cautery or by the use of escharotics. The operator must
always remember that the presence of proud flesh in a wound not alone
retards the normal healing process, but also prevents the wound from
healing without the formation of an abnormal amount of new tissue. If,
for instance, a mass of proud flesh the size of a pea were present
in connection with an ingrown nail and allowed to remain without
further treatment, the tissue would in time present a perfectly normal
appearance. That is, the exuberant granules would sooner or later
develop an epithelial covering which would be of like appearance to the
normal surface of the skin. But in doing so, the tissues would still
retain the shape and size of the original mass of exuberant granules
and we would find a teat of tissue, the size of a pea, jutting out of
the normal surface of the nail groove.
Keeping in mind, then, that to obtain a speedy and normal healing
action in a wound the proud flesh present must be eradicated, it should
appeal to the operator that the quickest means for its removal must be
the best. Two quick and complete methods for obtaining this desired
result are found in (1), excision (by the use of the scalpel or curved
scissors), and in (2), the actual cautery.
[Illustration: BEGINNING INGROWN TOE NAIL]
=Excision.= Excision of the proud flesh cannot be resorted to in all
cases, but in most cases at least the larger portion of the exuberant
granulations can be removed in this manner.
The condition in which the use of the curved scissors is particularly
advocated as most efficient is that in which the mass of proud flesh
is found in pendulous form, where its base is narrow and covers but
a small area and where the mass expands into an enlarged extremity.
In cases where the proud flesh is found generally throughout the nail
groove, and in some instances under the lateral edge of the nail
itself, the scissors or scalpel cannot be used with good effect, if at
all. Then of course other means must be employed.
=Method of Procedure.= After the field of operation has been thoroughly
sterilized and the ingrown portion of the nail has been located and
removed, the exact situation and amount of proud flesh is ascertained.
If at all practical, a sterile scissors (preferably of the curved
variety) is inserted under the granulating mass and the whole is
quickly snipped off at its junction with the normal integument. Where
the mass is considerable, it will be found advisable to ligate the toe
at its base by means of a few tight turns of adhesive tape or by the
use of a rubber ligature. This precaution will lessen the resulting
hemorrhage and it can be more readily controlled.
Where the amount of proud flesh to be excised is small, the blood flow
is easily arrested by digital pressure.
It will generally be found conducive to the best results to anesthetize
the parts by hypodermatic injections of novocaine or by means of the
ethyl chloride spray. This is not necessary in every instance, however,
as the advisability of producing anesthesia depends upon the amount of
tissue involved and the nervous condition of the patient.
After the exuberant granulations have been cut off, Monsel’s solution,
adrenalin chloride or some other styptic is applied to the bleeding
capillaries.
It may be found advisable to apply silver nitrate, 50%, or even nitric
acid, c.p., to the bleeding parts. This serves not alone to check
the hemorrhage, but the escharotic action tends to destroy whatever
remaining shreds of the proud flesh may still be present.
The oozing arrested, the ligature is removed. The nail groove is packed
firmly with sterile gauze (firmly, so as to further check the vascular
supply to the parts) and a wet dressing of liq. aluminum acetate is
applied. In the event of no further recurrence of the proud flesh,
the case is treated in any of the ways described under “uncomplicated
cases.”
=The Actual Cautery.= The electric cautery presents a quick and sure
means by which proud flesh may be destroyed. Local anesthesia should
first be induced by means of a hypodermatic injection of novocaine,
1%, or by use of a freezing spray, such as ethyl chloride. In most
instances the use of the ethyl chloride will be found sufficient
for the needs of the case although its anesthetic effect is quite
superficial and transient. Novocaine, on the contrary, is both lasting
and complete in its effect.
The argument against the use of the actual cautery is one of humaneness
rather than one of science. Regardless of the lack of sensation
produced by the anesthetic, patients will rebel at the sight of a white
hot cautery. The mental shock of seeing one’s flesh seared by a hot
iron is pronounced, and at the present time no podiatrist can take
liberties with the patient’s feelings as does the surgeon, without
jeopardizing his reputation and diminishing his clientele. On the other
hand, while the mental anguish of the patient may be greater during the
use of the actual cautery, the subsequent suffering is much less than
that following the application of an escharotic.
After the use of the cautery, a wet dressing of liq. aluminum acetate
or a solution of boric acid and alcohol, equal parts, may be applied
and renewed until all acute inflammatory symptoms have subsided when a
dressing may be employed to hasten granulation.
=Escharotics.= The use of caustics for the destruction of proud flesh
is probably the most generally used method in vogue today. Nitric acid,
caustic potash and silver nitrate, either in fused or in solution form,
may all be used in most every instance.
Inability for any reason to resort to the use of a curved scissors,
the scalpel, or the cautery compels us to look among the caustics
for an agent to accomplish the desired results. Keeping in mind the
aforementioned fact, that the quickest means for proud flesh removal or
destruction is the best, we naturally lean toward the strong corrosives
as a means to bring about this end.
=Nitric Acid.= Nitric acid (aqua fortis), in all probability, is the
most efficient member of this class of drugs, as its action is both
energetic and penetrating. In cases where the exuberant granulations
are found involving the entire nail fold and in no particular localized
area, aqua fortis is found very useful. Usually one application is
sufficient to destroy all vestige of the unhealthy tissue, but in
extreme cases added treatment may be necessary.
Care is taken to cover the surrounding healthy integument with some
greasy substance (vaseline is generally preferred) to prevent the acid
from coming in contact with it and avoiding the consequent bad effects.
The acid is then applied by means of a cotton wound applicator (wooden
applicators are preferred, as they are inexpensive and may be thrown
away after being used) or a glass rod. The nail groove should be firmly
packed with sterile gauze and a wet dressing of liq. aluminum acetate
or of bichloride of mercury, ¹⁄₅₀₀₀, or a boric acid and alcohol
solution, equal parts, should be applied over the affected parts. At
the next examination, any remaining shreds of the unhealthy granulation
are to be looked for and, if found, another but lighter application of
the acid should be applied. It is wise to remove the eschar caused by
the previous application so that deeper penetration and more efficient
action from the drug may be obtained.
This is continued until all remnants of the proud flesh are destroyed,
when the toe should be dressed to induce speedy and healthy granulation.
=Caustic Potash.= Potassium hydroxide (caustic potash) may be used
in place of nitric acid for the destruction of proud flesh. The
preference for the latter seems to be due to the fact that wound’s
caused by the action of nitric acid are prone to heal more rapidly than
those due to the use of caustic potash; also because the action of aqua
fortis can be more readily counteracted should the need for such action
arise.
Caustic potash should be used with care, the same precautions to
protect the healthy tissue being taken as in the use of nitric acid.
Apply caustic potash on a small cotton wound applicator, packing the
nail fold with sterile gauze to be followed by a moist dressing of liq.
aluminum acetate.
=Silver Nitrate.= The use of the silver stick or a strong solution of
the salt to destroy any great amount of proud flesh is not advocated.
In the first place the caustic action of silver nitrate is due solely
to the nitric acid generated by its use, and so the aqua fortis
should be used to obtain a speedier and more energetic removal of
the unhealthy tissue. Secondly, silver nitrate coming in contact
with the albuminous tissue, decomposes, oxidizing it and forming a
metallic deposit on the surface which becomes an impermeable eschar.
This hard crust not alone prevents the silver salt from penetrating
into the tissues--the action of silver nitrate is thus called
“self-limiting”--but also being unyielding, acts as a direct irritant
to the denuded tissues.
Silver nitrate is, however, particularly efficacious after the great
amount of the proud flesh has been removed by means of excision; in
this situation it acts as a styptic to arrest the capillary flow of the
bleeding stump, and as a mild caustic to destroy the remaining shreds
of the unhealthy granulation. It is also a beneficial application for
hardening the tissues of the nail fold to prevent further recurrence
of the ingrowing nail. This subject will be fully discussed under
“Prophylaxis.” After excision of the proud flesh, silver nitrate should
be used in solution of fifty per cent. and the toe dressed as has been
previously described.
=Burnt Alum.= Burnt alum is still another remedy used in podiatry for
the destruction of proud flesh. Its use is not now favored for that
direct purpose, but there are some situations in connection with the
treatment of the condition in which it may be used with good results.
It is the least energetic of all the escharotics herein mentioned,
and many prefer to class it rather as an astringent. The burnt alum
is dusted in the nail groove directly on the mass of proud flesh and
the groove is then packed with sterile gauze. Because of its extremely
mild action, comparatively speaking, burnt alum will not accomplish its
work of destruction with the rapidity nor the completeness of the other
mentioned drugs; moreover it causes considerable irritation and pain to
the patient. The modern practitioner is inclined to relegate this drug,
as a caustic, to the shelf, to be used only in cases where a strong
astringent action is desired.
=Liquor Ferri Subsulphate.= Monsel’s solution has been used to dry up
unhealthy granulations because of its astringent action rather than on
account of its caustic properties.
=Treatment of Acute Infective Inflammations.= Infection is in all
probability more generally met with in connection with ingrown nail
cases than in any other ailment primarily occurring on the foot. The
state in which the toe may be found is dependent upon the length of
time the case has progressed without proper treatment. Cellulitis may
be circumscribed or diffused, and lymphangitis, both of the reticular
or tubular variety, may be present.
Following the usual antiseptic and aseptic precautions relative to the
field of operation, the operator’s hands and the instruments, drainage
of the suppurated areas must first be obtained.
In the average case, an abscess cavity is usually found in or adjacent
to the lateral nail fold, and in many instances the pus sac will be
punctured during the removal of the ingrown portion of the nail. It
is sometimes found necessary to remove an overlying portion of nail,
other than the ingrown portion, to give free access to the suppurating
process and to afford drainage for its purulent discharge. A sterile
chisel of the straight variety is generally used to accomplish the
removal of the ingrown portion of nail, care being taken that the
cutting edge is inserted deep enough to penetrate only the nail and not
to pierce the underlying soft parts.
Some practitioners do not advocate the removal of portions of the
nail and prefer rather merely to drill a hole through the nail body
and excavate the pus through this channel. No doubt circumstances
alter cases, but the writer would prefer having the septic tract
wholly exposed so that thorough irrigation and proper treatment may be
accomplished.
Having given free drainage to the pus cavities, the parts should again
be sprayed with alcohol, 60%. Hydrogen peroxide, which manifests its
greatest efficacy in pus cases, should then be freely applied until
ebullition ceases.
In cases where the sinus is small and deep and an ordinary cotton wound
applicator is too large for insertion into its recesses, a wooden
applicator tipped with iodine (these applicators already prepared are
now on the market) will be found fine enough for this accomplishment.
There is also on the market a fine, hollow, flexible needle, with
a bulbous extremity in which there is an opening, that fits any
hypodermic syringe. Two or three drops of iodine are drawn into the
barrel, the needle is inserted into the sinus, and its contents are
evacuated by piston pressure. This enables the operator to get the
drug down into the sinus so that it comes into direct contact with its
deepest surfaces. This needle is made of a non-corrosive metal.
The next point to be considered is the form of dressing to be used.
If the case has progressed to a point where the operator feels the
necessity of a surgeon’s advice, the latter should by all means be
called in as a consultant. The writer feels, however, that in most
instances the modern practitioner of podiatry is well equipped to
successfully treat even severe cases of this nature.
The affected nail groove is packed with sterile gauze and a large
piece of the fabric, of several thicknesses, is placed over the whole
inflamed area. This is saturated with a solution of mercuric chloride,
¹⁄₅₀₀₀, and is remoistened at intervals by the patient so that it is
constantly wet. In some cases it may be wise to have the patient remain
in the office several hours to make sure that the infected parts are
kept constantly immersed in a solution of mercuric chloride, ¹⁄₅₀₀₀.
This treatment has been found to be extremely beneficial in reducing
the inflammation so that a moist evaporating dressing, as described
above, may be safely applied. Rest is another feature to be employed
in the treatment of these cases. The patient should be instructed to
refrain absolutely from the use of the affected parts until such time
when the inflammatory conditions have subsided or are under control.
The podiatry patient as a rule is loathe to have his or her energies
in any way curtailed, but the mention of “blood poisoning” is usually
sufficient stimulus to send the patient to bed when so ordered.
=Prognosis.= The prognosis in all cases of ingrown nail under proper
treatment is favorable. The length of time elapsing before a cure is
affected is of course dependent upon the condition of the toe and the
general condition of the patient.
In cases where the nail penetration is slight, and the inflammatory
conditions are in their incipiency, one or at most two treatments will
be sufficient to heal the ulceration and to restore the toe to its
normal condition. Complicated cases necessarily take longer to relieve
and longer to cure.
The surgeon is still rather reluctant to believe that an ingrown
nail can be cured without removal of the affected half of the nail,
the lateral nail fold, and a portion of the matrix. This method of
procedure in nearly every instance incapacitates the patient for fully
two weeks and it is doubtful whether anything is gained (taking all
matters into consideration) over the methods of ingrown nail treatment
as here outlined.
The surgical argument is based on the contention that unless the matrix
underlying the affected nail be removed, the nail will again grow into
the tissues. This is unquestionably so, but in a majority of cases, as
explained previously, the trouble is not due to a misdirected growth
of the nail, but rather to the tissues surrounding the free edge and
lateral nail border crowding up, around and over the nail.
It may then be safely stated that an ingrown nail properly treated and
which has been subjected subsequently to proper prophylactic measures,
is curable; not temporarily, but permanently.
PROPHYLAXIS
In considering the measures employed by which the general condition
of the nail may be improved so as to prevent a further recurrence of
the ingrowing tendencies, we will make, for simplicity’s sake, six
divisions. Five of these relate to the nail itself and to the subjacent
tissues, and one to the footgear and hosiery of the patient.
=1. Thinning the Nail Through Its Long Axis.= When the acute
inflammatory symptoms have subsided and the ulcerated areas healed, in
other words when the toe and the nail have returned to normal, measures
should be taken to prevent the latter from becoming again ingrown.
With a rotary file, the centre of the nail should be ground to a paper
thinness through its long axis. What is accomplished by this procedure?
The nail is normally convex on its outer surface and the apex of its
dome is the centre of the nail body. This portion, being the greatest
point of elevation, naturally receives the brunt of the pressure
from the shoe. If the nail, then, is allowed to remain thick in the
centre of its body, the shoe pressing upon it will find the nail
unyielding and in consequence will cause its lateral borders to be
forced down into the nail grooves. By thinning the body of the nail
to such an extent that it becomes thin and flexible, the shoe presses
upon a yielding surface, in consequence of which the nail “gives” or
spatulates at its centre and the pressure upon its lateral borders is
decreased if not prevented entirely.
Having done away with any untoward pressure which might be brought to
bear on the nail, we next turn to:
=2. Hardening the Nail Groove, and Shrinking the Flap.= In many cases,
after all acute symptoms of the disturbances have subsided, we find
that the flap of tissue adjacent to the once affected nail and forming
the outer side of the groove, is greatly thickened and enlarged.
This must be reduced in order that the new-forming nail will have
sufficient room to develop to its normal width and we must also harden
and toughen the nail groove so that it will present a surface that the
nail, as it grows out, will not be able to penetrate, should it be so
inclined.
Silver nitrate is the most generally used and most efficient agent to
carry out a treatment of this kind. Solutions varying in strength from
5% to 50% are recommended, and the selection depends on what is to be
accomplished and the length of time which may be given to the treatment.
By persistent use of silver nitrate solution, 50%, an enlarged and
thickened nail flap may in time be reduced to normal. Applications
about one week apart--in some cases ten days or two weeks to
intervene--will usually work wonders in conditions of this kind. The
groove should be thoroughly cleansed and dried and the silver solution
should be applied on a small cotton wound applicator and painted well
down under the nail and over the tissue in the enlargement. A dressing,
usually cotton and collodion, is then applied and allowed to remain
undisturbed until the patient’s return. The action of this solution is
astringent and sedative. It is bound to reduce the chronic inflammatory
symptoms that may be present and, acting as an astringent, it gradually
shrinks the enlarged flap until the normal line of the lateral nail
fold is reached.
During the treatment, there is absolutely no pain nor inconvenience to
the patient. Care should always be exercised that the silver solution
be not applied if any hemorrhage has been caused in the removal of a
previous eschar, as it is sufficiently caustic to cause ulceration
should it come in contact with such a denuded surface. Packing of the
nail groove will be discussed under the sub-heading “Packing.”
Subsulphate of iron (Monsel’s solution) may be used in the treatment
of cases of this nature, but its action as an astringent in this
connection is so mild that it is of necessity a slow process to effect
a complete cure.
The solution, usually applied to the groove on gauze, is allowed to
remain. In fact, the patient is often advised to procure a quantity of
the drug and keep the gauze moistened.
The patient should be seen at periods of about a week or ten days, when
both the dressing and the eschar caused by the action of the iron salt
are removed. Fresh gauze is packed under the nail and the treatment
continued.
Ferric chloride has much the same action in this connection as the
subsulphate, but this drug has never been so popular, for the reason of
its greater irritant qualities, few of which are to any degree manifest
in Monsel’s solution.
Ointments or collodion containing large percentages of salicylic
acid--as high as sixty to seventy-five per cent.--are sometimes used
to destroy an enlarged nail flap by strong disintegrative action. The
ointment is usually prepared on a cerate base and sufficient wax is
added to thicken the paste so that the tendency to melt and run over
portions of the integument, where its action would be detrimental, is
minimized.
The ointment is applied in the groove and over the top surface of the
mass to be destroyed and is allowed to remain for a few days when
the disintegrated portion is removed and another application made.
This action of salicylic acid, used in considerable strength, is at
times painful and cannot be borne by every patient. The treatment is
a good one, however, and is rapidly coming into the prominence and
popularity it deserves. Salicylated collodion is similar in action to
the ointments containing salicylic acid, and the same general procedure
holds good for both applications. The collodion is applied on all
surfaces of the mass, is covered with a cotton and collodion dressing
and a second application is made upon the removal of the disintegrated
portion.
It is sometimes advantageous to alternate the silver nitrate treatment
with that of salicylic acid. An application of the ointment or the
collodion is made and upon removal of the disintegrated portion, the
silver solution is applied. After the lapse of about two weeks, the
salicylic acid is again applied and the treatment continued alternately
in this manner until the desired result is obtained.
=3. Packing.= We here come to one of the most important procedures
necessary to a successful prophylactic treatment of an ingrown nail.
Whether the nail groove is to be packed loosely or tightly is a
question of great import and should be given careful consideration by
the operator. Often the comfort of the patient and always the ultimate
outcome of the case is dependent on the proper packing of the nail
groove as an after-treatment.
There appears to be a great tendency to pack the groove full to
overflowing with gauze, cotton, or what not, and, although there are
some instances where a procedure of this kind is necessary, it is
usually conducive to a great amount of pain to the patient and has a
decidedly deleterious effect on the tissues under treatment.
In general, it is wise to pack the groove as lightly as possible, using
only a small pledget of gauze or cotton and taking care that the fabric
is well under the nail and interposed between it and the tender areas
underneath. It must be remembered that no matter what fabric be used
for packing, it rapidly hardens and becomes more or less irritant to
the tissues. Should the nail groove be packed to such a degree that at
the time of dressing it is unyielding and hard, it is easily realized
what the condition of this dressing will be in the course of a few days.
The only time a nail groove might be tightly packed is in connection
with the treatment of proud flesh when the tight packing tends to
interrupt the circulation to the part and thus aids in retarding the
growth of the superfluous granulations. Another instance when a groove
may be packed tightly is in a case where no inflammation is present
and when it is the desire of the operator to hold the softer tissues
down and away from the edge of the nail so that sufficient room may be
allowed for the nail to grow out and attain its normal width. A word in
connection with this theory. Silver nitrate solutions, twenty-five to
fifty per cent., applied to the groove hardens the tissue by means of
the eschar developed on its surface and a tight packing to hold these
tissues in place is an ideal combination for the prophylactic treatment
of a previously acute ingrown nail case, when by such tight packing
no noticeable inconvenience is caused to the patient. If cotton is
used as a packing it should be rolled into a loose thin pledget, the
finer “point” of which is inserted under the edge of the nail near its
posterior fold, and the thicker end is packed under the nail at its
distal portion. One thickness of gauze is generally sufficient and, at
most, two thicknesses may be used, unless, of course, tight packing is
required.
In connection with this prophylactic treatment it may sometimes be wise
to place a shield of felt or buckskin between the tender part and the
adjacent toe to hold that member away from the affected areas and so
that the medications applied may be allowed a chance to complete their
therapeutic action undisturbed. This shield is not strapped but is
merely placed between the toes, resting on the interdigital web, and is
just high enough to reach the base of the nail and so does not come in
direct contact with the area under treatment.
=4. Allowing the Nail to Grow Long.= The nail should be allowed to
attain as great a length as possible, particularly at its lateral
points, without interference with the continuity of the patient’s
hosiery, and yet not long enough to cause pressure from the toe of the
boot.
This can be best accomplished by cutting the free edge of the nail
in a concave manner. The lateral points are kept, if possible, long
enough so as to extend to a point slightly beyond the distal end of the
nail fold and the rest of the free edge is cut in a circular manner so
that at its centre it is no longer than just sufficient to cover the
anterior edge of the nail bed. This manner of cutting, combined with
thinning the nail body through its central longitudinal axis, prevents
any great amount of pressure from being exerted by the shoe upon the
apex of the nail’s convexity. It will also, to a great extent, prevent
the nail from cutting through the patient’s hosiery. If the whole nail
is allowed to grow long, and its free edge to extend over the end
of the toe, some leverage is bound to be brought upon this extended
portion and in consequence there is a tendency to press the lateral
edges of the nail into the grooves, which, of course, is to be avoided
at all costs.
=5. No Lateral Cutting.= In connection with the length which the nail
is allowed to retain, it is absolutely imperative that no lateral
cutting be done. Some cases of ingrown nail have been observed in even
very young children (in one instance a baby of fourteen months). The
primary cause in every case was found to be the overzealous care on
the part of the parents to prevent just the condition they had caused
by injudiciously removing from time to time the lateral edges of the
sufferer’s toe nails.
=6. Proper Boots and Hosiery.= In addition to the various means for
preventing the recurrence of an ingrowing nail, great care should be
exercised in the selection of the patient’s footgear.
Shoes of sufficient width and length should of course be advocated so
that at no time will the toes be cramped by any degree of pressure.
The wearing of a pointed boot or slipper in which there is not
sufficient width at the ends of the toes to allow those members proper
latitude, should be discouraged. When footgear is worn in which this
cramped condition of the digits is brought about, it will be generally
found that the soft tissues lying adjacent to the lateral edges of the
nail are crowded up alongside the latter and an enlarged and thickened
flap, which is the cause of so much trouble, is formed. Lace boots are
probably the most practical of any in that they may be firmly fastened
about the ankles and over the instep, and thus prevent the foot from
sliding forward and coming in contact with the toe of the boot. Pumps
of all varieties are without a doubt the most detrimental footgear worn
today--for they have absolutely no support or anchorage at the ankle
and, in some cases, patients find themselves flexing the toes in the
endeavor to retain the slipper on the foot.
Hosiery, too, should be neither tight nor short, as a short stocking or
sock may cause pressure upon the toe nails and so be the forerunner of
trouble.
CHAPTER XV
DISEASES OF THE NAILS
The nails of the hands and feet are subject to various diseases. The
chief of these are:
Onychocryptosis, or ingrown nail.
Onychophosis, or calloused nail groove.
Onychia, or inflammation of the matrix.
Paronychia, or inflammation around the nail.
Onychauxis, or club nail.
Onychatrophia, or atrophy of the nail.
Onychoptosis, or falling off of the nail.
Onychorrhexis, or brittle nail.
Some of these diseases of the nails are the result of a general
systemic disturbance, but only the local treatment of such conditions
becomes the province of the podiatrist. It is often necessary to
distinguish between a local chiropodical condition and a local
manifestation of some serious systemic disease; it is then necessary
for the medical practitioner and the podiatrist to join hands in making
a diagnosis for the proper guidance of both practitioners.
=Onychocryptosis=, or ingrown toe nail, is a common affliction of the
nail, and is thoroughly described in a separate chapter.
=Derivation.= From the Greek, onyx, nail, and krypto, I hide or conceal.
=Onychophosis=, or calloused nail groove, is also one of the common
types of nail lesions, and is discussed separately. This lesion
is often mistaken for ingrown toe nail, and treatment, improperly
directed, often causes bad results.
=Onychia or Onychitis= is an inflammation of the matrix with
suppuration and final shedding of the nail.
=Derivation.= From the Greek, onyx, nail, and itis, inflammation.
=Etiology.= Onychia may be due to trauma, causing malformation of the
nail, and subsequent inflammation, but is most usually due to bacterial
infection. Removal of ingrown toe nails under septic conditions, or
the entrance of bacteria through self-inflicted or other wounds offer
opportunities for infective processes on a part of the body none
too clean at best. Syphilis, tuberculosis and eczema are also often
etiologic factors.
=Pathology.= Bacterial infection or trauma causes the nail matrix
to become inflamed, with the accompanying pathologic changes that
occur in all inflammatory processes. There is a gradual solution of
the continuity between the nail proper and the matrix, and as the
degenerative processes continue, namely the formation of pus and the
solution of the tissues which comprise the matrix, the grooves in the
nail matrix, which hold the corresponding ridges of the nail, are lost
and the mechanical union of the two parts cease. The nail subsequently
falls off. If the entire matrix has been destroyed, no new nail will
grow, but this does not usually occur. Malformation of the new nail is
quite common, due to partial destruction of the matrix.
=Diagnosis.= The matrix of the nail is inflamed and severe pain is felt
when pressure is brought to bear on the nail plate. The nail bed and
the nail grooves are often involved and the inflammation may continue
to such an extent as to involve lymphatics and cause destruction of a
large area of tissue.
Pus forms at the root of the nail, and the nail itself gradually
becomes loosened from its bed. In cases due to injury or local
infection, one or two toes may be involved, but when the cause is of
systemic origin, all of the nails, including those of the hand, may
become infected.
=Treatment.= The treatment of simple onychia consists in protecting
the part from further injury and irritation and it often becomes
necessary to cut the shoe to accomplish this. In severer cases, shoes
should not be worn until resolution commences.
Wet dressings are valuable, Burow’s solution or boric acid solution
being all that is necessary in mild cases.
When pus manifests itself, it is necessary to remove the nail over the
abscess and to establish free drainage. Wet dressings of bichloride
of mercury (¹⁄₅₀₀₀) for 48 hours may be used, and when drainage is
complete, the cavity may be swabbed with silver nitrate, 5 to 10%. Dry
dressings of thymol iodide or boric acid powder will usually suffice to
complete a cure.
The parts should be packed with sterile gauze so as to keep the soft
tissues separated from the nail and to prevent irritation and pressure.
This packing should not be too tight otherwise pus absorption with
subsequent infection, is likely to occur.
In extreme cases, in which the surrounding tissues are involved and
destruction has gone on to a greater extent, the entire nail must be
removed, and the matrix destroyed by caustics or by curettage.
=Paronychia, or Paronychitis=, is an inflammation of the tissues around
the nail, and may involve all the tissues of the distal phalanx,
including the bone.
=Synonyms.= Felon, panaris, whitlow.
=Derivation.= From the Greek, para, beside, and onyx, nail.
=Etiology.= Paronychia is usually caused by local bacterial infection,
due to treating the nail grooves with unclean instruments, or it may be
of systemic origin. It is often associated with onychia and in these
cases is due to a spreading of the inflammation of the matrix to the
surrounding tissues. Pressure of an ill-fitting shoe or stocking or of
a foreign body may be a cause, and ingrowing toe nail may later develop
into a paronychia. Syphilis often causes this lesion.
=Pathology.= The pathology of paronychia is much the same as that of
onychia. The tissues surrounding the nail become inflamed, either by
bacterial infection or by trauma, and all the signs and symptoms of
inflammation manifest themselves. Swelling is marked and pus may or may
not be present. Tissue destruction continues unless proper treatment is
given, and the bone is often involved, causing periostitis or osteitis.
=Diagnosis.= Simple paronychia may exist without any hypertrophy
of the nail itself, and may be due to pressure of a shoe or to a
chronic ingrowing toe nail. The great toe is most commonly affected.
The inflammation may be only slight and superficial, or it may be
quite severe with great pain and swelling, terminating in a general
intercellular infection with suppuration. Nourishment is interfered
with and the nail may be shed much the same as in onychia. Pain is of a
throbbing type which is immediately relieved when the abscess cavity is
opened and the pus drained.
=Treatment.= Like onychia, paronychia should be treated with wet
dressings and stimulating medications. In cases in which there is no
suppuration, the following ointment will give good results:
℞ Acidi salicylici grs. X
Ung. hydrarg. amm. Oz. 1
M. ft. ung. Sig. Keep on affected part constantly.
The corners and lateral edges of the nail should be separated from the
soft tissues by means of sterile gauze, or they may be removed. Pus
should be drained, with the assistance of antiseptic wet dressings such
as bichloride of mercury, ¹⁄₅₀₀₀, and if excessive granulations are
present, they should be snipped off or destroyed with silver nitrate.
If necessary, free incisions should be made, which will relieve the
pain as well as assist in draining the pus.
In chronic paronychia it often becomes necessary to remove the entire
nail, including the root, and under local anesthesia, this is easily
accomplished. Rest is essential in these cases, and after suppuration
has ceased, stimulants such as balsam of Peru or ichthyol may be used
to good advantage.
In cases of paronychia, due to syphilis, it must be remembered that
the treatment must be constitutional as well as local and the family
physician of the patient should attend to the former feature of the
treatment. Mercurial ointments, applied twice daily, are usually
employed locally.
[Illustration: ONYCHOGRYPHOSIS]
=Onychauxis=, or hypertrophy of the nail, is an overgrowth or
enlargement of the nails of the fingers and toes. When the hypertrophy
is accompanied by deformity, the condition is called onychogryphosis.
=Derivation.= From the Greek, onyx, nail, and auxe, increase.
=Etiology.= Enlargement of the nail is a result of hyperplasia of the
papillæ of the matrix, the thickening occurring at the base, front,
lateral edges or over the entire area of the nail depending on the part
diseased.
Pressure is no doubt a causative factor, and lack of care of the nails
will also cause a thickening. Injury to the matrix will cause the nail
to become hypertrophied, producing in most cases a true club nail
(onychogryphosis).
Chronic cutaneous lesions, such as eczema or psoriasis and other
diseases such as syphilis, gout and rheumatism, and nervous diseases
or injury to the nerves supplying the nails, may act as causes for
onychauxis.
=Pathology.= Pressure or injury causes a widening of the nail fold
which allows the formation of a thicker nail. The nail bed is irritated
at the same time and a horny mass forms on it below the nail, which
acts as a barrier to the forward movement of the nail cells, and by
raising them up, determines more or less, the degree of deformity. The
papillæ of the matrix become enlarged, and may be seen protruding above
the normal structure, when the nail is removed.
The thickened and deformed nail thus produced, is often the cause of
other nail lesions, due to its pressure on the soft tissues. Bacterial
infection is also common at this point, due to the fact that the mass
of epithelial cells is a good breeding place for microorganisms.
=Diagnosis.= Onychauxis may be congenital or acquired, usually the
latter. Simple hypertrophy of the nail is rarely found, but overgrowth
with deformity is quite common. The nail becomes hardened, due to a
closer cohesion of its component cells; its transparency is lost, and
it assumes a dirty brown or even black color. The surface becomes
rough, due to the presence of longitudinal and wavy transverse ridges.
One or all of the nails may be affected; there may be a simple
thickening or there may be a lateral overgrowth, which may result in
paronychia. The inflammation may be slight or it may be severe and
purulent. The nail, as it continues to become thickened, may assume
various shapes resembling claws, talons, horns, etc. The big toe
nail is the one most usually affected and often only the one foot is
involved. This is indicative of a traumatic etiology.
Tuberculosis patients have a moderate onychauxis in most cases,
particularly on the nails of the fingers, while hypertrophy is often
seen in the inflammatory lesions such as eczema, psoriasis, etc.
Older persons are more liable to be affected with hypertrophy of the
nail than younger persons, as there is a natural tendency to epithelial
overgrowth in the aged.
[Illustration: ONYCHAUXIS]
=Treatment.= To affect a cure in case of hypertrophy of the nails it
is necessary to recognize the cause. Thus, in cases of onychauxis,
in which the general systemic condition is at fault, treatment must
be directed by the family physician along constitutional lines and
includes the taking of tonics, arsenic, mercury, etc. If a cutaneous
lesion is the etiologic factor, it becomes necessary to treat the
case both generally and locally. If the cause be an external one
alone, local treatment is sufficient. For these latter conditions, the
treatment is divided into palliative and radical procedures.
The _palliative_ treatment consists in keeping the nail properly cut.
For this purpose, the rotary file, or surgical drill, as it is called,
is very efficient. Suitable burrs are used, and care is taken that the
skin of the nail grooves is not injured. Infections are easily caused
through the careless use of this instrument. After the nail has been
thinned and is as nearly like a normal nail as is possible, the part
should be cleansed with alcohol, and tincture of iodine (4%) should be
applied. The grooves may be packed with sterile cotton and covered with
collodion (cocoon dressing) which will avoid any tenderness that may
be felt after the nail has been cut down. The hard nails may also be
softened by the application of sodium sulphide or liquor potassae and
when softened, may be scraped away.
If thickened or club nails become very painful, it is often necessary
to resort to _radical_ measures, as this is the only permanent cure
for this trouble. The entire nail must be completely removed under
local anesthesia, and subsequently the entire nail matrix should
be thoroughly scraped away by means of a sharp curette. The wound
thus produced is kept in sterile dressings and is allowed to heal
by granulation. It is quite common to find only a small area of the
matrix that is vital, particularly in chronic cases of club nail, so
that curettage is really a simple procedure. A complete cure should be
effected in from two to three weeks, the patient being able to walk
with a cut-out shoe two or three days after the operation.
=Onychatrophia=, or atrophy of the nails, is a condition in which the
nails of the toes and fingers become smaller and often are shed from
the grooves in which they are contained.
=Derivation.= From the Greek, onyx, nail, and atrophia, atrophy.
=Etiology.= Atrophy of the nails may be caused by any one of many
factors, among which are the inflammatory skin diseases, nervous
diseases, constitutional disorders and injuries.
Injury to the nail matrix causes complete or partial cutting off of
nourishment. If the nourishment is completely cut off, the nail matrix
will disintegrate and cause the nail to be shed. New nails usually
grow in these cases. If the injury is less severe, there is only a
temporary arrest in the nail growth, and the nail becomes thin and
small discolorations are seen in the nail substance.
Inflammation of the soft tissues around the nail which is accompanied
by suppuration, may cause atrophy and shedding of the nail. The nail
will grow again as a rule, but often when the etiology is systemic, the
new nails shed as soon as they are formed (onychia maligna).
In nervous diseases, such as cerebral paralysis, tabes dorsalis,
syringomyelia, leprosy, division of the nerves, etc., from the
vasomotor disturbances due to the nerve lesion, a bleeding may occur
about the posterior nail fold, and atrophy of the nail may result. The
nails, as a rule, usually grow again.
In stasis of the blood stream in the extremities due to heart lesions,
in venous congestion from emphysema, or in any lesion in which the
circulation is impaired, the nails may undergo atrophy, particularly
the nails of the fingers.
Diseases causing scarring of the nail matrix, such as pustular
syphilides, gummata and variola, give rise to a partial destruction
of the matrix and a shedding of the nail. Subsequent scarring may
completely destroy the matrix, so that no new nail can grow.
In systemic diseases that cause wasting of the tissues, such as chronic
tuberculosis, nephritis and diabetes mellitus, the matrix is usually
under-nourished and the nails become discolored, soft and brittle, and
often crumble.
Chemical poisons, such as arsenic, silver and lead, may cause atrophy
of the nails. Those who work with chemicals and are compelled to put
their fingers in acids and in alkalies often develop brittle, opaque
nails. In general toxemias, the affliction of the nail is caused by
interference with the nail nourishment at the matrix.
=Pathology.= When the nourishment of the matrix has been interfered
with, the cells do not develop as rapidly as they should, and the nail
becomes thin and streaked. The lustre is lost and the nails become gray
or yellow, and often also become brittle. If the grooves in the nail
bed are destroyed, the mechanical attachment between it and the nail is
lost and the nail is cast off. Infective processes cause complete or
partial destruction of the matrix by solution, and this in turn causes
complete or partial loss of nail. White spots (leuconychia), said to
be due to the entrance of air under the nails, are often seen, and
gradually move toward the distal end of the nail.
=Diagnosis.= Atrophy of the nails may be congenital or acquired, the
former being rare and usually accompanied by imperfect development of
the phalanges and scantiness of the hair throughout the body (alopecia
universalis). Acquired atrophy in some form is the usual condition.
The nails present various appearances. They may be thin, soft,
brittle, lustreless or opaque, split very easily, may be streaked or
even worm-eaten in appearance. One or all of these conditions may
be present. Thinning and splitting of the free ends may accompany
systemic diseases, and some chronic inflammatory (especially scaly)
skin lesions. Some nails are thinned at the ends with a central fissure
extending toward the root. Transverse thinning or furrows are met
with in fevers. The nails are always affected when nutrition has been
lowered, due to depression of the general health.
In wasting diseases, such as chronic tuberculosis, diabetes, etc., the
spoon-nail is observed. This is a condition in which the lateral and
free margins are raised, leaving a spoon-like depression in the centre.
Trauma, parasites, lowered nutrition and nervous diseases cause a
crumbly, brittle nail. This is fairly common, and may be limited to one
or more nails of the toes and fingers or it may be general. The atrophy
may begin at either end, and extend forward or backward.
=Treatment.= Treatment of a local nature is worthless if the cause
be systemic. Much like hypertrophy, the cure of atrophy depends on
an exact determination of the etiology. Systemic treatment along
proper lines will usually effect a cure. Local treatment consists in
protecting the nails from irritation and sometimes even from water.
The nails should be cut even and smooth and mollifying ointments
and lotions are advisable. Cocoon dressings are very efficient
for affording protection. In atrophy, due to local circulatory
interference, balsam of Peru (50%), in castor oil, or even pure, will
stimulate nail growth. This should be applied once a day and can be
retained by cocoon dressing. As a soothing agent the following may be
employed.
℞ Acid. boric.
Bismuth. subnitratis aa 0.60
Ung. aquae rosae
Unc. zinci oxidi aa 16.00
M. Ft. ung. Sig. Apply to the nails morning and night.
=Onychoptosis=, falling off of the nail, and =Onychorrhexis=, brittle
nail, are atrophies and have been discussed as such in the preceding
sub-head.
CHAPTER XVI
FISSURES, BLISTERS, AND BURNS
FISSURES (_Fissura_)
=Definition.= Fissura or fissures, as used in this sense, are cracks or
clefts in the surface of the skin, some involving only the epidermic
layers, some penetrating deep into the corium.
=Etiology.= Fissures occurring on the foot, due to trauma, are far in
the minority as compared with those occurring as secondary lesions
in hyperidrosis, uric acid diathesis and other systemic conditions.
They are usually due to a too strenuous drying of the interdigital
surfaces with a rough towel. They may also be caused in like locations
by excessive walking, but the condition of the skin of the patient has
much to do with their formation. If the skin be dry and a great amount
of its elasticity is gone, these lesions are much more prone to develop
than where the skin tension is practically normal. The interdigital toe
webs are often cracked or fissured in spreading the toes too far apart,
and this has been caused, at times, by the podiatrist working between
the toes and stretching them to obtain room for his instruments or
dressings.
=Treatment.= The natural treatment for a condition of this kind
would be to obtain astringent action. This may be accomplished by a
number of drugs, principal among which is silver nitrate. Tannic acid
preparations are also frequently used, but they cannot compare in
efficiency with the silver salt. A number of mild vegetable astringents
of the same group are similarly employed by podiatry practitioners.
If the fissure is superficial, involving only the epidermic layers,
compound tincture of benzoin, painted freely over the parts, after they
have been thoroughly cleansed and dried, will be found advantageous
in inducing rapid healing. Dusting powders such as tannoform,
bismuth subgallate, bismuth subnitrate and thymol iodide, may also
be successfully employed in these cases, but where the fissure is
deep, the edges angry and red, and the whole area is involved in the
inflammatory process, none of these are, as a rule, of avail, and more
radical methods must be employed.
Nitrate of silver presents the most efficient means whereby astringent
action may be obtained in the parts. Weak solutions, from 1% to 10%,
are most generally employed, but it is often found necessary to use
stronger solutions, even as high as 50%.
[Illustration: FISSURED TOE WEB]
=Technic.= The parts are first thoroughly cleansed and any callous
around the edges of the fissure is carefully and completely removed.
This is an essential procedure, for no lateral granulation will take
place, nor can direct apposition be obtained if this callous be allowed
to remain.
Small particles of material from the hosiery or other foreign bodies
should also be thoroughly removed. The recesses of a deep fissure
present excellent places of lodgment for minute particles which are
always to be found in footgear, and it is these bodies which produce
infective processes. The above precautions having been observed,
alcohol, 60%, should be freely applied and the parts thoroughly dried.
Silver nitrate may then be painted deep down into the floor of the
fissure, by means of a cotton wound applicator. This will produce some
smarting, but it is transient and there will be no great amount of
irritation. The silver solution should also be applied to the surfaces
adjacent to the edges of the fissure, for it must be remembered that
silver nitrate is sedative and this action is desirable in reducing the
local inflammation.
Where the fissure is deep and of long standing, it may be found
necessary to resort to a 25% or 50% solution or even to the fused
stick. When cases are observed where proud flesh has developed in
the fissure, due to continued irritation, it is necessary to use the
stronger solutions or the stick at once. The proud flesh may be in such
form as to permit of surgical removal. Where this can be accomplished,
the bleeding stump is usually cauterized with silver solution, 50%. If
a surgical procedure is impractical, the fused stick may be used to
cauterize the neoplasm and thus eradicate it.
A dressing should be applied over the parts after the fissure has been
treated. This may consist of several thicknesses of gauze, fashioned to
fit between the toes, if the fissure be in that location; if the lesion
be upon a plane surface, a square of gauze should be applied and held
in place by adhesive strips.
A cocoon dressing may be substituted for that of gauze, and in many
instances will be found more practical. It has been found necessary
at times to apply some ointment or grease over the fissured area to
aid in softening the parts and rendering them more flexible. Massage,
at intervals, with olive oil or mutton tallow, will also be found
advantageous in bringing about this result.
No dressing is applied over the parts after the use of compound
tincture of benzoin, for this drug forms its own coating, which is
practically impermeable. If a dusting powder be used alone, the parts
are first thoroughly dried, whereupon the powder is dusted lightly into
the fissure, and a wisp of cotton is placed over the part and held in
place with collodion.
Pure ichthyol has also been found efficient in these instances; a drop
is placed in the fissure and is retained there by means of cotton or
gauze.
Astringent treatment, as described, should be continued until the
fissure has entirely healed, and in the use of silver nitrate it will
be found advisable to remove all remnants of the previous application
before the drug is again used. The eschar is easily removed, but it
must also be remembered that in some instances it may be advisable
to allow the eschar to remain, and the wound to granulate under its
protective covering.
This article has been confined almost entirely to fissures occurring in
the interdigital webs for the reason that these parts are their usual
sites of occurrence. At times, however, they do form in other parts of
the foot--on the heels along the sides of the foot, and on the ends
of the toes. The treatment in any locality is similar. When infection
is present it should be arrested; if proud flesh has developed, that
must be eradicated; in all cases astringent treatment is necessary to a
successful outcome.
BLISTERS (_Bullae_)
=Definition.= A blister is a collection of fluid in the skin beneath
the outer epidermic layers, which latter are raised to form the upper
wall of the sac, the base of the blister being formed by the mucous
layers of the epidermis or by the corium.
=Etiology.= The cause of practically all blisters met with in podiatry
is traumatism. Those occasioned by the friction brought to bear on
the surfaces of the foot by a new or unyielding shoe predominate, but
occasionally the podiatrist is called upon to treat these lesions
arising from a burn. In discussing the subject of blisters under this
heading, those of traumatic origin only will be considered. Those
occasioned through burns, or superficial vesicular developments of
specific origin will be discussed in chapters dealing with the disease
or diathesis in connection with which they may develop.
=Pathology.= The pathologic process causing the formation of a
traumatic blister is a simple one. Due to the constant rubbing of a
shoe, the superficial epidermic layers are loosened up, one layer from
the other, and, owing also to this external irritation, the serous
elements of the blood are caused to leave the vessels and thence find
their way into the intercellular spaces caused by this loosening.
Collections of fluid of this nature are known as bullae or blisters.
The so-called “blood blister” is of a similar origin except that the
injury (in this case usually a severe trapping or pinching of the
tissue) is sufficient to cause the rupture of one or more capillaries
whose blood contents extravasate into the overlying epidermic layers.
=Usual Points of Location.= Blisters developing upon the pedal
extremities are most common in the spring of the year when people
begin to wear Oxford ties or other styles of low shoes. They occur
principally upon the posterior surfaces of the heel at the upper
extremity of the os calcis, or upon the tendo Achillis, just above this
point, and are caused by the rubbing of the stiff heel of the shoe upon
these parts.
Bullae are also often found to develop over or immediately adjacent to
the prominent extensor tendon on the dorsum of the hallux. In these
locations the stiffness of the shoe in “breaking” over this point is
found to be the irritant agent.
Whilst the two foregoing locations are the most general sites of
occurrence, they are, at times, also found to develop upon the plantar
surfaces, and in some instances upon the ends or between the toes.
=Treatment.= The method of treatment to be accorded these cases depends
upon the condition that the affected part may be in at the time of
observation.
=Ordinary Conditions.= When the blister is found to be unbroken and
no great degree of inflammation is present, the sac should be opened
and its contents evacuated. This is best accomplished by means of a
fine-pointed, sterile scalpel or bistoury. The blister is punctured
through the unaffected epidermis immediately adjacent to its base,
and thereupon gentle yet firm pressure is exerted until all the fluid
contents are evacuated.
Once the contents have been removed, thorough asepsis should be
inaugurated. The parts should be swabbed with alcohol, 60%, and
allowed to dry by evaporation, or be dried with a sterile wipe. In
dressing these conditions it must be remembered that protection must
be obtained as well as granulation induced. Recognizing these to be
important factors in treatment, the choice of a proper dressing should
be carefully made.
The cocoon dressing (see “_Dressings and Bandaging_”) is practical in
these cases, as the cotton serves to afford great protection to the
parts and also to confine whatever medication is to be applied as a
curative agent.
Dressings of sterile gauze or surgeon’s lint may also be used, and
consist of a square of gauze or lint applied over the part and held in
place by means of adhesive strips.
The cocoon dressing may or may not be reinforced by adhesive strapping,
as the judgment of the operator determines. If strapping becomes
necessary in this connection, half-inch or one inch width plaster is
generally used. The strips (each about three or three and a half inches
in length) are applied in the form of a triangle, binding down the
edges of the dressing. It is also found advisable to avoid using too
much collodion on the cotton. These dressings should never be hard; it
is, therefore, preferable to bind down the edges and then merely paint
the collodion in one narrow strip across and with the fibre of the
cotton. If adhesive strapping is to be used for the adherence of gauze
or lint, the one-half inch plaster is the most practical in almost
every instance.
The strips are each cut about three inches in length, unless the size
of the gauze or lint squares makes it desirable to have them longer,
and they are placed in rectangular fashion over each of the four sides
of the dressing. It should always be the endeavor, when possible, to
bind down the edges of the fabric to the skin, and to accomplish this
the adhesive strips are made adherent, half on the dressing and half on
the underlying skin. This serves to hold the dressing more firmly in
place and also to prevent foreign matter from getting under its edges.
Ointments are generally found to be the most advantageous applications
in cases of ordinary bullae. There are several of these from which we
may choose. Ammoniated mercury, 10%, and ichthyol, 10%, are probably
the most generally used and are efficient.
=Broken Conditions.= In many instances the blister, through neglect
and improper puncturing, has become broken and the affected epidermic
layers are stripped off, being attached at one point only, or are
entirely gone.
The parts should be thoroughly cleansed with alcohol, 60%, and all
loosened epidermis removed. Never leave any flaps of skin about the
edges of the denuded area, for they not alone serve as excellent places
for the lodgment of hostile bacteria, but are also apt to curl up and,
becoming thickened, may irritate the denuded surfaces by pressure.
The lesion being thoroughly aseptic, a dressing should be applied. If
infection be already present in the part, the treatment should consist
of the application of wet dressings of mercury bichloride, ¹⁄₂₀₀₀,
or weaker, until all inflammation has subsided. If no infection be
present, a dressing which will be protective, healing and sedative
should be placed over the parts. A shield is usually a necessary
adjunct to every successful treatment in cases of this nature.
It will always be found advisable to have the aperture of the shield
sufficiently large, not alone to protect the denuded area, but also to
include some of the surrounding integument.
In locations about the os calcis region and along the surfaces of the
tendo Achillis, an oval pad of a soft grade of felt is found to afford
the best protection. In cases where the blister has developed over the
extensor tendon on the dorsum of the great toe, a strip of white felt,
about one inch long and one-half inch wide, placed parallel to the
tendon, and of sufficient thickness to be higher than its elevation, is
found to be the most practical means of shielding the affected area.
An oval shield, if used in this latter instance, should have a groove
fashioned on its under surface in which no adhesive is placed and which
allows for the free play of the tendon in movements of the foot.
The choice of an ointment, if one is to be used, should be carefully
made, for asepsis is to be at all times maintained and granulation must
be induced.
Ammoniated mercury, 10%, and sulphur, 10%, are to be highly recommended
as antiseptic ointments, and the latter, in particular, has tissue
stimulating properties. Ichthyol, 10%, balsam of Peru, 5%, or scarlet
red, 3%, may also be used, the latter two where the lesion shows signs
of indolence and needs stimulation.
At times a dry dressing, either of plain sterile gauze, or gauze,
combined with a dusting powder, secures good results in these cases.
Thymol iodide and bismuth subgallate probably lead the list in
popularity but a very efficient substitute is found in a combination of
equal parts of bismuth subnitrate and powdered calomel.
The areas should be thoroughly dried before any dusting powder is
applied. This is best accomplished by applying alcohol and allowing
it to dry by evaporation, which may be hastened by blowing air upon
the area. A practical means of applying dusting powder is afforded by
compressed air. Under low pressure any powder may be blown from the
nebulizer upon the parts in a thin and even coating.
Both the ointment and the dry dressing should be changed in from
twenty-four to thirty-six hours until complete granulation is observed
and the structures of the denuded corium are entirely covered.
Dressings which are allowed to become stale and which harden, are apt
to act as irritant agents to the tender granulating surfaces and not
only retard normal healing but further break down the tissues.
Cocoon dressings may also be employed to apply either ointments or
dusting powders, as just described for gauze. They will remain in place
for much longer periods of time than will gauze or lint, but in these
cases, as the dressing must be changed daily, this is not an important
consideration.
=Prognosis.= The tissue lost in blister cases properly dressed and
protected should be replaced rapidly and stimulation is seldom found
necessary. The course is active but short. It is advisable to have
the patient refrain from wearing the shoe which originally caused the
disturbance so that no untoward irritation is brought upon the part
during treatment. After the epidermis covering is complete, it will be
found advantageous to paint the parts with silver nitrate, 50%. The
eschar so formed will act as a protective agent to the parts until the
skin regains its normal strength.
BURNS
The podiatrist is not called upon to treat many burns on the foot, and
when these conditions are present they are, as a rule, not extensive.
The subject is so important, however, and so much progress has been
made in recent years along the lines of burn treatments, that a
thorough knowledge of this subject is of great interest to the modern
practitioner.
=Definition.= A burn is a lesion caused by heat or by caustics. The
lesion may be superficial in the tissue involvement or it may have
penetrated to the deeper tissues and, if extensive, may cause permanent
injury or death.
=Pathology.= Intense heat being applied to the surface of the body
destroys the vascular supply, and so shocks the nervous sensibility
of the part that the nerves are temporarily, sometimes permanently,
paralyzed. This causes the tissue to slough and a more or less deep
ulceration is formed. The edges are found to be a dark, angry red in
color and the floor of the ulceration is usually a pale, unhealthy
yellow or white. In small areas the pain is intense, while if large
areas be involved to such an extent as to include the main trunks, the
parts rapidly become anesthetized and gangrene ensues. Discharge from
the ulceration is generally profuse.
As the podiatrist will only come in contact with the smaller burns the
discussion in this chapter is confined to their consideration.
=Treatment.= The burn, whether caused by direct heat or by chemical
reaction, is at first aseptic and this asepsis must be maintained
throughout the entire treatment. If the burn is very recent, an
immediate application of carron oil (equal parts of linseed oil and
limewater) will be found to relieve much of the pain, and to keep
the tissues in fairly healthy condition. If this medication is not
obtainable, a paste of sodium bicarbonate will also prove efficient.
All air should be excluded as soon as possible, and many advocate the
application of a simple grease smeared freely on the abraded surfaces.
These are purely first aid procedures, however, and have no part in
scientific treatment.
After the acute pain has been reduced or entirely relieved, treatment
should be instituted which will at once induce granulation and maintain
asepsis. Strong germicides, particularly those with toxic properties,
should be studiously avoided, for it must be remembered that the
vitality of the part has been severely shocked, even in a superficial
burn. Nothing must be done to retard the healing process.
Ointment or dusting powder dressings are advocated in these cases,
but the most efficient treatment lies in the use of one of the newer
paraffin preparations (see _Dressings and Bandaging_). The method
of application of these paraffins is as follows and is the original
technic as formulated by Dr. de Sandfort, who is the originator of this
method of treatment:
=Method of Use.= Paraffins are used warm, consequently in a liquid
state (158°-176° F.).
=Heating.= Place a piece of the material in a bowl, tin cup, or other
convenient receptacle, set in any vessel containing a little water,
which should be kept on the point of boiling for ten minutes.
=Precautions to Be Taken.=
1. Care should be taken to prevent the splashing of the boiling water
into the container holding the paraffin. When the water begins to boil,
reduce the temperature to avoid drops of water being thrown into the
wax. It must be remembered that these compounds, completely devoid of
water (anhydrous), do not burn the tissues at 176° F., while even the
smallest quantity of water added would have the contrary effect.
2. While the mixture is being heated, cut a piece of absorbent cotton
of sufficient size to amply cover the burned area, and divide it into
layers as thin as possible. At the same time, have ready the gauze and
band, needed to bind and keep the waxen shell in place.
=The Dressing.= When the paraffin is in a liquid state, and is at a
temperature of from 140° to 150° F., take a soft camel’s hair brush,
dip it into the mass and spread it on the wound, without pressing;
that is, as much as possible dabbing it on and not brushing it on.
This operation is repeated until the glazing is complete, taking care
to leave no spot uncovered. Immediately afterwards, place quickly on
the first wax glaze one of the thin layers of absorbent cotton already
prepared, as explained above, so that it becomes easily impregnated
with the wax, and then, with the same dabbing movement, brush on
several more applications of the paraffin.
If the wound is extensive, the operation is done on small square
surfaces, successively and close together (about 4 by 4 inches). These
little surfaces become, by the application, part of one another. This
proceeding is to avoid the first coat of glaze, because it is essential
to form (on the whole surface of the wound) a shell uniformly warm
which keeps its warmth a long time, thanks to the close attention of
the wax with absorbent cotton. Two layers of cotton can be applied
successively, saturated with the mixture, although this is not
indispensable.
When the application is complete, the dressing is finished by binding
with ordinary gauze or cotton, kept in place by bands. If desired,
gauze can be replaced in part by oiled silk, or even paper.
=Note.= In not following the precise instructions already given, grave
errors can be committed. Thus, should the layer of absorbent cotton be
applied directly to the wound and afterwards covered with the first
layer of the paraffin it causes:
1. A very painful burning sensation. These applications on a wound
are very soothing, while cotton impregnated with the paraffin applied
direct to the wound causes a distressing, burning sensation.
2. At the moment of removing the dressing, a pulling and even tearing
of the tissues is caused. If the wound has not been previously glazed
by an application of a first layer of paraffin, as explained above, the
cotton will adhere.
=Removing the Dressing.= For the first few days the waxen shell must
not be left in place for more than twenty-four hours, on account of
an abundant secretion of lymph, which takes place beneath it. The
sero-purulent liquid flows under the wax covering (which proves that
the waxen layer does not adhere to the tissues like collodion, with
which paraffin has been wrongly compared) and exudes from under the
edges of the dressing. After a few days, this exudation diminishes and
the dressing can be left in place for forty-eight hours at a time and
even longer.
To remove the dressing, untie the bands and take off the ordinary
gauze or oiled silk, thus exposing the “shell.” An incision is made
in the “shell” by means of a blunt knife or scissors and it is easily
peeled off. The dressing is removed more easily than a glove. The wound
is afterwards bathed with boiled water and the cleansing is further
perfected by washing with absorbent cotton soaked in boiled water. Then
it is dried, either by a current of warm air or by a piece of cotton
wool, care being taken not to rub, or cause the granulations to bleed.
The new dressing is not applied until the surfaces are thoroughly dry.
=Important Recommendations.=
1. In washing the wounds, antiseptic solutions must not be used, unless
extremely weak.
2. Anxiety need not be occasioned by the grey aspect and fetid odor
which emanates from the wound when the waxen shell is removed. In fact,
after this washing, it is seen that beneath this purulent liquid, the
tissues present an intense vitality and an excellent appearance. In
order to properly proliferate the elements of healing, it even seems
as if they have need to bathe in this purulent liquid, which might be
termed auto-serotherapia.
3. In application, the wax should be brushed on with strokes or daubs
all directed the same way, and these should commence at the top of the
part and be carried downward, never starting at the bottom and going
upward.
After several days of treatment, skin granulation will be observed,
white spots appearing more especially at those points, where the
sero-purulent liquid has remained in the greatest abundance.
Care should be taken not to apply paraffin at a temperature of more
than 105° F.
Contrary to the usual practice, the abundant granulations must never be
cauterized with nitrate of silver or any other caustic. In spite of
their development, at times considerable, little by little they begin
to be strangled by the regenerating elements of the skin, which finally
replace them.
In case of persistent atony of the wound or of excessive growth of
granulations, the paraffin treatment can be interrupted every three or
four days by a wet dressing (water slightly alcoholized) for a period
of twenty-four hours. Paraffin treatment is afterwards resumed, which
the patient often requests himself, on account of the comfort derived
from the waxen shell.
After some days of treatment, there appears sometimes on the healthy
skin surrounding the wound an eruption of sudamina, caused by the
perspiration confined under the waxen shell. To make it disappear,
cover it with an ointment of oxide of zinc, then powder with talc,
always continuing the paraffin application over the wound.
=Conclusions.=
1. Paraffin preparations instantly alleviate the pain.
2. They constitute a warm shell, a heat retainer, under which the
tissues, protected against outside contamination and maintained at a
temperature always constant, rapidly heal.
3. They become non-adhesive after a short period, thus rendering
removal instantaneous, without pain, without hemorrhage and without
tearing the tissues of neo-formation, thus permitting the integral
healing of the tissues, without apparent scars, without contraction of
the skin or of the tendons.
4. Without causing persistent and incurable functional weakness.
=Important.= Heating these preparations in a bath of boiling water
raises the temperature to nearly 212° F., therefore, before applying to
the wound, they should be removed from the water bath and allowed to
stand for a minute or two so as to reduce the temperature below 105° F.
If an ointment be used, a bland healing type should be chosen.
Among these ichthyol ointment, 5% to 10%, is probably found to be as
efficient as any, although zinc oxide, 10%, balsam of Peru, 5%, and
various sulphur ointments, 3% to 10%, may be substituted with equal
results.
On a freely discharging surface, of course, an ointment is
contra-indicated and a dusting powder must be resorted to or merely a
dry aseptic gauze dressing applied. The dusting powders to be used are
the two bismuth salts, subgallate and subnitrate, although the latter
is found to be irritant at times; thymol iodide may also be used and
its antiseptic and healing action makes for its general popularity in
these cases.
The ointment or dusting powder is covered with a cocoon, gauze, or
lint dressing which is held in place by collodion or adhesive strips,
respectively.
The dressing should be changed daily until granulation is complete.
Burns are stubborn lesions to heal and the podiatrist should not slight
them in any way. They are prone to infective processes, and the least
neglect is apt to cause the undoing of all that previous treatment has
accomplished.
CHAPTER XVII
BURSITIS
Bursae are closed sacs or pouches containing fluid, found in all
parts of the body, covering and protecting exposed or prominent bony
surfaces, and interposed between tendons and parts over which they
play. They serve as protective cushions to prevent physiologic wear and
tear.
There are two varieties of bursae found in the human body: the bursae
mucosae, those secreting a mucous or a gelatinous substance, and the
bursae synovia, those secreting a thin, viscid substance, and which are
similar in structure to synovial membranes.
The principal form of bursae found in the foot is of the synovial type
and for this reason the treatment of this variety is that discussed
in this chapter. Bursae may be either deep-seated or subcutaneous and
the latter variety are those which, through trauma, usually become
inflamed and troublesome in the regions of the foot. The deeper seated
bursae, however, often become involved in a pathologic process, and
the podiatrist is called upon to treat these cases as well as those
involving subcutaneous variety.
=Definition.= Bursitis is an inflammation of the bursa sac. The
inflammation may be acute, subacute or chronic. Acute bursitis is a
condition in which the general inflammatory symptoms are active, the
course short, and in which the overproduction of synovial fluid has
found an outlet and is discharging on the surface of the skin. Subacute
bursitis is a condition in which the inflammation has not reached a
true acute stage, but in which it is more in evidence and more active
than in the chronic form. Chronic bursitis is a condition in which the
inflammation is long standing and of an inactive nature and where no
great amount of overproduction of synovia is in evidence. In chronic
cases the walls of the sac itself are generally found thickened and
leathery; where this condition occurs in the bursa over the first
metatarsophalangeal joints it is often inadvertently called a “bunion”.
[Illustration: ACUTE BURSITIS]
=Etiology.= Bursitis occurring in the foot is in nearly every instance
due to trauma. A blow, a knock, a part being stepped on, or the
continued pressure of an ill-fitting shoe, may be the exciting causes
of this disturbance. Malalignment of a joint may be a secondary cause,
such as would occur in hallux valgus. In this instance the deep-seated
bursa would be affected. Bursitis would hardly develop from this alone,
however, and the exciting cause is found in the pressure of footgear or
some other injury to the part.
=Location.= As bursa sacs are only found covering a bony prominence,
or interposed between the sheaths of tendons and muscles, or between
these structures and the skin, serving in each capacity to prevent
physiologic wear and tear, bursitis occurring in the foot will be found
in these locations.
The first and fifth metatarsophalangeal joints (metatarsophalangeal
bursitis); the interphalangeal joints of the toes (interphalangeal
bursitis); the posterior and outer surfaces of the os calcis
(retrocalcaneal bursitis); and the tarsometatarsal region on the dorsum
of the foot (dorsal bursitis) are the principal sites of occurrence.
The base of the fifth metatarsal is also a spot over which bursal
inflammation will occasionally develop.
=Pathology.= The pathology of bursitis is primarily that of any
inflammation. Due to trauma, the parts are subjected to a severe
irritation which causes an engorgement of blood in that location.
Serous infiltration of the tissues takes place and the functional
activity of the sac is increased. Materials from the blood for the
production of synovia, are secreted in abnormal amounts, and in
consequence the sac becomes distended from the superabundance of fluid.
In time this fluid must find some outlet, for synovia is secreted
so rapidly that the lymphatic system cannot absorb the excess. This
outlet must naturally develop toward the point of least resistance,
which, in these cases, is outward toward the periphery. The tissue
is broken down to a small extent and a minute sinus is formed which
permeates the tissues and opens upon the surface of the skin. From the
peripheral opening the excess of fluid is thrown off, and when this
stage is reached the distension in the part is naturally lessened and
the patient is fairly comfortable.
=Symptoms.= _Objective Symptoms._ The parts will be found considerably
swollen, red and hot. Loss of function is noted and fluctuation is
present.
_Subjective Symptoms._ Pain on slightest pressure and at times upon
forced movements; impaired function; heat, and a feeling of fullness or
distension in the part.
=Characteristics.= The characteristics of bursitis, whether acute or
chronic, are so plain that no error in diagnosis should ever be made.
However, many of these cases are mistaken for suppurated helomata,
probably through the fact that both are conditions in which a discharge
is present. Why this error should be made is a mystery, for while it is
true that there is an exudation in both instances, the characteristics
of the discharges are so different that only a careless or
inexperienced person could mistake one for the other. The important
characteristics are:
(1) The distension in the bursa sac proper causes a swelling of the
parts adjacent and superjacent so that the whole area over and around
the affected part will be found enlarged and puffy. Fluctuation is
present and often the sac itself may be grasped in the fingers, so
distended are its walls.
(2) Removal of the overlying calloused area, should one be present,
brings to view the sinus opening, in the acute stage. The tissues
are blanched in appearance and are leathery and hard to digital or
instrument touch. The opening of the sinus is usually very small
and its edges are circumscribed and even. The sinus itself has the
appearance of a healthy granulating surface and at no time is there
apparently any membranous lining. Probing will determine that the sinus
follows an almost vertical course with no sub-borrowings or offshoots
in any direction. There is no loss of tissue upon the surface of the
skin, such as would be found in connection with an heloma involved in a
suppurative process, except at the opening of a canal.
(3) Digital pressure exerted laterally and anterio-posteriorly usually
is rewarded by the oozing of a thickish, viscid, almost colorless
fluid from the sinus opening. There is nothing in the appearance of
this fluid that should lead one to mistake it for pus. Very often this
fluid oozes from the part of its own volition, due probably to the
pressure of the excess fluid in the sac beneath. The fluid causes no
active decomposition of hydrogen dioxide and the ebullition caused by
the contact is almost negative. This constitutes one more point of
differentiation between the changed synovial fluid discharged from an
acute bursitis and a pyogenic exudation.
=Treatment.= The treatment of bursitis varies according to the degree
of inflammation, and the general conditions present. We may divide the
treatment into three classes: the radical operative, the non-radical
operative, and the palliative. The first mentioned is a purely surgical
procedure, complete in itself, and consists in the removal or curettage
of the inflamed sac. The last two are usually combined and are
procedures which are generally practised by the podiatrist.
=The Radical Operative Treatment.= Under proper aseptic conditions an
incision is made in the overlying tissues and the sac is removed in its
entirety; the parts are then sutured, and a few days rest and elevation
of the foot brings complete union. This method may be varied in that
the sac is not removed, but a free incision is made into it and the
parts thoroughly curetted. One other of the purely surgical procedures
is to make a free incision into the sac to accomplish thorough
drainage. This latter procedure is generally practised in cases of
infected bursitis.
Inasmuch as the non-radical operative and the palliative methods of
treatment are purely podiatry procedures and are usually combined, they
will be discussed as one subject.
=The Non-Radical Treatment.= There are several methods by which
bursitis in its various stages may be successfully treated. They vary
in some details but all agree on two most important points: rest and
the absence of pressure.
A bursitis developing over a bony prominence upon the foot, usually
occurs in connection with some form of superficial callosity or an
heloma. The inflammation of the sac may be due to the neglect of a
growth of this nature, or, as previously explained, to some distinct
injury to this part.
To successfully treat a condition of this nature it is found necessary
at all times to accomplish the removal of the excrescence. This is done
in the usual manner by either the shaving or dissection method. These
growths must be removed for several reasons:
(1) To remove all hardened and thickened epidermis so that no further
irritation from that source will be present.
(2) To allow the operator a chance to effect drainage for the
overproduction of bursal fluid.
(3) To allow the medications used to come in direct contact with the
underlying tissues without the necessity of penetrating several layers
of epidermis and expending their action upon and through them.
Under proper aseptic conditions, the superficial thickened epidermic
layers are removed and the excess fluid is allowed to drain off. It
will often be found that the callous forms a “plug” which extends down
into the surface opening and prevents this excess fluid from being
thrown off. Once this drainage is accomplished, other procedures,
dependent upon conditions present, should be utilized for the
alleviation and cure of the bursitis.
=Rest.= By far the most effective means of bringing about a speedy
cessation of the inflammation occurring in the bursa sac is to procure
absolute rest for the part involved. It has been noted that in a number
of cases when no medical or surgical treatment has been afforded,
inflammations of this nature resolve themselves speedily upon complete
rest. There is nothing remarkable or supernatural about this for
inasmuch as the bursa is only used during the movements of a part, it
is easily understood why a trouble of this nature will clear up rapidly
if the part is kept immobile.
=Removal of Pressure.= There are many cases of bursal inflammation
which occur in people who are not able to lay up and give complete
rest to the affected part. The next most effective measure in these
cases is the judicious and proper use of shielding. In applying a
shield to a case of this nature it should always be remembered that
the parts affected are usually swollen to a considerable extent around
the tissues immediately overlying the sac itself. For this reason a
shield such as would be employed for the protection of an heloma in a
like situation, is not practical. This is more particularly the case
where the bursitis is located on one of the interphalangeal joints of
the toes. In this location an individual shield which is to rest on
the affected toe alone cannot be applied, for the whole area overlying
the inflamed sac will be found swollen and leathery and the tissues
anterior and posterior, as well as those covering the interdigital
surfaces of the toe, are ordinarily more or less involved in the
general inflammation. In this instance, then, we must resort to some
sort of shielding which will take the shoe pressure from the part, and
yet which will be distributed over the whole digital surface and not on
the diseased toe alone. A dorso-digital oval or crescent shield (see
chapter “Shields and Shielding”) answers the purpose and is entirely
effective in most instances.
Probably the most practical method of removing all pressure from the
inflamed areas is to have a circular portion of leather immediately
overlying the part removed from the shoe and another softer piece
adhered over the opening. The appearance of this will be inconspicuous
and the small pouch thus formed allows the patient to wear a shoe,
affording comfort, which, however, exerts no pressure upon the lesion.
It is wise to remove a piece of leather considerably larger than the
circumference of the affected part, otherwise the edges of the aperture
cut in the shoe may become depressed and press upon and irritate the
already inflamed areas.
=Strapping.= Enlarging upon the theory of rest, inasmuch as complete
absence of movement aids materially in reducing the local irritation,
strapping is a practical means of immobilization.
This procedure, although used in these situations, is not so practical
in bursitis occurring over the first and fifth metatarsophalangeal
joints, or over the interphalangeal joints, as it is in other locations
upon the foot.
Adhesive strapping is applied in such manner and at such tension as
to accomplish almost complete immobilization, and for this reason it
will be readily seen that this method cannot be used in cases where the
added pressure will produce additional irritation. Several lengths of
adhesive plaster are placed over the part and adhered tightly to the
surrounding integument so that very little or no movement is allowed in
the affected part.
Strapping, to prevent movement, is particularly effective when the
bursitis has occurred in the os calcis region between that bone and the
tendo Achillis (retrocalcaneal bursitis). The foot is placed in plantar
flexion and a long strip of 1¹⁄₂ or 2 inch plaster is anchored at the
centre of the upper part of the calf and is then carried down over the
heel on the plantar surface of the foot. This strip is then reinforced
by transverse straps applied over the heel at the insertion of the
tendon.
Aside from these general methods of procedure thus discussed, the
podiatrist must resort, in a majority of cases, to local treatment
which will hasten the ultimate resolution of the inflammatory process.
These local methods of treatment are conveniently divided into six
groups:
1. Hydrotherapeutic measures.
2. Moist and wet dressings.
3. Unguent dressings.
4. Counter-irritation.
5. Massage.
6. Electricity.
=Hydrotherapy.= Hydrotherapeutic measures may be resorted to in the
treatment of bursal inflammations and either thermal extreme may be
used with equal results. As one person will react to one extreme more
readily than to the other, the choice of heat or cold usually depends
upon the individual case.
=Hot Applications= are probably most practical in these instances in
the form of compresses. Several thicknesses of gauze, saturated in
water, as hot as can be borne, are applied over the affected areas, the
hot water being replenished as soon as the compress commences to cool.
Hot applications act as mild poultices and their action is similar to
them in a limited and modified form. They tend to hasten resolution
of the inflammatory process by accelerating absorption. It is unwise,
however, to continue hot applications for too long a period; it is
found preferable to have the patient apply hot compresses for periods
of one hour duration two or three times a day, allowing the part
complete rest in the intervals.
Hot compresses, applied continuously for some hours, are apt to bring
about an over-stimulation in the parts to such an extent as to produce
a slough. To be effective, it must be remembered that the compress
must be kept hot for the entire period of application. This may be
accomplished by immersion in hot water, by moistening intermittently,
or by keeping the compress covered with some heat-confining covering.
In the latter instance, oiled silk is in all probability the most
practical agent, but even the use of an impervious covering does not
relieve the patient of the necessity of remoistening the compress with
hot water, at frequent intervals.
[Illustration: INFECTED BURSITIS]
=Cold Compresses=, as here advised, are either applications of cold
water on a compress of gauze or some similar material, kept constantly
wet, the use of ice bags or packs, or a cold water drip. The surfaces
of the foot, particularly if the bursitis be on the toes, are so
small, however, that as a general rule, ice bags or packs are not
practical. The cold produces anemia of the parts by contracting
the calibre of the blood vessels, and forcing the blood from the
capillaries. They also tend to anesthetize the nervous sensibility
and are in that way also pain reducing. There is one bad feature,
however, in the use of cold as a hydrotherapeutic agent. The resulting
reaction, which is generally bound to occur, gives the patient
considerable annoyance and is apt in time to increase the infiltration
and distension in the part. Again, should the patient have any tendency
toward chilblains, the moist cold is almost always sure to develop the
tendency into a reality.
=The Poultice= is the older and now obsolete method of applying moist
heat to a part. The stimulative action of this form of application is
at times so severe as to cause deleterious effects upon the diseased
tissues. A cataplasma should never be used where a distinct loss of
tissue is in evidence, in the presence of pus, or where the vitality
of the parts is considered to be subnormal, either from the age or
condition of the patient, or because of the diseased condition of the
part.
The most generally used materials in this connection are flax-seed, and
slippery elm, and the most practical manner for preparing a poultice
for use in podiatry is to make several small bags (about two or three
inches square) from cheesecloth or some like material. These are filled
half full with the meal and are dropped into a vessel containing
boiling water. The bags and their contents are allowed to boil for
eight or ten minutes and are then applied to the part as hot as can
be borne. This method does away with the rather “messy” procedure of
laying a cloth on the part and then applying the warm mass by means of
a spatula, spoon or like implement; also the poultice, so made, may be
used again and again. The usual method of procedure in using poultices,
when recommended, is to have the patient apply them continuously for
about an hour during some part of the day. It is found much more
effective to have moist heat applied for a longer period at one time
than to apply three poultices a day, one in the morning, one at noon,
and the last at night. The patient removes one bag as soon as it starts
to cool and replaces it with another taken hot from the boiling water.
This form of treatment, of course, tends at first to increase the
overproduction of synovial fluid, and proper drainage must at all times
be preserved so that this excess may be carried off.
=Baking.= With the development of the modern baking apparatus,
this method of applying heat to a part has come into use in cases
of subacute or chronic bursal inflammations. The heat applied by
this means is dry, in contradistinction to that obtained from hot
applications of water and from poultices. As the synovial bursae are of
similar structure to the true synovial membranes of the joint cavities
and capsules, they are subjected to similar ailments. It stands to
reason, therefore, that if baking is beneficial in several forms of
arthritis, it is also beneficial in some forms of synovial bursitis.
Some podiatrists have baking apparatuses installed in their offices;
where this is not the case it is recommended that, when such treatment
is thought advisable, the patient be sent to some hospital or institute
where this treatment can be administered. Baking serves as a hyperemic
agent (to bring an abnormal supply of blood to the part) and in this
way to aid in the more rapid absorption of the exudates in the affected
region.
=Moist and Wet Dressings.= In conditions of acute bursitis, an
efficient means of reducing the inflammatory symptoms is found in
the use of wet dressings. Moist dressings (those with mackintosh
protection) should not be used in these cases when the skin is broken,
when there is any suspicion of a discharge, or where infection is
present.
The agents which may be used with such wet dressings are mercury
bichloride, liq. aluminum acetate, saturated solution of boric acid and
alcohol, equal parts, and lead and opium wash.
=Mercury Bichloride= may be used as a wet dressing in all cases of
acute bursitis, but more particularly where infection is present. It
should never be used with mackintosh covering, for even without the
confinement thus afforded, its action serves to macerate the skin to
a great extent. The solution may be used either hot or cold and in no
instance stronger than ¹⁄₄₀₀₀. This strength solution should only be
resorted to in cases where the infection is acute and has progressed
to some extent, weaker solutions, ¹⁄₅₀₀₀ or ¹⁄₁₀₀₀₀, being found
efficient in a majority of cases. Mercury bichloride, on account of its
toxic properties, should not be used after the infective process has
been reduced, and there are many arguments in favor of an efficient
substitute for it even in the initial instance. However, no solution
which is practical for use in these cases can be depended upon for
beneficent results as surely as corrosive sublimate. In chronic bursal
inflammations, corrosive sublimate is contra-indicated.
=Liq. Aluminum Acetate= can be used in place of bichloride of mercury
in many cases of acute bursitis. The solution is decidedly astringent,
and while this action is to be desired at times, nevertheless it
has been found detrimental in the treatment of some cases of acute
bursitis, because when it penetrates through the sinus into the bursal
sac it has been found to create a decided irritation upon these deeper
tissues. Liq. aluminum acetate, therefore, is shunned by many in the
treatment of these cases, but aside from this one detrimental feature,
the action of the acetate is efficient and is productive of good
results. The drug may be used plain, or diluted with sterile water to
reduce its irritant, astringent qualities. A dressing of liq. aluminum
acetate, like bichloride, should never be confined in a mackintosh
covering, as it will macerate the skin, quickly and thoroughly.
This solution is particularly effective in subacute cases where no
infection is present when its astringent action goes far to reduce the
infiltration in the parts. It should be applied cold.
=Boric Acid-Alcohol Solution= may be used in all cases of acute or
subacute bursal inflammations. It is efficient in septic cases and
its quality of rapid evaporation aids materially in reducing the
inflammatory symptoms, independent of the therapeutic action of the
component drugs. This solution, on account of its rapid evaporation,
must be renewed more often than either of the foregoing, but while this
demands more attention on the part of the patient, it is immeasurably
better for the general condition of the disease. The one disadvantage
in having the patients attend to the moistening of the dressing is
that often they will fail to carry out instructions properly; but a
condition of this nature, properly attended, will respond as quickly
to the boric-alcohol application as to aluminum acetate or to mercury
bichloride, and with none of the irritant or toxic tendencies of both
of these. This solution is applied cold.
=Lead and Opium Wash= may be used in the treatment of bursal
inflammations, usually in the subacute or chronic stages. In cases
where the integument is broken, avoid the use of this medication on
account of the irritant qualities of the lead it contains. Prolonged
applications are apt to develop a dermatitis, and if the skin is
broken, local lead poisoning will not only be more pronounced, but
will be manifest in a shorter space of time. Lead and opium wash, hot,
is an advantageous application in the treatment of chronic bursal
inflammations, the heated applications being continued for about thirty
minutes at a time, at intervals of two or three hours. It should always
be remembered in using this wash that it exhibits marked irritant
qualities upon prolonged application.
The choice of a moist dressing to be used in subacute or chronic cases,
especially the latter, should be carefully made. Boric acid, saturated
solution, is an efficient and safe drug to use under rubber, fish skin,
or oiled silk covering but, as before mentioned, mercury bichloride and
liq. aluminum acetate are contra-indicated in this connection.
=Unguent Dressings.= Ointment dressings are used in this instance
under the same rules and considerations which govern their application
in all other conditions. No ointment should be applied on any inflamed
bursa where there is a discharge of any nature. The operator must never
forget that the base of all ointments is either oily or fatty and a
serous discharge, coming from any surface, cannot be absorbed by the
fabric used as a dressing if even a thin unguent film is interposed.
Certain classes of drugs, however, which are known to be beneficial in
certain stages in the treatment of bursitis, can be readily applied
in unguent form and for this reason the question of using them may be
profitably discussed here. The action demanded of drugs to be used in
the treatment of bursal inflammations are antiphlogistic, analgesic and
antiseptic. The latter action is particularly demanded in cases where
surfaces denuded of epidermis are found. Some stimulant action is at
times desired and drugs which have properties of this nature may also
be included in this armamentarium. The following named ointments may be
used, therefore, with beneficial results in certain stages of bursal
inflammations: ichthyol, sulphur, menthol, balsam of Peru, scarlet red
and salicylic acid.
=Unguentum Ichthyoli=, 3% to 10%, is used in all cases where an
emollient action is desired. The stimulating action of the drug in
this form is negative, but it can be relied upon to reduce acute
inflammatory symptoms. Ichthyol may be combined best with either
lanolin or vaseline as a base; the former is preferred inasmuch as it
does not become rancid when exposed to a variety of conditions as does
the latter. Lanolin being a wool fat product is supposed to have a
beneficent action upon certain pathologic conditions of the skin, and
so it is used as the base of many ointments.
=Unguentum Sulphuris=, 10%, may be used in many conditions of subacute
or chronic bursitis. Its antiseptic action makes it a desirable
choice for use when the integument is broken or when a distinct
antiseptic action, in addition to the general action of sulphur as an
antiphlogistic, is sought.
=Unguentum Balsamum Peruvianum= is used in these instances, principally
when some loss of tissue in the part is noticeable and where
stimulation is required to accelerate granulation. Peruvian balsam is
sometimes combined with ichthyol (5% of each) in ointment form. In this
combination the ointment has marked stimulative and antiphlogistic
qualities. Balsam of Peru is used in strengths of from 3% to 10% in a
vaseline base.
=Scarlet Red= is a highly efficient stimulative ointment. It is used
alone, with zinc oxide or with borated vaseline, and should never
be applied in too thick a coating. The parts should first be made
thoroughly aseptic and dried, and then scarlet red applied on gauze in
a thin even coat. Care should be taken that the application of scarlet
red does not cause over-stimulation to the parts, and thus prove
detrimental to the general condition of the lesion.
=Unguentum Acidi Salicylici=, 2% to 5%, may be used to good advantage
where the parts overlying the thickened sac are found to be somewhat
calloused. One application of an ointment of this strength will serve
to disintegrate this overlying thickening, thus making the parts
flexible and soft. A stronger ointment than this should never be used
in these cases, as salicylic acid is a strong epidermic disintegrant
and will cause decided irritation if used in greater than 5% strength.
In such cases salicylic acid may also be combined with collodion in
the same percentage, 5 grains of ext. cannabis indica being added as
an anodyne. Unguentum salicylic should never be used when the skin is
broken or the tissues show any tendency to thinness. All ointments used
in the treatment of bursitis are applied and kept in place by the use
of a cocoon dressing. If a shield is to be used, it is first applied;
the ointment is then placed in the shield aperture and the cotton and
collodion dressing is made to cover the whole. The ointment should
be renewed at frequent intervals in order that the dressing may not
become hardened, and thus become an irritant.
=Counter-Irritation.= Counter-irritation means literally an
irritation which is developed to act against a previous irritation.
It would seem, theoretically, that in cases of bursitis, this form
of treatment is particularly advantageous. A bursal inflammation is
a fairly deep-seated condition which should readily respond to a
counter-irritation developed on the surface overlying the trouble.
Counter-irritant agents should be used only in subacute and chronic
cases, more particularly in the latter; for it is found that this form
of treatment applied to an acute bursal inflammation tends to intensify
rather than reduce the symptoms.
In treating such cases we have a number of counter-irritants which may
be used with consistently good results: iodine, capsicum, turpentine
and mustard, are the most important and most commonly used.
Iodine is today, in all probability, the most generally used agent to
induce counter-irritation in podiatry. Its present popularity as a
germicide, however, has over-shadowed its action as a counter-irritant.
To obtain the maximum counter-irritant action from tincture iodine (U.
S. P. 7%) it should be applied in a heavy coat at frequent intervals
until such time as the inflammatory symptoms have entirely subsided.
The continued use of iodine after this has been accomplished should be
avoided as the tincture is irritant and mildly corrosive, and numbers
of patients will be found whose skin will not stand its activities.
Churchill’s tincture of iodine (about 16%) has been advocated for
general use as a counter-irritant, but its action in many cases will be
found too irritant for ordinary use.
The theory of counter-irritation, simplified, is that a drug applied
at a spot more or less distant from an inflamed area will cause an
irritation in this new locality and thus aid the original condition,
inasmuch as it will draw away the excess blood in the original part and
allow the vessels to contract to normal calibre and the circulation
there to become normal. Realizing this, it is readily understood why
tincture of iodine should not be used as a counter-irritant in acute
cases. With a discharging sinus to contend with, applying iodine over
its opening at the periphery might be the cause of a severe irritation
in that location which would further increase the tissue loss and thus
prove a detriment to the general condition.
=Capsicum= is generally applied in these conditions in the form of
a plaster. It should never be used in acute cases as its greatest
efficacy is apparent in those cases with chronic characteristics.
Capsicum plaster is applied and renewed as necessary, until the
symptoms of the deep inflammation have subsided. Shields are usually
employed to remove the pressure while a chronic case is under
treatment, and this removal of all irritation which the shoe might
produce aids materially in the relief and cure of these conditions.
=Turpentine= may be massaged into the parts for the purpose of
counter-irritation although its action is at times severe; it should
never be used where the skin is broken or where a discharge is present.
It is not so desirable an application as either of the foregoing for it
is found impractical to give proper massage to the comparatively small
areas which are affected in bursal inflammations.
=Mustard= has been recommended for use in cases of chronic bursitis,
either in the form of a moderate local application or in a general
foot bath. It is decidedly energetic in action, and should be used
with great discretion and care. Every skin will not stand the action
of mustard and for this reason it is not advocated as a general
counter-irritant agent. Upon the failure of any of the other drugs
mentioned under this heading, however, it may be tried, and if properly
used, may prove conducive to good results.
=Massage.= Massage is at times a potent factor in aiding absorption in
chronic cases. There is no question but that the stimulation afforded
by this procedure is efficient and will aid materially in returning the
tissues to normal.
Some cases of bursitis which occur upon the foot, however, are confined
to such limited areas that massage is impractical.
Several drugs which are reputed to have great powers of penetration
are recommended as agents which can be safely massaged into the parts
and even if the action claimed for them is overestimated, their use at
least serves to reduce the friction upon the surface tissues.
Many of the so-called “petrogen compounds”--drugs in combination with
petroleum (mineral oil)--are recommended for use in these cases, and
are undoubtedly of some benefit. Petrogen iodine, 10%, and petrogen
camphor, 5%, (Wyeth) are the two most generally used, and have been
found to be productive of good results.
The compound is applied to the parts and then rubbed, first lightly,
then gradually increasing the pressure, by the fingers and palm of
the hand. It is found advantageous to massage the parts at first with
a circular movement, confining the energy to the areas immediately
overlying the enlarged sac. After about five minutes, the pressure is
increased and considerable of the surrounding integument is included in
the massage. The direction of the finger movements is then changed from
a rotary one to a series of long strokes under considerable pressure,
first toward the diseased sac, following as nearly as possible the
blood supply to the part, and then away from the sac, following the
outgoing vessels. This serves first, to increase the vascular supply,
and then to aid in its quick removal, and reduce the congestion in the
part. With this, the lymph activity is also increased so that it helps
to absorb the waste products more rapidly.
Massage should be recommended as a daily treatment and should
be continued until all signs of infiltration have disappeared.
Perseverance is necessary, for in chronic bursal inflammation, the
changes are not noticeable nor should they be expected to be rapid.
=Electricity.= Many forms of electrical application are recommended
in the treatment of chronic bursal inflammations. Among those most
commonly employed are the high frequency, and the faradic currents.
Vibration, induced by electric impulses, is also recommended and is
employed generally by the podiatrist.
=High Frequency Current=, more popularly known or rather misnamed
“violet ray,” is generally found efficient and is more generally used
than any other form of electric application. This current serves to
produce active stimulation in the parts and by this means tends to
accelerate all functional activities and to hasten absorption. Whether
the more popular priced and small sized high frequency machines on the
market today really do create any but a very superficial stimulation,
is a question, and for this reason a machine of greater power is
recommended. The parts are treated daily, the glass electrode being
applied for about eight or ten minutes at a time.
=Faradic Current= is also recommended for daily use being applied by
means of a moistened sponge electrode. The treatment is from five
to ten minutes duration. Stimulation is obtained by this treatment
which, as in the case of the high frequency current, aids the general
absorption in the affected areas.
=Vibration= used in these cases may be produced by electricity direct,
or through a modern air compressor, controlled by electricity.
Vibration is only recommended in chronic cases; it increases the
functional activities of the part. It should be applied daily.
Bursitis is a stubborn condition in any form, and can only be relieved
and finally cured by scientific and rational treatment. The operator
should bear in mind that rest and the absence of shoe irritation will
do as much or even more for the general improvement of the condition
than can be accomplished by drugs. Surgical procedure is certainly to
be recommended in cases where no improvement is shown under palliative
methods, even though this requires a cessation of activity on the part
of the patient, and means the transfer of the patient to the care of a
practitioner of surgery.
CHAPTER XVIII
CHIMATLON
Chimatlon, or pernio, is an inflammation of the skin and of the deeper
structures which is the result of exposure to reduced temperatures. The
severity of the condition depends upon the length of the exposure as
well as upon the degree of temperature. If the skin alone is involved
and there is no loss of tissue, chimatlon mild, or chilblains, is the
term applied to the lesion; where there is an involvement of the deeper
structures the condition is called chimatlon severe, or frost bite. In
many instances it becomes difficult to distinguish between a severe
chilblain and a mild frost bite. However, for the sake of scientific
study, in all cases in which the deeper tissues are involved and
suppurative processes affecting these structures manifest themselves,
the condition should be considered as chimatlon severe, for these cases
are usually due to prolonged exposure to low temperatures.
CHIMATLON MILD
=Derivation.= Chimatlon, from the Greek, meaning the severity of winter.
=Synonyms.= Chilblains, Dermatitis Congelationes, Erythema Pernio.
=Definition.= Chimatlon mild, or chilblains, is a local inflammation of
the skin due to exposure to cold and dampness.
=Etiology.= Chilblains are primarily due to exposure to cold in varying
degrees. When the part is exposed to a decreased temperature, the
vasomotor nerves become affected and the cutaneous circulation is
impaired. This interference with the blood flow produces congestion,
leading to inflammation, which latter is followed by a serous discharge
or even by the production of pus. Dampness hastens the affection of
the vasomotor nervous system of the skin, and where this organ is very
sensitive, in the presence of moisture, only a moderate decrease in
the temperature is necessary to produce all the symptoms of severe
chilblains.
The parts of the body most usually affected are the hands and feet;
the distance of the extremities from the heart is probably the reason
for this impairment under the other abnormal conditions. Where the
horny layer of the skin is thin, it receives its nourishment normally,
regardless of the distance from the heart; but on the hands and feet
the skin is thicker and is imperfectly nourished and a decrease in
temperature, in the presence of moisture, results in local inflammation.
Females are more disposed to chimatlon mild than males, and young
people more than old. Aside from cold as an etiologic factor, there
is also the predisposition which is equally as important in the
production of chimatlon mild and should be considered in every case.
Imperfect circulation in the limbs, due to varicose veins and arterial
disturbances, caused by a deranged nervous system, are often causes of
chilblains and must be given consideration.
Any part of the body exposed to the air may become affected,
particularly the ears and nose. Several cases of chimatlon mild of
the skin over the throat have been recently reported, due to walking
against a strong wind, with the throat bared to the weather.
=Symptoms.= The symptoms in the mild form of chimatlon vary with the
severity of the exposure. In very mild cases the only perceptible
symptoms are a tingling or slight itch, and the part feels cold and
clammy to the touch. The most common cases show the parts colored dark
blue or purple, immediately after exposure and during the reaction.
The parts are inflamed and there is severe itching coupled with pain.
After reaction has set in, the color of the lesions varies from a
scarlet to a purple. There is no sharp line of demarcation between the
affected and the surrounding area, but there is a gradual blending
between the discolored and the normal tissues. There is considerable
congestion, the parts are swollen and after a complete reaction, heat
manifests itself. These symptoms may soon subside or they may persist
for many months. In general, they are of a transient nature, but
the parts remain permanently weakened and congested, and are easily
affected from the slightest cause.
In the more severe types of chilblains, blebs are formed which, when
opened, exude serum or even pus. The blebs are commonly found at the
ends of the toes, and sometimes the entire distal end of the digit is
covered by one lesion.
No pain is felt immediately after exposure, but as reaction commences,
shooting pains develop, and if the reaction is severe, these pains
become almost unbearable. Itching is present to a marked degree, and
after reaction is complete, dull pains and burning are noticed until
the affected parts become normal.
=Pathology.= The immediate effect of cold upon the skin is to constrict
the small blood vessels and to retard the stream within them. Under
quite severe or prolonged exposure there may ensue a destruction of
the minute vasomotor nerve terminals in the arterioles, which control
their constriction and dilation. This nerve function is thereafter
permanently affected and the muscular coat of the vessels in the parts
impaired, atrophies from disuse. It is this degree of chimatlon which
is classified as chimatlon mild, or chilblains. (Destruction of tissue
beyond this, is classified as chimatlon severe or frost bite).
In winter there is a natural conservation of heat, by the constriction
of the superficial capillaries; the blood supply to the skin is
diminished and heat radiation is thus controlled. This reduction in the
peripheral blood pressure especially affects the feet and other parts
remote from the heart.
Later on besides this natural deficiency in the blood supply, there
is in chimatlon mild a deficiency of freely circulating blood, due
to the blood vessels relaxing. The reverse condition may seem to be
proven by the heightened color but in reality this redness is due to
too much blood in the tissues. There is however, congestion; the blood
entering the tissues has but little motion, the pulse wave is lost in
the relaxed vessels and the stream is in consequence a sluggish one.
The reduction in the supply of fresh blood is probably the direct cause
of the pain; the lack of oxygen brought to the parts and the retention
of excrementitious chemical substances, act as irritants to the sensory
nerve terminals. Persons suffering with chilblains have feet which
are generally cold to the touch in spite of their being surcharged
with blood. The blood in them is rendered sluggish and the heat is not
retained long, nor is there a sufficiently rapid supply of fresh blood
to replace it.
In summer time, when the general peripheral circulation is at its
maximum, vascular conditions are equalized throughout the entire body
surface and are congenial to conditions in affected areas.
All the peripheral vessels are dilated and the blood pressure within
them is increased to facilitate heat radiation and the maintenance
of a cool body. “The season is congenial to persons who suffer with
chilblains in winter because the pathologic condition is compensated
by the physiologic vasodilatation and heightened blood pressure.”
(Maximilian Stern, M.D.)
[Illustration: CHIMATLON MILD FROM THE JACOBI ATLAS]
=Diagnosis.= Chimatlon mild is a true inflammation of the skin with or
without bullous formation and serous or purulent exudation. The color
varies from a light scarlet to a deep purple and the lesions blend
gradually with the surrounding normal tissue. The part feels cold and
clammy to the touch, this being a characteristic symptom in spite of
the heightened red color. The blood present in the parts is sluggish
so that its temperature is below normal.
Chilblains of the metatarsophalangeal joint of the great and fifth toes
may be mistaken for bursitis. The chief difference between the two
conditions is found in the history of the case, which in chilblains
shows exposure, while in bursitis the lesion is usually accompanied
by hallux valgus. The usual sites of chimatlon mild of the foot are
the heel, the tips of the toes, the great and little toe joints and
the webs between the toes. The pains of chilblains are transient and
of a shooting variety, and are present with the shoe on or off, while
those of bursitis are constant and dull, and are present only when the
shoe is worn. Where inflammatory processes have continued so that the
deep tissue are involved, the pains are of a throbbing nature in both
lesions, so that other symptoms must be observed to determine upon a
proper diagnosis.
CHIMATLON MILD BURSITIS
History of exposure No history of exposure
Hallux valgus not usually present Hallux valgus usually present
Pains of shooting variety Pains dull and steady
Pains present at all times Pains absent with shoes off
Intense itching No itching
The lesions of chimatlon are irregular in shape and may involve the
entire forefoot, including both the dorsal and the plantar surfaces.
The heel over the tendo Achillis, as well as the skin on the sole and
lateral surfaces over the os calcis, are common sites of chilblains.
These lesions are usually deeply colored, the redness gradually
diminishing as the periphery is reached.
The blebs which have formed, may exude serum or even pus, and these
lesions may be easily differentiated from the blebs of pompholyx and
eczema by carefully noting the history of the case, the age of the
patient and the general appearance of the foot and leg.
=Prognosis.= The ultimate cure of chilblains is uncertain. Cases of a
mild type often respond immediately, while others persist indefinitely.
The painful symptoms are readily relieved, but the lesion itself often
continues until the change of season, when the warmer weather brings
about a cure. This is due to the changes that occur in the cutaneous
circulation during warmer weather. Recurrence is the rule in those who
have poor circulation from anemia or other causes.
=Treatment.= The treatment for chimatlon mild consists in bringing
about a gradual reaction. This should be commenced immediately after
exposure, and is accomplished by rubbing the parts with snow or cold
water. It must be remembered that the reaction must be gradual. If the
parts exposed are rapidly warmed, the reaction will be equally rapid,
and serious results may follow. After reaction has been established,
the treatment varies with the severity of the resulting inflammation.
When the skin has been broken and blebs or bullae are present, the
lesions must be healed first. For this purpose ointments are most
desirable. The parts should be thoroughly cleansed with an antiseptic
such as phenol (1-40) or bichloride of mercury (1-2000), and by
removing serum or pus present, with hydrogen peroxide. The surface of
the lesion may then be dressed with any of the following:
℞ Ichthyol 8.00
Petrolatum q. s. ad. 32.00
M. ft. ung. Sig. Apply over affected parts twice daily.
℞ Acid. carbol. 0.60
Acid. boric 2.00
Petrolatum q. s. ad. 32.00
M. ft. ung. Sig. Apply on chilblain once daily.
℞ Spirit. terebinthinae 2.00
Acid. boric 2.00
Petrolatum q. s. ad. 32.00
M. ft. ung. Sig. Apply on chilblain once daily.
Wet dressing of Burow’s Solution, diluted with equal parts of distilled
water, applied for a few days, produces satisfactory results in lesions
where there is marked inflammation and swelling.
In severe ulcerative processes that do not granulate readily, a strong
stimulant, such as balsam of Peru or some iodine preparation, should be
used until the entire area is healed.
After the skin has been healed, or in cases where the skin has not been
broken, the treatment varies with the severity of the lesion. In very
mild cases, massage followed by an application of the compound tincture
of benzoin, which, because it furnishes an occlusive coating and acts
as a support for the skin, is often sufficient. The liquor alumini
acetatis (Burow’s Solution) may be used as an astringent wet dressing
to reduce the swelling and inflammation. The part may also be painted
with a four per cent. solution of silver nitrate at frequent intervals,
to be then covered with raw cotton; or nitric acid, diluted with aqua
cinnamoni, 15 minims to the ounce, may be painted over the unbroken
skin.
A very satisfactory liniment which has been used extensively to relieve
the pain and reduce the inflammation in this condition consists of the
following:
℞ Guaiacol 8.
Spts. terebinth. 28.
Ol. olivae q. s. ad. 64.
M. ft. lin. Sig. Rub on affected parts at bedtime.
The itching, which is a marked symptom of chimatlon mild, can readily
be controlled by the application of camphorated soap liniment. Its
action is almost instantaneous.
Ichthyol has proven to be a valuable agent in the treatment of
chilblains; it may be used with collodion, or as an ointment, the
following being found satisfactory:
℞ Ichthyol 8.
Lanolin q. s. ad. 32.
M. ft. ung. Sig. Spread on gauze or lint and apply.
It must be borne in mind that the apparent cure of an acute lesion
of chimatlon mild, is not in reality an absolute cure, and thorough
precautions must be taken to prevent recurrence. Stimulation of the
cutaneous blood supply and the vasomotor nervous system is essential,
and for this purpose, massage and the alternate hot and cold foot baths
are advisable. The latter treatment should be used at least once daily
and if possible, twice a day. The feet should be kept in hot water for
thirty seconds and then plunged into cold water and kept there for
fifteen seconds. This is repeated for an entire ten minute period.
Electricity, in the form of the faradic or the high frequency
currents, may be used to assist in the stimulation of the action of
the skin. These treatments should be given for ten minutes, three times
a day.
The hygiene of the foot is all important, and this should be explained
at length to the patient. The feet should be protected by wearing
woolen or cashmere stockings, the latter being preferred, and should
be used from early in the fall until late in the spring. Hose of this
kind prevent heat radiation, so necessary for those who suffer from
chilblains; they also absorb excretory moisture, all of which prevents
recurrence of the lesions. It is necessary to conserve the body heat
as much as possible, and warm underclothing, covering the entire body,
should be worn; the patient should be instructed to take some form
of general exercise. Footgear should be wide enough to allow freedom
of the toes and the shoes should be made of either calf skin or vici
kid. The wearing of silk stockings and patent leather shoes must be
discouraged if good results are to be expected.
Where the skin is not broken, Dr. Charles T. St. Clair of Bluefield,
West Virginia, advises as follows: “coal oil (kerosene) applied night
and morning to old itching frost bites of the feet gives almost
immediate relief. It should be applied with a cloth and cotton soaked
in the kerosene and allowed to evaporate, which it will do in a few
minutes. If the sock is put on and the person goes to bed with the foot
still wet with the oil, it may burn the skin.”
CHIMATLON SEVERE
=Derivation.= Chimatlon, from the Greek, meaning the severity of
winter; severe, with extremely bad effects on the tissues.
=Synonyms.= Frost bite, pernio, dermatitis calorica.
=Definition.= Chimatlon severe is a local inflammation of the skin
and deeper structures, produced by exposure to extreme cold, and is a
result of complete or partial paralysis of the vasomotor nerves.
=Etiology.= The one cause for the severe form of chimatlon is
prolonged exposure to an extreme degree of cold. The decrease in
atmospheric temperature lowers the temperature of the parts exposed,
thereby causing complete or partial paralysis of the vasomotor nerves
and producing congelation of the blood vessels. When the congelation
is complete the parts are deprived of their nourishment, and finally
become devitalized.
=Symptoms.= Immediately after exposure, numbness develops and all
sensation is gradually lost. The parts are congealed and if there is
complete freezing, they present a white, blanched appearance. The
tissues affected may be so completely frozen, that upon thawing, they
are either found to be absolutely dead, or their vitality so greatly
impaired that there is very little reaction and gangrene may result in
a very short time. If the area is not completely frozen, the reaction
is rapid, the tissues become purple, swollen and very painful. The
parts may become gangrenous, in which case the line of demarcation and
separation between the gangrenous and the healthy tissues evidences
itself. The affected tissue is at first white but gradually becomes
blue and finally black. The fluids in the tissues rapidly evaporate and
the odor of decaying flesh is very apparent.
If the parts do not become gangrenous, the symptoms that present
themselves are those of inflammation. The tissues become swollen and
assume a deep purple color, which, as the circulation is restored,
becomes lighter and, after inflammation has subsided, gradually
disappears. Blebs may form and there may be an exudation of serum or
even of pus.
=Pathology.= The changes that occur in chimatlon severe are much
the same of those of the milder type, the former however, causing
complete destruction of tissue, or the development of gangrene. The
cold causes a constriction of the blood vessels and the stream within
them is retarded. The minute nerve terminals in the smaller arteries,
which control the dilation and constriction, are destroyed and their
function is lost. The vessels now contract and in extreme cases remain
so. Where the exposure has not been severe enough to cause complete
death of the vessels, there is a dilation after the contraction, with a
very slow movement or even complete stasis of the blood stream.
Gangrene or necrosis will manifest itself in extreme cases almost
immediately, and often after reaction has commenced, the tissues may be
cast off. At the line of demarcation between the normal and the dead
tissues, the changes that accompany inflammation take place.
=Diagnosis.= The diagnosis of frost bite is not very liable to be
confused with any other condition, in that the history shows exposure
to an extremely low temperature. The disease known as “Trench Foot,”
when it first manifested itself, during the world war, was considered
a form of chimatlon, but since research work has been done along
the lines of the new disease, it has been found to be quite another
condition. Trench Foot will be discussed following this chapter.
The color of the part is characteristic. Immediately after exposure,
the tissues are blanched, and as reaction progresses, the color deepens
from a light scarlet to a deep red purple or black, depending on the
length of the exposure and the severity of the condition. As reaction
advances, the gangrenous tissue is separated from the normal tissue by
a distinct slough, which, as previously stated, is known as the line of
demarcation.
The milder cases of frost bite and the severer cases of chilblains are
often confused, particularly in cases of the former when the loss of
tissue has been avoided. The confusion, although of no great moment
(inasmuch as the treatment of both lesions is identical), may be
avoided by remembering that frost bite develops quickly and that the
parts have been exposed to a very low temperature, while chilblains
develop more slowly, are less painful and do not require exposure to a
very great decrease in temperature for their causation.
=Prognosis.= When the part has been completely frozen and the
circulation to the parts has ceased, there is no possibility of saving
the tissues. However, in cases seen immediately after exposure, in
which proper treatment is commenced at once, it is often possible to
save large areas that would otherwise be lost. Amputation is the only
cure in cases where gangrene has developed. The ulcers which result
after the dead tissue has been removed, respond very slowly, requiring
from one to four months to heal.
Recurrence is the rule, due to the fact that the vasomotor nerves never
regain their normal vitality, and persons who have had frost bite will
develop symptoms from the least imaginable cause.
=Treatment.= In all cases of frost bite, even when the parts seem
hopelessly frozen, the first treatment should consist of bringing the
parts back to normal temperature by a gradual reaction. This should
be carried out as thoroughly as possible, for it often is the means
of saving large areas of tissue. A case in which the entire forefoot
is involved may be thus saved so that only one or two toes are lost.
Such a patient would be able to walk comfortably, whereas if no care
were taken with the preliminary treatment, the patient might become a
hopeless foot cripple.
A gradual reaction is brought about by rubbing the parts with snow or
cold water. The affected parts may be placed in a vessel containing
cold water, or they may be wrapped in cloths wrung out in cold water.
The final result depends largely upon the length of time elapsing
between the exposure and the inauguration of the first treatment.
If the parts are completely frozen, gangrene will soon manifest itself.
If the affected part is only partly frozen, a gradual reaction can
be brought about by the above-described means and if the subsequent
inflammatory reaction is gradual, gangrene may be averted or at least
limited. Cold water dressings should be continued for some time after
reaction has occurred, and should be maintained until the certainty
of the avoidance of gangrene is fixed. The line of demarcation and
separation will be indicative of this fact.
When all of the gangrenous tissue has separated, the remaining ulcer
should be treated just as though it had arisen from any cause. In
cases of gangrene of the toes and feet, complete or partial amputation
should be practised as soon as the lines of demarcation and separation
are well established. When gangrene has been avoided in frost bite,
the treatment consists in stimulating the affected area. Various
medicaments are useful, among which may be mentioned oil of turpentine,
balsam of Peru, tincture of iodine, ichthyol and strongly carbolized
ointments.
If the frost bite is of the bullous, pustular, vesicular or escharotic
type, soothing agents such as ichthyol, Burow’s solution, etc., should
be applied to the affected parts.
Wrapping the affected parts in dry salt has been suggested by a western
chiropodist, who claims to have obtained excellent results by the use
of this agent.
In cases where gangrene has been averted, the following have proved of
great value:
℞ Acid, carbol. 1.
Acid, boric 2.
Petrolat, q. s. ad. 32.
M. ft. ung. Sig. Apply every morning.
℞ Ichthyol 8.
Lanolin q. s. ad. 32.
M. ft. ung. Sig. Apply on lesions once daily.
℞ Ichthyol 8.
Aquae q. s. ad. 32.
M. Sig. Paint over the affected area.
In frost bite, after the gangrenous tissue has been removed, the
resulting ulcer may be treated with a stimulant. For this purpose
balsam of Peru, iodine, ichthyol and other agents have proven
successful. These ulcers do not respond readily, because of the
decrease in vitality of the surrounding tissues, and patience is
essential for a final cure. The patient must be told that the lesion
will require a long time to heal.
Hernance (Therapeutic Gazette, 1895) draws the following conclusions
from the study of thirty cases: “1. Ichthyol is the drug that
gives most relief to pain and is as good a protector as any other
application. 2. Acetanilid ointment is the best dressing when the
parts are raw and ulcerated, preventing suppuration and promoting
granulation. 3. In a certain number of cases one can do nothing but
keep the parts clean and wait until nature throws off the diseased
tissue.”
Massage is a very good therapeutic agent for chimatlon severe, and
should be applied twice a day, if possible. This will help stimulate
the circulation and tone up the faulty nerve endings. Electricity
should also be used wherever possible, the high frequency and the
faradic currents being the best. Applications directly to the affected
parts for ten minutes, once or twice a day, will aid materially in
bringing about a rapid cure.
The prevention of the recurrent attacks may be accomplished by
treatment commenced in the early fall, and including massage, proper
shoes, cashmere stockings, and other prophylactic measures. This
treatment is essential, particularly for those who are anemic and
under-nourished.
CHAPTER XIX
DISEASES OF THE SWEAT GLANDS
HYPERIDROSIS
=Derivation.= From the Greek _hyper_, in excess, and _hidros_, sweat.
=Synonyms.= Idrosis; ephidrosis; hydrosis; sudatoria; polyidrosis;
excessive sweating, sudorrhea.
=Definition.= Hyperidrosis is a functional disorder of the sweat
glands (usually of the hands and feet) characterized by the excessive
excretion of sweat. The condition may be limited to certain areas or it
may be distributed over the entire body.
=Etiology.= When hyperidrosis is general it is caused by faulty
innervation. The cause in localized forms is doubtless varied from
that of pure idiosyncrasy to grave systemic disturbances. In instances
there seems to be an inherited tendency to this disturbance. Excessive
drinking of water or tea will produce hyperidrosis pedum in some
people. Localized sweating may follow some debilitating diseases for a
period of time. Anything that causes a depression of the nervous tone,
may be an etiologic factor. Neurasthenics often display this symptom.
Physical or mental excitement will cause profuse sweating in many
individuals.
=Pathology.= The normal sweat excretion is closely related to the
nervous system, hence pathologic excretion must have some nervous
cause. It is most probable that any disease or injury that affects the
function of the sympathetic nervous system, is the direct cause of
excessive sweat excretion. Examination of sections of the glands fails
to show any increase in size or in the epithelium of the gland.
=Symptoms.= Hyperidrosis may occur as a result of a general disease
such as rheumatism, tuberculosis, malaria, etc., or it may be
idiopathic and persist for a long period. The latter phase is of most
interest to the podiatrist. The disease is quite common. The sweating
may be immediate or profuse, and is always more marked in regions where
excessive sweating is normal, such as the hands, feet, axillae, etc.
It is more pronounced in hot weather, but is excessive even in cold
weather, and is increased by the least exertion. In hot weather it is
frequently accompanied by miliaria, intertrigo, or acute eczema.
On the feet, hyperidrosis is often disgusting, and may become
exceedingly troublesome. The excretion is excessive and the feet are
constantly damp or wet and clammy. The stockings become moist and the
shoe may become water-soaked. Sweating is most profuse on the soles and
between the toes. The skin is soggy and macerated and, in severe cases,
the sole and surrounding areas are reddened, puffy and irritated,
with ill-defined vesicular or flattened bullous lesions. In ordinary
hyperidrosis of the feet, the sweat is not offensive immediately after
it is exuded, but rapidly becomes so, unless the footgear is changed
frequently. Bromidrosis is often associated with hyperidrosis.
=Prognosis.= As a rule, localized cases are obstinate, but with
continued treatment, good results will follow. It is often necessary to
change the treatment from time to time. Relapses are not uncommon.
=Treatment.= The treatment of hyperidrosis is divided into two groups,
local and general. Excessive general sweating following fevers and
debilitated conditions of the system should receive general treatment
at the hands of the physician. When nervous disorders produce sweating
in limited areas, they also require specially directed general
treatment. In localized sweating of indefinite cause, under the advice
of the physician, it is often advisable to administer general tonics,
and remedies such as ergot, belladonna, gallic acid, etc., may be
locally applied. Precipitated sulphur, taken internally, one dram
twice daily, is the resort of many physicians in such cases and the
treatment has given satisfactory results.
While constitutional treatment should be used in every case of
hyperidrosis pedum, the external treatment is more positive in result
and therefore is more essential. This external treatment consists of
the application of ointments and powders, with frequent washing and the
use of lotions. Astringent lotions, used for the purpose of hardening
the skin may be chosen from the following:
Alum powdered 1 ounce.
Water 1 pint.
or
Zinc sulphate 2 drams.
Water 1 pint.
or
Formalin 3 drams.
Alcohol 1 pint.
The feet should be thoroughly cleansed and dried. Lotions applied two
or three times daily, should be allowed to dry on the foot. This may
then be followed by a dusting powder of the following:
Acid salicylic 15 grains.
Boric acid 1 ounce.
The local application of belladonna in the form of the diluted
tincture, the liniment or the ointment, has given excellent results
in some cases, but great care should be exercised in their use, as
belladonna may produce toxic effects, through absorption.
Many cases have responded readily to the alternate foot bath (See
Chapter, _The Care of the Foot_). After the alternate foot bath,
the feet are thoroughly dried, and in severe cases, the lotion of
formalin and alcohol may be used, or in ordinary cases, grain alcohol
is applied. When the lotion has dried, the feet are dusted with the
following powder:
℞ Acid salicylic 15 grains
Alum powdered
Lycopodium aa 1 ounce
M. Sig. Dust on feet morning and night.
Diachylon ointment, freshly prepared, is the best remedy among the
unguents. It is prepared as follows:
℞ Lead plaster 1 ounce
Oil of lavender flowers 15 grains
Olive oil, q.s. ad. 3 ounces
M. Sig. Apply on gauze and bandage.
Another ointment which has astringent properties and which has been
used with some success is:
℞ Tannic acid 2 drams
Petrolatum 1 ounce
M. Sig. Spread on gauze and bandage.
Before these ointments are applied, the parts should be thoroughly
washed with soap and water, dried, and the ointment spread on gauze
and held in place with a bandage. The application should be removed
after twelve hours, the parts rubbed dry with a towel, and the ointment
reapplied. This should be continued for a week or two, when, if results
have not followed, other forms of treatment should be used.
The X-rays have a drying influence upon the skin, but if this treatment
is used, great caution should be exercised, as the rays are likely to
have a very harmful influence upon the tissues generally.
At the suggestion of a prominent chemist and physician, a series of
experiments were performed with oxygen gas and vanadium chloride
solution for the treatment of hyperidrosis, which proved more or less
successful. The solution of vanadium chloride (1-20,000) was applied
to the foot, and the oxygen gas was slowly sprayed on the foot, from
a large gas container. This treatment lasted for ten minutes and was
applied twice a week. In one particular case, which had resisted the
ordinary methods of treatment, the use of this remedy was of great
benefit to the patient. After several weeks, the case showed marked
improvement, but the inability of the patient to continue treatment
prevented further trials. In many other ordinary cases of hyperidrosis,
the results were excellent, while in others there was no marked
improvement[6]. The use of formalin and alcohol solution in conjunction
with the oxygen treatment, has proven very effective. The lotion is
used at night, immediately before retiring.
Stillians, in the Journal of the American Medical Association, states
that a 25% solution of aluminum chloride in distilled water, dabbed
gently on the part every second or third day and allowed to dry, will
cause a rapid amelioration of the excessive sweating; three such
applications are usually sufficient. If the condition recurs, the
treatment may be repeated.
Potassium permanganate solution, 5 parts to 1,000, has been found
efficient as a wash for the feet. More active, and therefore to be used
with more care, are “chromic acid” solutions, as:
Chromium trioxide 2.5
Water 50.0
Sig. Use as a paint once a week.
Less active, but more pleasant than the foregoing, is:
Tannic acid 5.
Alcohol 100.
Water, q. s. ad. 200.
Sig. Use as a wash twice a day.
The lotions and washes should be used in conjunction with drying
powders, such as have been already mentioned.
The use of the various solutions of aluminum chloride, or of chromium
trioxide, may, in some cases, cause a mild dermatitis, perhaps
with itching. This may be relieved by the application of protective
dressings to prevent scratching, and the application of ointments, such
as cold cream containing 12 per cent. boric acid, or a calamine lotion.
Itching may be relieved by adding 0.5 per cent. phenol to the calamine
lotion.
BROMIDROSIS.
=Derivation.= “_Bromos_,” a stench; and “_hidros_,” sweat.
=Synonym.= Osmidrosis.
=Definition.= Bromidrosis is a functional disorder of the sweat glands,
characterized by a sweat excretion which has an offensive odor.
=Etiology.= The etiology of bromidrosis is much the same as that of
hyperidrosis, occurring in those who are anemic, chlorotic and nervous
and in those who are compelled to stand for long periods. Eating
certain foods and drugs will give peculiar odors to the perspiration,
among which are garlic, onions, assafetida, and sulphur. The cause of
the odor of the sweat in bromidrosis pedum is the decomposition of the
fatty acids of the sweat, as well as the presence of the bacterium
fetidum, which is found on the feet, especially between the toes.
=Pathology.= Immediately after the sweat is excreted, it is not
offensive, but soon becomes so, due to the presence of microorganisms
and the decomposition of the fatty acids.
=Symptoms.= The sweat has a disagreeable odor and is usually associated
with hyperidrosis, but not necessarily so, as it may occur in persons
having a normal sweat excretion. When the excretion is excessive, there
are the usual symptoms of hyperidrosis, viz., puffiness, tenderness,
sogginess and possibly blebs or vesicles. The odor is offensive, stale,
penetrating and peculiar and often is sufficient to make the sufferer
unfit for society.
=Treatment.= The treatment is essentially the same as for hyperidrosis,
coupled with absolute cleanliness and frequent change of footgear.
Shoes should be allowed to stand in the air for at least twenty-four
hours after having been worn, so that several pairs are required.
Constitutional treatment is the same as for hyperidrosis as is also the
external treatment. The feet should be washed in boric acid solution,
and the powder used freely in the socks and on the feet.
The feet may be painted once every three weeks with a 5 to 10 per cent.
solution of chromic acid, or they may be washed every other day in one
per cent. solution of potassium permanganate, and in the interval the
following powder proves efficacious:
℞ Acid salicylic 10 grains
Tannoform 2 drams
Zinc oxide
Talc aa 3 drams
M. Sig. Dust on feet morning and night.
ANIDROSIS
=Derivation.= _a_, without; and _hidros_, sweat.
=Synonym.= Decrease or absence of sweating.
=Definition.= Anidrosis is a functional disorder of the sweat glands
characterized by a diminution or suppression of sweat.
=Etiology.= Anidrosis is rare as an idiopathic condition, occurring
generally in diabetes and fever, also in some skin diseases such as
ichthyosis and pityriasis rubra pilaris; also in the parts affected
by anesthetic leprosy, scleroderma and keloids. Localized sweat
suppression follows injury to the nerves.
=Symptoms.= The skin seems to be abnormally dry, and this dry skin may
be a form of ichthyosis or may predispose to eczema. When the sole
of the foot is dry and the skin shows clefts, which contain helomata
miliare, and has a yellowish color, diabetes may be suspected. There
may be but slight diminution of sweat excretion, or total absence.
=Treatment.= In congenital cases, nothing is of much avail. In the
acquired cases, applications of hot water or vapor baths externally,
and general tonics, the free drinking of water and the use of warm
clothing, are indicated. Pilocarpin or jaborandi may be given
internally, but this must be on the prescription of a physician.
Massage with oil or the application of galvanic or faradic electricity
have proven of benefit. Hot alkaline baths, preceding the massage with
oil, are also at times beneficial.
In addition to the above there are a number of rare granular
perversions which occasionally are seen by the podiatrist and of which
but brief mention need here be made:
_Chromidrosis._ A condition in which the sweat is colored, usually
black. When this condition arises from accident, the sweat may be
colored green. Red sweat, which occasionally occurs in the axillae, is
due to the action of bacterium prodigiosum.
_Sudamen._ A collection of sweat in the upper layers of the epidermis,
due to obstruction of the sweat ducts, which gives rise to an eruption
of numerous pinhead, transparent vesicles. Occurs during the course of
fevers and is usually of but short duration.
_Uridrosis._ Characterized by the excretion of urine constituents
through the sweat glands. Usually the result of suppression of urine by
reason of impaired kidney function, whereupon the sweat glands assist
in the elimination of the urinary deposits. There is a urinous odor to
the skin.
_Hematidrosis._ Characterized by hemorrhage from the sweat glands. A
very rare condition.
_Phosphoridrosis._ In this very unusual disease the sweat glands exude
a phosphorescent sweat, said to be due to a species of photobacterium
following the ingestion of phosphorus or of food stuffs containing
phosphorus.
_Miliaria._ A mild inflammatory affection caused by obstruction of
the sweat ducts, characterized by the occurrence of small papules and
vesicles at their mouths.
_Hydrocystoma._ A condition characterized by the formation upon the
face of firm, pinhead sized vesicles, due to sweat gland obstructions.
_Hydradenitis Suppuration._ An inflammatory disease of the sweat glands
followed by deep-seated, shot-like nodules, which suppurate and leave
scars.
_Seborrhea._ A lesion of the fat-producing glands characterized by an
increased and altered secretion of sebum resulting in an oily or scaly
condition of the skin.
CHAPTER XX
ULCERS
=Definition.= An ulcer is a lesion of a cutaneous or mucous surface,
caused by a molecular disintegration of the superficial parts, usually
attended by more or less suppuration. A wound, or superficial loss of
tissue due to traumatism, is not primarily an ulcer, but may become
such if the healing process is arrested or the wound becomes infected
with pyogenic microorganisms.
The following ulcers frequently come under the observation of the
podiatrist:
=Simple Ulcer=, a local non-constitutional lesion attended with no
marked pain or inflammation.
=Indolent or Callous Ulcer=, a chronic lesion, with hard, elevated
edges and few or no granulations and showing no tendency to heal.
=Varicose Ulcer=, localized destruction of the skin over a varicose
vein, usually of the leg, due to mechanical pressure, to nutritive
disturbances, or to bacterial action.
=Perforating Ulcer of the Foot=, malum perforans pedis, a round, deep,
trophic lesion of the sole of the foot, following disease or injury (in
any part of its course from the centre to the periphery) of the nerve
supplying the parts.
=Syphilitic Ulcer=, due to syphilis in late secondary or in tertiary
stages.
Before describing the characteristics of the various forms of lesions
just mentioned, together with their differential diagnosis, treatment,
etc., it is deemed advantageous to briefly discuss the general etiology
and pathology of all ulcers.
=Etiology.= One or several factors may be concerned in the etiology of
ulcers, which are grouped under: (a) predisposing causes; (b) exciting
causes. The first group includes local as well as general causes.
=Predisposing Causes.= Age can hardly be considered as a very important
factor, except that old age is accompanied by retrogressive tissue
changes, hardening of the arteries, impaired circulation, etc., and one
would therefore expect the statistics to show a greater proportion of
ulcers during the later years of life.
As regards sex, ulcer is more common among men than women in the ratio
of about three to one. Alcoholism, syphilis, and traumatism may in
some measure explain why ulcers are more common in men than women.
Occupation seems to have little to do with the etiology beyond the fact
that it may predispose to various forms of infection, and it is due to
this element that we have the most important factors in the causation
of ulceration. Varicose ulcer is always associated with varicose veins
in the lower extremity, and these may be described as veins whose
valves are incompetent. The most obvious cause of the breaking down
of the valves is hard work, that is the lifting or carrying of heavy
loads, as in the case of laborers, freight handlers, and longshoremen.
The great strain occasioned by work of this kind lays a heavy load
upon the veins of the legs. Whether the valves become useless through
stretching of the vein walls, or are directly broken, is immaterial.
The occupations which involve standing for long periods without moving
the legs are, in a lesser degree, a source of valvular incompetence,
and this is not from excessive back pressure but from stasis due to
lack of muscular movement. Among women, the venous engorgement of the
legs, so often seen in pregnancy, may, after the birth of several
children, result in varicosity.
Many of the constitutional diseases such as gout, anemia, diabetes,
syphilis, and tuberculosis, which lower the vitality of the tissues,
and other conditions, such as valvular disease of the heart, general
obesity, and arterial hardening which prevent proper circulation,
predispose to the formation of ulcers when there is in addition some
exciting cause.
Embolism, which cuts off the nutrition of the part, may also act as a
local cause. Certain vasomotor disturbances, such as occur in frost
bite and in Raynaud’s disease, may produce small areas of localized
gangrene which subsequently become the seat of an ulcer.
Interference with the return of venous blood from a part predisposes to
ulceration. Where phlebitis and periphlebitis occur, especially in the
smaller venous radicles, small abscesses often form, the adjacent skin
becomes involved, and an ulcer results; or the rupture of the diseased
wall of one of the small veins may become infected, and ulcer develops.
Perforating ulcer of the foot is a frequent complication of tabes
dorsalis. Myelitis, and other pathologic conditions of the nervous
system may also, either through trophic changes or by reason of
impaired sensation, bear a distinct relationship to ulcerative
processes.
=Exciting Causes.= Traumatism is one of the most frequent causes of
ulcer formation. Its degree may, of course, vary greatly, and whether
it will produce an ulcer depends upon one or more of the predisposing
causes already mentioned. Infection by any of the staphylococcus or
streptococcus group of organisms as well as by the tubercle bacillus
will produce ulcers; malignant ulceration also occurs.
=Pathology.= The pathology will vary according to the conditions
causing the ulcer, although in the non-specific forms of ulcer
the phenomena of congestion, exudative and necrotic inflammation,
together with reparative inflammation or granulation, will only be
in evidence. In the development of an ulcer the degenerative process
predominates; in the healing stage, the reparative. When the ulcer
develops from without, as when infection enters the skin through an
abrasion, congestion first occurs. This is rapidly followed by the
emigration of leucocytes, by a diapedesis of red blood cells which
rapidly disintegrate, and by an exudation of serum and fibrin. At
the same time there is a proliferation of the epithelial cells and
also a proliferation of the connective tissue cells of the corium. The
tissue next becomes softened by the exudate between the cells. Then,
as a result of the pressure of the exuded serum, of the crowding by
the leucocytes, and of the cutting off of the blood supply, and also
in some measure through the effects of the toxins furnished by the
bacteria, there occurs necrosis of the cells, which are thrown off
from the surface with the products of exudation, until there is formed
an ulcer with its base consisting of spheroidal and a few epithelioid
cells developed from the connective tissue cells by proliferation.
When an ulcer in its complete stage of development is examined,
the surface is found to be covered with a layer formed by the
overproduction of new round cells, together with the exudate of fibrin,
serum, and the cellular elements of the blood. When the discharge from
the ulcer is profuse, this may be constantly washed away. When the
ulcer is sluggish, it may be in a condition of coagulation necrosis. In
this latter condition a croupous material covers the base of the ulcer,
and below this is a more or less distinct layer, largely composed of
cellular elements, with very little cellular substance, the cells being
spheroidal and epithelioid in character and mingled with polynuclear
leucocytes. As we go deeper, the amount of intercellular substance
increases, and a number of transparent fibres and fusiform cells are
found. In this layer of granulation tissue are also the newly formed
blood vessels, the most superficial branches being vertical to the
surface, and developing by a process of budding from the endothelial
cells of the capillaries deeper down. This layer is paler in color than
the layer made up of the cellular elements, but may contain pigment
from the disintegration of the red blood cells. It gradually merges
into a layer of cicatricial connective tissue which lies beneath the
ulcer.
A section of a chronic ulcer would show an enlargement and
prolongation of the papillæ, with a marked proliferation of
the epithelial cells covering them. This is most pronounced in
the condition known as callous ulcer, where the edges may, by
proliferation, be considerably raised about the level of the
surrounding skin, and often overhang the base of an ulcer. Under proper
treatment the reparative process proceeds faster than the degeneration
of the cells and the ulcer begins to heal by granulation. Small sprouts
or buds of protoplasm protrude from the capillaries below or in the
base of the ulcer, developing from the cells in their walls. These
are hollowed out by the blood pressure and form new blood vessels
which anastomose with others. Nuclei form in the protoplasm and thus
endothelial cells develop. At the same time small spheroidal cells,
developing from the connective tissue cells, become grouped around
the blood vessels. These are closely crowded together at first, being
separated by only a small amount of fluid intercellular substance. Some
of the round cells then become larger and fusiform or branched. The
larger cells are known as epithelioid cells. Some of the fusiform and
branched cells, called fibroblasts, develop the new delicate fibrillar
intercellular substance, while others form the connective tissue cells.
Gradually the fibrous intercellular substance increases in amount,
while the cells become fewer and flattened, and cicatricial tissue
is formed. The contraction of this cicatricial tissue constitutes an
important element in the healing of an ulcer.
During the process of granulation, more of the round cells are produced
than are necessary. These die and are thrown off in the discharge.
Healthy granulations should be small, even, and of a reddish pink
color. Where the growth of the blood vessels proceeds more rapidly than
the development of the cells and the formation of connective tissue,
there is produced a soft, pale, flabby condition known as exuberant
granulations, or proud flesh. On the other hand, both the cells and the
blood vessels may develop very slowly, forming indolent or sluggish
granulations. In order that the ulcer may heal it must eventually
become covered with epithelium, and this can develop only from the
epithelium at the edges of the ulcer. Under favorable conditions,
when the granulations reach the level of the surrounding skin, the
epithelium begins to spread in a thin bluish white line from the edges
out over the surface, until the latter is entirely covered, when the
ulcer is healed.
=Simple Ulcers.= By far the greatest number of ulcers coming under the
observation and within the province of the podiatrist are of the simple
variety. Heavy calloused areas which are neglected are apt to become so
irritant as to cause the softer tissues underneath to break down and
ulcerate, and a similar condition very often occurs in connection with
helomata, particularly heloma molle.
Constitutional diseases, either trophic or specific, may be
predisposing causes of these conditions but the exciting cause is
surely traumatism.
Simple ulcerations are most generally found upon the plantar surfaces
of the feet, under the heads of the first or fifth metatarsal bones. As
has been previously mentioned, however, the interdigital surfaces are
also prone to these conditions. In this latter location the amount of
perspiration excreted in the locality undoubtedly has much to do with
the lowering of the vitality of the skin covering the part, and renders
it susceptible to disintegrative processes.
=Treatment.= All the overlying callous must be immediately removed
so that the parts may be properly cleansed and so that drainage may
be maintained. This may be done with a sharp sterile scalpel, but
sufficient care should be exercised so that no hemorrhage is caused.
After the hardened tissue has been cut away, all necrosed tissue
adhering to the floor and edges of the ulcer should be removed. A spray
of alcohol, 60%, may then be employed to obtain thorough asepsis and
after the parts are thoroughly dried, a dressing is applied in keeping
with the conditions present.
=Wet Dressing.= If infection is present, or if the parts be
considerably inflamed, due simply to the traumatic irritation, a
wet dressing of mercury bichloride, ¹⁄₄₀₀₀, liq. aluminum acetate,
or alcohol and boric acid, equal parts, should be employed for a
sufficient time to reduce all infective or other inflammatory symptoms.
Bichloride of mercury should not be used for a prolonged period of time
in these cases, for its corrosive action will prevent new granulations
and thus retard healing. The aluminum acetate and alcohol, boric acid
combination may be used without fear of toxic irritation. If simple
inflammation is present in the parts, Goulard’s extract may be employed
to reduce the acute symptoms, but care must be exercised and the parts
watched so that no lead dermatitis shall develop from the drug.
It is unwise under any condition to prolong the use of wet dressings
beyond a time when they are thought to be necessary. The constant
moisture is not conducive to prolific or to healthy granulation and
for this reason these applications are best discontinued as soon as
possible.
=Boroglycerine=, a combination of boric acid and glycerine, applied to
a simple ulceration, particularly one of the indolent type, is found to
stimulate granulation and thus aid materially in the healing process.
It is applied on sterile gauze and allowed to remain unchanged for from
twenty-four to forty-eight hours.
=Dry Dressings.= Dry dressings, either of plain aseptic gauze or
of dusting powders, are found effective in the treatment of simple
ulcerations. The choice of the dusting agent is, of course, dependent
upon the conditions present, but it should combine astringent and
antiseptic properties.
=Thymol Iodide=, while not astringent, is a general favorite for most
simple ulcerations. Contrary to the action of most powders, this
combination of iodine and thymol induces a discharge rather than
prevents it. This is due to the action of its constituent thymol and
is desirable in dry ulcerations where more or less coagulation is
present. This powder, known best by its trade name, aristol, has an
energetic, antiseptic action due to the liberation of iodine and is
used practically to the exclusion of all other iodine powders. It
is principally used as an iodoform substitute, having none of the
disagreeable odor of this drug.
=Bismuth Subgallate=, a combination of gallic acid and bismuth, is an
efficient powder for use in these conditions. Its action is markedly
astringent and it can be depended upon for antiseptic action as well.
=Bismuth Subnitrate= is also an astringent and antiseptic powder which
may be substituted for the other bismuth salt in these conditions. The
molecules of this powder are very fine and there is a tendency for it
to cake so that when used, the dressing should be changed at regular
and short intervals; the parts should be thoroughly cleansed of the
dried powder from previous application before the new dressing is
applied.
=Zinc Powders=, such as the oxide and the stearate, are also applicable
in cases of simple ulcer. Zinc oxide may be combined with various other
powders and numerous such combinations are now in the market. Zinc
stearate is used alone and can be depended upon for a mild astringent
action, although not comparable with either bismuth subgallate or
subnitrate.
=Ointment Dressings.= The use of ointments is contra-indicated in the
presence of a discharging surface and for this reason drugs in fatty or
oily bases are not generally used in all stages of ulcer regeneration.
Several ointments may be used, however, either for antiseptic or
stimulative action after the acute discharge, if present, has subsided
or if no great amount or exudation is present.
=Ung. Hydrargyri Ammoniati=, white precipitate of mercury, will be
found useful where antiseptic action is desired.
=Ung. Acidi Borici=, an antiseptic ointment, is also used in this
connection.
=Ung. Acidi Tannici=, twenty parts of tannic acid, twenty parts
glycerine, sixty parts cerate, is an astringent ointment efficient in
these cases.
=Ung. Eucalypti= is used as an antiseptic and stimulant application for
indolent ulcers.
=Ung. Zinci Oxidi= is a soothing and mildly astringent ointment which
can be used advantageously.
=Ung. Balsam of Peru=, a 3% to 10% ointment of Peruvian balsam in
vaseline or lanolin, is both antiseptic and stimulant.
=Scarlet Red=, an ointment prepared from medicinal scarlet red
(Biebrich), may be used in strengths from 1% to 8% as a stimulant and
healing application.
In the use of all ointments it is advisable to place only a thin film
of the mass over the parts. Avoid the tendency to use a large quantity
of any ointment.
A shield may, at times, be used in connection with the application
of the dry or of the ointment dressing. These appliances, however,
particularly if made from a thick material, tend to arrest the
circulation to the localized area, and, as free blood flow is to be
desired at all times, the shield should be omitted in cases in which an
ointment dressing is being used, unless it is sure that circulation is
not being thereby impeded.
Squares of sterile gauze held in place by adhesive strips or by a
soft cocoon dressing, are practical means of retaining a powder or an
ointment to the part. In choosing the latter form of dressing, never
use a great amount of collodion in binding down the cotton fibre. If
applied too freely, it is absorbed by the cotton and is apt to come in
contact with the ulcerated surface itself. The dressing, if applied
over a discharging area, should be absorbent, and this possibility is
nullified when it is hardened by collodion.
INDOLENT OR CALLOUS ULCER.
This form of ulcer occurs principally on the leg, but occasionally is
found on the foot and ankle. Callous ulcers vary in size from a five
cent piece to the entire circumference of the part attacked.
The surface is usually smooth and glistening and of a dirty yellow
color, with perhaps a few badly formed granulations. The edges are hard
and sharply cut and elevated considerably above the surface, while the
surrounding skin may be inflamed over the margin and is either covered
with sodden cuticle or is congested. The skin surrounding the part
is often deeply pigmented from chronic congestion, the pigmentation
starting in separate papillæ as maculae, which gradually coalesce. The
discharge is purulent or serous and may be so abundant and irritating
as to cause eczema of the skin. The base is adherent to the underlying
tissues and this constitutes one of the main difficulties in healing,
as contraction is thus prevented. If the ulcer is situated above a
bone, such as the tibia, chronic periostitis may result. Such ulcers
are sometimes very painful from pressure on cutaneous nerves, or from a
localized cellulitis associated perhaps with inflammation of veins and
lymphatics. Thrombosis not infrequently occurs in both sets of vessels,
leading to chronic edema of the feet.
=Etiology.= _General Causes_: (a) Various devitalizing fevers and
diseases such as typhoid, scorbutus, diphtheria, chronic nephritis,
etc. (b) Mineral poisoning, such as is produced by phosphorus. (c)
Anemia and debilitating conditions brought on by starvation, improper
food, poor hygiene, overwork, lack of sleep, etc.
_Local Causes_: (a) Old scar tissue, the contraction of which has cut
off the circulation. (b) Continuous pressure, from splints, lying in
bed, etc. (c) Local destruction of the tissues such as is produced by
extremes of heat and cold. (d) Local irritation or injury of tissues
from violence. (e) Various diseases of the skin, for example, pemphigus.
=Symptoms.= These ulcers are most commonly found on the inner side of
the lower third of the leg. They show great variety in size, shape and
appearance, of base, edges, and surrounding area, and in accordance
with these differences, many different names are applied to them. They
may be round, very irregular, or funnel-shaped, as in perforating
ulcer of the foot. When the granulations are large, irregular, and
bleed easily, they are spoken of as exuberant or fungating; when
pale, soft and flabby, as weak or edematous; when small and growing
slowly, as indolent. Sometimes the base is covered with a grayish or
yellowish-white necrotic layer formed of fibrin and necrotic cellular
elements. When this is removed, no granulations appear, but instead it
presents a smooth, shining base resembling mucous membrane. This form
is known as the croupous ulcer. The edges also vary greatly. They may
be irregular or sharply cut, moderately thickened, or very much so,
due to chronic congestion and edema, with enlargement of the papillæ
and proliferation of the epithelial cells. When this is a prominent
feature, the name callous ulcer is applied. The edges may be adherent
to the deeper structures, thus preventing contraction and healing; they
may be rounded, elevated, undermined, or overhanging.
The discharge from an ulcer is usually slight in amount, serous in
character, and contains very few pus cells. The surrounding area may
be swollen, red, congested, pigmented, edematous, eczematous, or the
ulcer may be surrounded by smaller sores, by vesicles, or by masses
of varicose veins. As a rule, there is an absence of severe pain
accompanying leg ulcers, unless there is an exposure or involvement of
some nerve filaments; but frequently, after the patient has been on his
feet for a long time, there is a dull, aching pain in the part, due to
chronic congestion which causes tension in and about the ulcer.
=Differential Diagnosis.= The diagnosis of a chronic indolent or
callous ulcer can be easily made by the character of the granulations
and by the location of the ulcer itself. The history points usually to
an injury or infection and the situation of the sore is at the site
of the previous injury or infection. The base is shallow, inflamed
and often of a grayish-yellow color, with no thickening or elevation
of its edges. The surrounding area is usually round and inflamed. A
varicose ulcer is differentiated by the history of varicose veins or
phlebitis, by its occurrence at the lower third of the leg and by the
undermined thickened and irregular-shaped edges. A syphilitic ulcer is
diagnosed by the history of lues; by its usual occurrence at the upper
third of the leg; by a dirty sloughing and deep base; by punched out,
thin, dense, firm and undermined red edges; and by scars of a dusky red
color. A tuberculous ulcer, by the history of previous glandular bone
or lung disease; soft, pale, edematous granulations; thin undermined
edges; involvement of glands and other signs of tubercular sinuses,
bone disease, etc. A perforating ulcer, by the history of the case; the
appearance of the ulcer upon the sole of the foot or in the vicinity of
the heel; the presence of a sinus leading to necrosed bone; the pale,
flabby granulations; all these signs should make the diagnosis easy.
[Illustration: CHRONIC ULCER OF THE FOOT
(BEFORE OPERATION)]
=Treatment.= This naturally depends upon the stage at which the
ulcer is seen and the conditions present. If there is considerable
inflammation, accompanied by marked cellulitis and pain, wet dressings
are indicated. Two distinct therapeutic actions may be derived
from the wet compress, depending upon whether or not an impervious
covering is employed. These actions are antiphlogistic and hyperemic,
and these in turn may be either antiseptic or astringent. The wet
dressing, without a covering, is cleansing and heat reducing,
because of evaporation. There should be frequent replenishment of
the solution where there is considerable discharge, or where it is
desirable to reduce inflammation. A wet dressing with an impervious
covering is contra-indicated in the presence of pus, the warmth and
moisture of such a dressing, being congenial to the growth and to
the multiplication of bacteria. For the relief of pain and for the
reduction of inflammation, wet dressings are the most effective form of
treatment because (1) they are aseptic; (2) they permit free drainage;
(3) no new granulations are disturbed in changing the dressing.
A great many different solutions are used and among these are: (1)
sterile water; (2) ordinary saline solution (a teaspoonful of salt
to a pint of water); (3) saturated solution of boric acid (prepared
by dissolving a teaspoonful of boric acid in a pint of water); (4)
Thiersch’s solution (prepared by dissolving 15 grains of salicylic acid
and 90 grains of boric acid in a pint of water); (5) Burow’s solution
(prepared by dissolving 675 grains of alum and 270 grains of lead
acetate in a pint of water); (6) solution of bichloride of mercury
(varying in strength from 1 to 3,000 to 1 to 10,000); (7) lead and
opium wash (U. S. P.); (8) Dakin’s solution (hypochlorite of soda).
After the reduction of the inflammation, the next step is the cleansing
and sterilization of the ulcer. Before healthy granulations can
form, the removal of sloughs and the cleansing of the base must be
accomplished as thoroughly as possible. Many means toward this end may
be effective. A one-half to two per cent. creolin or lysol emulsion
is very useful for those dirty ulcers from which a profuse, foul
discharge escapes. A one per cent. solution of formalin is of great
value for smaller ulcers, especially those due to tuberculous disease.
The destruction and removal of sloughs may be hastened by cauterization
with the solid stick of nitrate of silver. The use of certain ferments,
such as brewer’s yeast, papoid, or protonuclein, may help to clean up
a chronic ulcer. The most frequent means employed for the cleansing
and sterilization of the ulcer, previous to the application of some
stimulating dressing, is washing the part with tincture of green soap
and water. Peroxide of hydrogen can next be used, then sulphuric
ether, and finally ninety-five per cent. alcohol. Where there is an
accompanying eczematous condition, the scales can best be removed with
benzine.
[Illustration: CHRONIC ULCER OF THE FOOT
(AFTER OPERATION)]
Having reduced the inflammation and succeeded in cleansing the ulcer,
the next thing to consider is the means by which granulations may be
stimulated. This may be accomplished by applications in the form of
powders, solutions, ointments and grafts.
Dusting powders are employed either as antiseptics or as astringents
or for both purposes. Their use in this instance is limited, and they
are employed only where the secretion is scanty. Among the various
powders used are: aristol, dermatol, boric acid, orthoform, calomel,
protonuclein, alum, zinc oxide, etc. Thymol iodide, or aristol, is
a superior antiseptic powder and enjoys the advantage over iodoform
of being inodorous. Iodoform should be used only in tuberculous
conditions; calomel only in syphilitic cases. Dermatol, or bismuth
subgallate, combines the astringent and mildly antiseptic qualities of
bismuth and gallic acid. Boric acid is mildly antiseptic. Zinc oxide
and alum are both astringent. Scarlet red, five per cent., with boric
acid, ninety-five per cent., is indicated when the granulations are
sluggish.
Among the various solutions used are silver nitrate in various
strengths, zinc and copper sulphate, ichthyol, balsam of Peru, and
calamine. Silver nitrate, zinc and copper sulphates are employed for
their astringent action. Balsam of Peru, fifty per cent., with castor
oil, fifty per cent., is used for its stimulating action.
Ointments are used in the treatment of ulcers either to stimulate the
granulations or to soften thick epidermis. Ointments should never be
employed where there is a profuse discharge. Many different kinds of
ointments are used, prominent among them being: balsam of Peru, in a
ten per cent. strength for the stimulation of the granulations; boric
acid and ichthyol, in the same strength; Lassar’s paste (which consists
of salicylic acid, one dram; starch and zinc oxide, each one ounce,
and vaseline to make four ounces). This latter ointment is especially
indicated when there is an eczema present. An ointment which has given
good results is scarlet red, 1% to 5%. Scarlet red (Biebrich) was
originally prepared as a dye for wool and silk, and is so named because
of the fact that it was first manufactured in the town of Biebrich.
Its application to granulating surfaces induces healing, not by the
formation of scar tissue, but in every case by producing a high grade
of normal skin which very soon becomes freely movable on the underlying
tissue. The return of sensation in the healed area takes place from
the periphery inward, instead of upward from the underlying tissue.
Usually the dressing should be left undisturbed for from twenty-four to
forty-eight hours, then reapplied, as indications warrant. In removing
the dressing, if it be adherent to the granulations, peroxide of
hydrogen should be used to loosen it. The skin about the granulating
surface is best cleansed by benzine, as this removes all traces of
scarlet red better than any other solution. The following formulas are
recommended:
Scarlet red (medicinal Biebrich) fifteen grains; ungt. acidi borici, q.
s. ad three ounces (one per cent.).
Scarlet red (medicinal Biebrich), forty-five grains; ungt. zinci oxidi,
q. s. ad three ounces (three per cent.).
Scarlet red (medicinal Biebrich), seventy-five grains; balsam of Peru,
seventy-five minims; petrolati, q. s. ad three ounces (five per cent.).
The first is indicated where scarlet red is desired over a large area
and for a long time; the second, where an astringent action is required
because the granulations are profuse; the third, where the granulations
are sluggish and require stimulation.
VARICOSE ULCER.
=Etiology.= To chronic ulcers of the leg, associated with varicose
veins, especially of the smaller venous radicles, the name varicose
ulcer has been given. The usual development of this variety of ulcer
is as follows: persons who suffer from varices of the leg usually
complain, for some time before the external manifestation of the
disease, of a dull, aching pain in the limb, with a sense of weight,
fullness and fatigue. In a more advanced state of the disease the
ankles swell after a day’s hard work, and the feet are constantly
cold; an embarrassed state of circulation is denoted by these symptoms
and the deep-seated veins begin to swell. After a time, which varies
with the idiosyncrasy and occupation of the patient, small, soft,
blue tumors are seen at different points of the leg, most of them
disappearing on pressure, but returning when it is removed, or when
the patient stands up. Each little tumor is caused by a vein, dilated
at the point at which it is joined by an intramuscular branch. Around
many of these tumors a number of minor vessels of a dark purple color
are clustered; these are the small superficial veins which enter the
dilating vein and in which the passage of the blood is retarded. An
increasing area of veins gradually becomes involved and a number
of irregular, knotty, consolidated tumors are developed, grouping
themselves around the point at which the dilatation first began. The
external and internal saphenous veins are those primarily affected,
but long tracts of tortuous veins may extend up the leg and thigh.
Dangerous and even fatal hemorrhage may ensue from the bursting of a
varix through the skin. The vessels may become filled with clots and
permanently obstructed, and ulceration with thrombosis or phlebitis
may be the sequel. The capillaries become engorged with blood, and
hence the assimilation changes are retarded and sometimes altogether
checked. Gradually the entire circulation of the part is arrested. The
vitality of the superficial structures becomes permanently impaired;
consequently they are unable to resist the effects of slight injuries
and repair fails to take place after a portion has been destroyed, and
an open sore or ulcer is established.
=Symptoms.= The varicose ulcer is usually single, oval, round or
irregular in outline, and is most often seen on the lower third of
the leg near the internal or external malleolus. The edges are thick,
everted, and swollen. The swelling is largely due to edema and is found
to pit on pressure. The floor is generally covered with rather large
granulations which bleed freely when touched. In a varicose ulcer the
destruction of tissue often begins at the margin of a congested area
and advances toward the centre. The size varies from the small ulcers,
less than one-half inch in diameter, formed by the breaking down of an
area of periphlebitis around a small vein, to those several inches in
diameter. Several ulcers may be present on one limb. The granulations,
as a rule, are weak and flabby. The discharge is thin, serous, mixed
with débris, and may be blood-stained. The skin surrounding a varicose
ulcer is often of a brownish blue color, due to a deposit of pigment.
The recognition of varicose ulcers is usually easy; but the mere
presence of enlarged veins, it should be noted, is not pathognomonic,
because they may exist along with ulcers of other origin--the luetic,
trophic, etc. The most frequent complication is phlebitis; cellulitis
is also seen. This latter may sometimes be so severe as to necessitate
operation. Complications such as necrosis of bone, involvement and
ankylosis of the ankle joint, together with atrophy and contracture
of muscles and adhesions of tendons (perhaps giving rise to various
deformities of the feet, such as flat foot or even club-foot) are
extreme and unusual complications.
Where the varicose ulcers have persisted for a long time and refuse
to heal, it is always advisable to apply the Wassermann test in order
to exclude the possibility of syphilis. In doubtful cases it is also
advisable to test by the Noguchi luetin skin reaction.
[Illustration: VARICOSE ULCER]
=Treatment.= In these cases of varicose ulcers it is impossible to
effect a cure until the chronic congestion of the limb is relieved
and the blood supply of the part approaches normal. Often all that is
necessary is a gauze, muslin, rubber or flannel bandage.
A bandage, when applied with moderate, even pressure, has for its
purpose the relief of congestion. In a great many cases rubber has an
irritating effect upon the skin, and that kind of a bandage should
therefore be cautiously used. When the granulations are almost on a
level with the skin, and also where there is considerable thickening
of the edges of the ulcer, the best means of keeping up an even
pressure and causing absorption of the thickened margins, as well as of
hastening epithelial growth, is to apply zinc oxide adhesive plaster
in strips, one-half to one inch in width. These strips should overlap
to the extent of about one-third of their width, should extend about
three-fourths of the way around the limb, and should be evenly and
smoothly applied. They should be started about one inch below the ulcer
and should run from two to three inches above it.
In order to effect a permanent cure, varicose veins must be operated
upon, and a number of operations have been devised, as follows: the
ligation of the internal saphenous, as advised by Trendelenburg; the
multiple percutaneous ligations of Schede; the total extirpation of the
internal saphenous, as recommended by Mayo; the dissection after the
method of Madelung; and the spiral of Rindfleisch.
=Perforating Ulcer of the Foot.= This type of ulcer usually occurs
where pressure and irritation are greatest and is therefore commonly
found on the plantar surface of the foot under the heads of the first
and fifth metatarsal bones, and on the under surface of the great toe.
Occasionally, however, they develop on the dorsal surfaces or ends of
the toes, in cases such as hammer toe.
=Etiology.= There are various theories relative to the causation of
lesions of this nature. One claims injury to be the sole cause; another
attributes it to arteriosclerosis and capillary thrombosis; still
another charges it to chronic peripheral neuritis and alteration in
the nerve terminals. One writer states that traumatism is an important
factor in their development, conceding, however, that various systemic
conditions must necessarily enter into the etiology, among them,
locomotor ataxia and injuries to the spinal cord, diabetes and injuries
to the peripheral nerves. This latter, known as the “mixed theory,”
is the one most generally accredited and is in all probability most
correct.
This type of ulcer is found more frequently in males than in females
and it occurs almost exclusively in adult life (between 40 and 60
years). Occupation is a predisposing factor, and work demanding long
periods of standing or walking unquestionably has much to do with the
development of a perforating ulcer, all other conditions being equal.
[Illustration: POST-OPERATIVE DIABETIC ULCER]
=Characteristics.= The ulcer is usually found to be irregularly
circular in shape, with a tendency to progressive development,
involving the deeper soft tissues, finally attacking the periosteum
and the bone itself, causing necrosis. The superficial edges of the
ulceration are heavily calloused and the lesion shows little or no
tendency to heal. One of the most marked characteristics is the entire
loss of sensation. Many cases have been observed where the patient
feels no pain, even when the lesion is deeply probed.
=Symptoms.= At times, particularly in diabetic patients, a purulent
blister is the initial lesion, but in most instances these lesions
develop under a heavy callous, the centre of which breaks down into
an indolent superficial ulceration, discharging a thin, discolored,
odorous pus, but never in great quantities.
The fact that changes in the peripheral nerve supply usually take place
in the development of perforating ulcer probably accounts for the
absence of pain, as above mentioned, and also explains the progressive
degeneration which takes place, allowing the ulcerative process to
progress into the deeper tissues.
=Treatment.= The systemic disturbances which may be present are
important factors to be considered in the treatment of perforating
ulcer, but local applications may be made and local conditions must
be considered. If the ulcer be upon the plantar surfaces of the foot,
walking and standing, which would bring continued pressure, must be
avoided. Shoes must be well fitted and must not irritate the parts,
and cleanliness must be obtained and maintained. All callous must be
removed from the edges of the ulcer and proper drainage is of great
importance. All necrosed tissue must necessarily be removed and any
burrowing sinuses should be thoroughly opened. Artificial hyperemia,
massage and electricity are found to be of benefit in improving the
general circulation in the foot and leg.
In the local treatment of the ulceration itself, prolonged application
of strong germicidal solutions is to be avoided at all times. Cleansing
with warm normal salt solution is recommended as a non-toxic and
stimulant application.
Dressings may be of plain aseptic or iodoform gauze packed lightly into
the ulcer. These lesions are discouraging to treat, inasmuch as even
after complete healing, relapses usually occur which leave the parts as
bad or worse than the original lesion.
Stimulant applications may be employed locally, with some success in
connection with internal medications for the systemic disturbance
present. Balsam of Peru or scarlet red (1% to 3%) are advocated in this
connection.
The prognosis in cases of perforating ulcer is bad, inasmuch as the
progress of the lesion sooner or later involves sufficient tissue in
the degenerative process to necessitate surgical interference--perhaps
amputation of the foot. As has been previously mentioned, even when
fully healed, relapse almost always occurs.
=The Syphilitic Ulcer.= The syphilitic ulcers do not properly come
within the province of the podiatrist for treatment, but he should be
able to recognize them. They may develop from pustules or begin as
original lesions in the tertiary stages of the disease. Developing in
this latter instance from gummata, they are immediately deep ulcers.
The worst superficial ulcers of syphilis may develop early in the
course of the general disease.
[Illustration: SYPHILITIC ULCER OF THE LEG]
=Symptoms.= These ulcers vary in size from a quarter to a silver dollar
and occur on the upper third of the leg, occasionally on the upper
part of the middle third. During the early stages of the lesion it is
surrounded by an inflamed area of skin at the ulcer and presents an
even, “punched out” edge. Being a new growth, developed in the corium,
the edges are usually more firm and dense than in other forms of
ulcer. The floor of the lesion is of a dusky red or coppery color,
and has a characteristic slough of a greenish color. The discharge is
frequently bloody and is filled with broken-down tissue.
If on account of the presence of enlarged veins, it is difficult to
distinguish a syphilitic from a varicose or other type of ulcer, a
positive Wassermann test will confirm the diagnosis.
Being merely a local manifestation of a general infection, the systemic
disturbance must be treated by a licensed physician. It is generally
found that a lesion of this type, once healed, remains so.
=Treatment.= Treatment for syphilitic ulcers comprehends the use of
mercurials as local applications. Mercury bichloride ¹⁄₁₀₀₀₀ may
be employed with beneficent results in most cases where a profuse
discharge is present. Where there is little or no discharge, calomel
powder dusted into the ulcer will give good results.
As in most cases where a syphilitic lesion has developed locally on the
leg, the patient is or has been under a physician’s care, practically
none of these cases come to the podiatrist for his treatment alone.
Many times, however, he is called in by the physician to do local
dressings under his direction, and it has even happened that the
podiatrist has been the first to recognize the significance of the
local lesion.
CHAPTER XXI
CUTANEOUS MANIFESTATIONS OF SUPER-ACIDITY
A surcharging of the blood with an abnormal amount of acidity leads
generally to conditions which come under the domain of the physician.
So-called rheumatism, gout and kindred ailments of all forms and
varieties are every-day occurrences, and, being symptoms of systemic
disturbances, should be treated by internal administration.
The podiatrist, however, in his daily treatment of foot troubles is
called upon to treat locally certain forms of skin disturbances due to
hyper-acidity which manifest themselves upon the surfaces of the foot.
Uric acid eczema is the general term employed to designate these
annoying conditions and is synonymous with the older and now obsolete
terms, lithemia and uric-acidema.
=Definition.= Uric acid eczema is a skin eruption due to a surcharge of
uric acid in the blood and a precipitation of this acid in a certain
part, so that the acid elements or urates are carried by the blood
stream to the skin and there set up a dermatitis.
=Characteristics.= These manifestations may be found in all varieties
and degrees from a mere dryness and hardness of the skin, in which
the normal flexibility is gone, and in connection with which there is
usually intense itching and burning, to the formation of deep fissures
(usually found in the toe webs) and small ulcerative processes which
may manifest themselves in any part of the foot and often present a
stubborn resistance to all endeavors at healing. These symptoms may
occur singly or, as in the most instances, in combination.
These conditions are usually met with in the spring of the year and no
doubt are brought about by a series of changes in habits and diet which
occur at this time.
=Etiology.= During the winter months the average person takes but
little physical exercise as compared to his activities during the
warmer weather. The foot, being at the base of a column of blood which
must be forced back to the heart, against gravity, is coming constantly
in contact with cold surfaces. This, together with a lack of exercise,
tends to stagnate the blood circulation in the pedal extremities.
Coupled with these two conditions, during the winter months, people
are inclined to over-eat and over-drink, the waste materials from
which excesses are but improperly eliminated, due also, to a great
extent, to insufficient exercise. Here, then, we have a stagnation
of the blood current in the pedal extremities, a surcharging of the
blood in the feet with certain urates, and a precipitation of these
solid constituents, due to the cold surfaces with which those members
constantly come in contact.
This condition is present in the spring of the year when fresh
vegetables and fruits begin to come into the market. A great many of
these edibles, particularly strawberries and tomatoes, are markedly
acid and when ingested tend to exaggerate the conditions in the blood
already present. The result is generally a cutaneous eruption which may
appear on any part of the body and which frequently occurs in the feet.
(See chapter on Fissures and Burns.)
=Fissures.= Probably the most common condition met with from this cause
is the cracking or fissuring of the toe web. This may be accompanied by
itching and burning in varying degrees, but these latter complications
are not always present. The skin between the digits is found to be
blanched and macerated and often the superficial epidermic layers
will become slightly thickened and exfoliated. The fissures occur in
the web and are due to the skin losing its normal flexibility so that
the tissues, as they expand in walking or in drying the parts with
a heavy, rough towel, are not sufficiently extensible, and so they
crack or fissure. These cracks may be merely superficial splits through
the epidermic layers or they may become deep and ugly fissures which
penetrate well into the corium. When they reach this latter stage, the
parts are found to be exceedingly tender and the irritation to the
tissues is severe. These fissures are prone to infective processes as
their deep recesses present an excellent lodgment for invading bacteria.
The fissured area is usually confined to the web, but may be found
extending around under the toe on either side or upon the plantar
surface of the foot. When these conditions are of long standing, the
edges of the fissure will be found to be thickened and calloused; it is
found necessary to remove this growth before normal granulations may be
expected.
=Treatment.= In cases where only pruritis is present and no distinct
lesion manifests itself, tr. benzoes compositas will be found an
efficient agent in reducing the itching and in aiding the general
irritation to subside. In superficial fissures, tr. benzoin compound
may also be used in many cases with good results. The parts should
first be thoroughly cleansed with alcohol, 60%, dried, any loosened
or exfoliated epidermis to be removed before the benzoin is applied.
More or less smarting is to be expected from the application of the
tincture, but as this is very transient, no great amount of pain is
suffered by the patient. The tincture is applied by means of a sterile,
cotton wound applicator, and is painted well down into the fissure
itself, and over considerable of the surrounding integument. This
tincture is very sticky and should be allowed to dry thoroughly before
the hosiery is replaced. As compound tincture of benzoin forms a thin
film or coating upon thoroughly drying, no gauze or cotton need be
placed over the painted areas. This application may be renewed daily,
the coating from the previous application being removed by alcohol and
the parts cleansed and dried before the second application is made.
Mild vegetable astringents may also be employed in such cases.
Principal among these are gallic and tannic acid. These drugs may
be used in solution, ointment or dusting powder form and seem to
be efficient in all. Dusting powders are usually preferred and the
two most popular are bismuth subgallate (dermatol), a combination
of bismuth and gallic acid, and tannoform, a powder containing 5 to
10% of tannic acid. These are applied after the parts have been made
aseptic and thoroughly dried. Bismuth subnitrate may also be used with
good results in this condition, as may thymol iodide (aristol). The
latter has very little astringent action and, therefore, except for its
antiseptic properties, cannot compare with the other powders mentioned.
Pure ichthyol may also be used in the treatment of superficial
fissures. The drug is dropped into the lesion and covered with gauze or
cotton, as are the dusting powders. Another drug recommended in these
cases is sodium bicarbonate. This agent is alkaline in its reaction
and, coming in contact with the perspiration (acid) in these parts,
serves to neutralize this excretion and so aids in returning the
tissues to normal.
There are many other preparations, any of which may be used in the
treatment of fissured toe webs. Among these are ichthyol ointments, 5
to 10%; balsam of Peru, scarlet red, and a 5% ointment of ammoniated
mercury. Reports of cases treated by the above varying drugs show good
results.
When the fissures are deep, and the discharge from their surfaces
is considerable, slightly different measures must be adopted to
hasten granulation. The edges of deep fissures are almost always
found to be calloused and thickened and this condition, of course,
must be eradicated before further treatment is administered. This is
accomplished with a knife or shallow curette and the operation is
usually painless to the patient and creates no hemorrhage. After the
removal of this tissue, if the fissure be deep, silver nitrate, 5%
solution, will be found efficient as an astringent to contract the
parts and reduce exudation. After this application, a bland ointment
is smeared over the area for the purpose of keeping the tissues soft,
and this is covered by a sheet of gauze or cotton to hold it in place.
Applications of the silver solution are made at frequent intervals
until the desired result is obtained, when it may be discontinued and
some dusting powder resorted to, to complete the healing process.
Should proud flesh have developed in a lesion of this nature, through
neglect, stronger solutions of silver nitrate or the fused stick must
be resorted to for reduction of the superfluous granulations, followed
by a wet dressing of liq. alum. acetate to aid in the reduction of the
accompanying inflammatory symptoms. Lanolin and cocoanut oil have both
been found efficient to massage into the parts in order to keep them
soft and to prevent continued dryness and fissuring.
=Blebs.= Aside from the fissuring of the interdigital webs,
super-acidity manifests itself upon the skin of the foot, and the whole
body for that matter, in the formation of yellow or brownish blebs or
vesicles. They are found to be a more or less circumscribed eruption
and are met most frequently in the foot on the plantar surface in the
hollow of the longitudinal arch. They range in size from a pinhead to a
pea and, in most instances, are but slightly elevated above the surface
of the surrounding epidermis. This is in all probability due to the
involvement of the superficial parts of the true skin.
These lesions are usually uniform with a tendency to coalesce, and
cases have been noted where patches of these eruptions covered a
considerable area, in one instance, from the under surface of the foot,
over its inner side, to the internal malleolus. Vesicular developments
of this nature seldom occur singly but are often found in several
groups on different parts of the integument, each group consisting of
two, three or four distinct blebs.
Pruritis may or may not be present in connection with this dermatitis.
When itching is present it is usually intense and the patient often
breaks and tears the skin in an effort to relieve the irritation.
The areas of normal tissue adjacent to the eruptions may be found
involved in a slight inflammatory process, although this is not common.
These inflammatory symptoms usually subside rapidly under treatment.
=Treatment.= It is usually found advisable, if possible, to allow these
blebs to remain intact, making no effort to puncture them but simply
applying a dressing which will promote and hasten their absorption.
Cases have been noticed where these lesions have been opened and have
developed into angry, deep ulcerations which showed a marked tendency
toward indolent granulation accompanied by profuse discharge.
However, when a bleb for any reason must be opened, it is best
accomplished by use of a sharp pointed, sterile knife. The fluid
contents are found to be a thin, syrupy, translucent, discolored serum,
without any great odor, although resembling ichorous pus to some
degree. There is a distinct loss of tissue as the ulcerations are often
found to involve the upper parts of the derma. Upon evacuation of the
fluid contents, the parts should be thoroughly sprayed with alcohol,
60%, and a moist, unguent or dusting powder dressing, as the operator
desires, applied.
The solutions which may be used as moist applications are liq. aluminum
acetate, or boric acid (saturated solution). Powerful germicides, such
as mercury bichloride, are not necessary unless an infective process be
present, and when used needlessly, they simply prevent or break down
new granulations.
The dusting powders found useful in this connection are aristol (thymol
iodide) and dermatol (bismuth subgallate). The parts should first be
thoroughly dried before the powder is dusted on. If the discharge is
found negative and the pruritis still persists, an ointment of ichthyol
and sulphur, such as follows will prove efficient in reducing the
itching and in stimulating healthy granulations:
Ichthyol 1.
Sulphur 1.
Menthol 1.
Vaseline 32.
This unguent is best held in place by a cocoon dressing and should be
renewed until granulation is complete. Other unguents which may be used
in this connection are sulphur, 10% (lanolin or vaseline base), balsam
of Peru, 5%, and unguentine (a proprietary but useful combination of
ichthyol, balsam of Peru and zinc oxide). These, however, do not tend
to relieve the intense pruritis which usually accompanies these lesions
as efficiently as the first mentioned combination.
URIC ACID AND THE NAILS
The toe nails also manifest conditions of super-acidity. They may be
affected as to color or texture, and sometimes in advanced or neglected
cases, as to size and shape.
=Discoloration.= The nails, due to functional derangements in the
matrix, become loosened and discolored from the presence of an abnormal
amount of uric acid. They may be whitish, yellowish or brown, and in
some cases are found almost entirely black, as if bruised. The nails
in these instances are usually entirely loosened, or at least in part,
from the bed, and sometimes fall off, practically of their own accord.
=Treatment.= Nothing much can be done locally for these conditions,
and the main concern of the podiatrist is to see that the edges of the
loosened nail are not allowed to irritate the softer tissues adjacent.
This is best accomplished by packing cotton or gauze under these edges
so that the nail, if movable, will rub upon this packing and not upon
the skin. It may be found advisable to first clean out (from under and
around the nail) any excrementitious matter which is always present to
a greater or lesser degree. However, too much “digging” about these
parts should never be indulged in, as the operator is liable not only
to cause a lesion, but to loosen the nail to such a degree that its
removal is imperative. If possible, this is to be generally avoided,
for it has been found advantageous to allow the older nail to remain
in place as long as possible in order to protect the new-forming
nail beneath. Alcohol, 60%, sprayed over the part after removing the
disintegrated material, will serve as a cleansing agent and will insure
asepsis to the parts.
=Texture Changes.= Under the influence of uric acid precipitation in
the pedal extremities, the texture of the nail is often found changed
to a marked degree. The nail becomes exceedingly hard, dry and brittle
so that it powders, chips off and breaks away under any sort of
pressure. The nails are often found ridged, and in some instances these
longitudinal ridges have become decided and permanent cracks in the
nail body.
=Treatment.= In clipping nails of this nature, care should be taken
that too much does not chip off or break away from the pressure of the
clipper blades. It will be found advisable to cut but a small portion
of the nail at a time, and that very carefully. The waste material
found around or under the nail body should be carefully removed and, if
necessary, the nail itself should be thinned out by the use of a rotary
file. The parts should be thoroughly cleansed, and the grooves and free
edge should be packed with gauze or cotton to prevent the nail from
moving during the movements of the toe and thereby developing trouble.
=Changes in Size and Shape.= The so-called “club” nail is found in
many cases where the patient is a sufferer from a uric acid diathesis.
This does not occur as frequently in cases of acute dermatitis as in
cases of chronic rheumatism and gout. These are cases where there
is functional derangement of the matrix which causes the nail’s
longitudinal growth to be arrested, followed by an increased vertical
development.
The nail is generally found to be about one-half its normal length and
may be from one-sixteenth to one inch or more in thickness. Cases have
occurred where the nail in appearance and structure closely resembled a
cow’s horn.
Club nails of this variety do not, as a rule, cause a great amount of
discomfort and then only when they develop to such thickness as to
receive and transmit direct pressure from the shoe.
=Treatment.= Club nails are not curable and the treatment is merely
cosmetic. It consists in grinding and filing the nail down to what
would be its normal thickness, or as nearly that as possible. This,
of course, is best accomplished by means of a rotary file. As much of
the nail is clipped away as is possible, when the rotary file with
a coarse-grained “barrel” bur is used. Considerable pressure should
be brought to bear unless the patient complains of heat due to the
friction. When the greater portion of the nail is thus removed a
“finishing” bur is substituted and the roughened surfaces are smoothed
off. The clippers should then again be used to give the nail a fairly
normal shape and the parts under the nail are to be then cleansed out
as much as is advisable.
In using a rough cutting bur the operator must exercise great care that
the skin covering the posterior or the lateral folds is not broken. If
the handpiece of the file is grasped firmly in the palm of the hand and
directed by the index finger while the thumb is rested on the toe and
the bur is directed to it (the thumb), the operator will always have
complete control of the instrument, and this danger is minimized. It
will be found advisable, after cleaning under and around the nail, to
spray the parts with some antiseptic solution or to paint the parts
with tincture of iodine. This is done to insure complete asepsis.
Should the skin be broken during the filing or cleaning, the parts
should be first made thoroughly aseptic and a dressing to prevent
contamination should be applied.
=Prognosis.= It must always be remembered that these lesions are merely
local manifestations of a systemic derangement and although the
painful or annoying characteristics may be alleviated or cured, the
cause of the trouble must be reached, through internal channels.
Diet is the principal means of removing this surcharged acid condition
of the blood and, although some medicines or waters may be and are
ordered by the physician as eliminants, proper care as to dietetics
is essential to the patient’s well-being. Systemic treatment by the
physician, combined with local applications by the podiatrist, are
usually conducive to beneficent and lasting results. In cases of
manifestations of a uric acid diathesis in the nails, nothing much can
be done except through the channels just described; and in cases of
club nails due to a like etiology, nothing can be done to cure them.
Removal of the nail does not, as is sometimes supposed, effect a cure,
and in many instances serves but to make the new nail even worse than
its predecessor.
CHAPTER XXII
VOCATIONAL FOOT DISORDERS
Among the numerous diseases of the foot, there is a class of lesions
produced by strain and misuse, in consequence of the occupation of the
individual. Many occupations cause those who are engaged in them to
stand or walk for long periods of time on hard and unelastic ground,
and others subject the foot or a part of it to such unusual work that
the entire foot, or a part of it, ceases to functionate normally.
=Weakfoot.= The general term “weakfoot” is used to indicate all types
of disability caused by improper functioning of the foot. It is
particularly applied to that condition of the foot in which the muscles
and ligaments on its inner side have become weakened by overuse or by
improper use, and it is, as a vocational foot disorder, common among
barbers, waiters, letter-carriers, policemen and servants. It manifests
itself by pain in the foot, particularly in the heel and on the inner
side, and sometimes by pain in the calves of the legs, in the knees and
lower part of the spine.
At rest, the foot has a normal appearance, but, under weightbearing, it
assumes an attitude of deformity varying in degree with the extent of
the overwork to which it has been subjected. The chief characteristics
of weakfoot are: abduction of the forefoot, an inward rotation of
the upper part of the heelbone and a flattening, or obliteration, of
the longitudinal arch under weightbearing, only. When seen in its
incipiency, an anatomically correct shoe, together with suitable
exercises, can be made to arrest the progress and effect a cure of
weakfoot; but when found in the advanced stages it takes from several
months to several years of conscientious work on the part of the
practitioner and the patient to get results. In such cases, massage,
adhesive plaster strapping, corrective braces and shoes, exercises
and sometimes immobilization in an overcorrected attitude by means of
plaster of Paris dressings, have to be employed in order again to get a
normally functionating foot.
=Flatfoot.= This is a condition in which the longitudinal arch is
depressed and does not regain its normal position when relieved from
pressure. The forefoot is abducted, the head of the astragalus rotates
downward and inward, and the os calcis rotates inward from above and
outward from below. It is the successor to the weakfoot and differs
from it only in that it exhibits also at rest, the abnormal attitude
that a weakfoot assumes under weightbearing only. In flat foot this
attitude is static, in weakfoot it is only temporary. The person
afflicted with it walks with a shuffling gait, due to the accommodative
changes that have taken place in the muscles and ligaments of the foot.
=The Subjective Symptoms= are similar to those in weakfoot and quite
often are not as pronounced as in weakfoot, due probably to the fact
that in this condition a further stretching and strain of the ligaments
is impossible as the limit has already been reached.
=The Treatment= is similar to weakfoot, but must be augmented by means
to overcome the accommodative changes in the foot and leg. The same
class of patients suffer from this condition as are sufferers from
vocational weakfoot.
=Chauffeur’s Foot.= As the term indicates, this condition is found in
people who professionally, or otherwise, drive an automobile for many
hours each day. It is an affection, usually of the right foot and leg,
due to the excessive use of those members while “feeding the car.”
The constant pressure of the “ball” of the foot on the accelerator
causes pain in that part of the foot, followed by a numbness of the
entire foot. The foot feels as if it were dead and when moved, later
on, feels as if a thousand needles were penetrating it. Cramps in the
calf muscles are usually associated with the symptoms in the foot.
=Treatment.= Massage of the foot and leg together with flexion
exercises of the foot and toes.
=Policeman’s Heel.= When a person is compelled to stand upon hard
pavements for a long period of time, great strain is put upon the
tissues over the os calcis or heel. The calcaneo bursa becomes inflamed
and gives rise to pains in that region. This inflammation may affect
the periosteum, causing periostitis and finally a spur may develop
on the under surface of the heel bone, which will become a source of
constant pain.
=The Treatment= consists of rest to the part, and of transferring the
weight to a place other than the painful area, by means of a felt pad
or a brace. If a spur has developed, surgical intervention will be
necessary.
=Dancer’s Foot.= This is a foot lesion first described by Miss Bryde
Campbell, of New York City, who termed it the “Modern Dancer’s Foot,”
because she found it to occur almost invariably in women who were in
the habit of dancing excessively in a modern high-heeled slipper. It
is a painful enlargement of the tissues under the head of the first
metatarsal bone and is found, as a rule, in the left foot only. The
under and inner side around the head of the first metatarsal bone
becomes painful to the touch, and under weightbearing. It is best
described as a periarthritis although it is often complicated by a
bursitis.
=Treatment.= Measures to relieve the painful part from weightbearing.
(Felt pads, braces, etc.) Rest and means to reduce the existing
inflammation.
=Golfer’s Foot.= The attitude assumed in playing golf, especially when
driving the ball from the tee, often gives rise to a painful condition
called “Golfer’s foot.” This pain is felt on the dorsum of the foot
over the course of the extensor brevis digitorum muscle. The extreme
extension of the foot, while striking at the ball, is the direct cause
of the pain. Massage and rest have proven of benefit in Golfer’s Foot.
(Full details of all orthopedic lesions have been but
superficially treated in these pages by reason of the fact
that “Podiatry Orthopedics,” a volume now in the course of
preparation and the next of this series (Otto F. Schuster and
Alvah H. Stafford, authors), will provide exhaustive material
bearing upon all phases of foot orthopedics).
CHAPTER XXIII
LOCOMOTION AS AN AID IN DIAGNOSIS
One need not be a very experienced physician to know that there is a
group of diseases, mostly of the nervous system, which at a certain
point of their evolution, stamp the sufferer with a characteristic mode
of locomotion. To observe such a modification of the normal walk is
often sufficient to make a correct diagnosis.
It is strange, however, how little attention this important subject
has received from the medical profession. In fact, other than the work
of the brothers Weber, who established the physiology and mechanism
of human locomotion, of Neugebauer and of Gilles de la Tourette, who
developed the ichnogram method of gait study, scarcely anything of
importance has been done along these lines for the last quarter of
a century. The study of the mode of locomotion in various diseases
and ailments remains, therefore, a fertile field of research for the
podiatrist.
=Elements of Locomotion.= The act of locomotion or the _power_ of
progression is not a simple one. Various co-related movements combine
to form what we ordinarily term the _walk_. The three chief elements
are: (1) _Posture_, (2) _Station_, and (3) _Gait_. These three factors
may be influenced by local or general diseases, either separately or
together.
=Posture.= Posture is the term applied to the position of the body
in space and is not of much interest to the podiatrist except as
corroborative of the two other elements of locomotion. It has, however,
its value in diagnosis and the new practitioner of podiatry will do
well to learn to observe the position of the body at various angles
and in various diseases. One should learn early, for instance, that
_immobility_ is not always due to paralysis. It may be due to _pain_,
as in rheumatism or to a disinclination to move as in scurvy, rickets
or any condition causing dyspnea. The _restlessness_ in fevers and in
large hemorrhages, as well as the _throwing about_ in renal, gallstone
or intestinal colics, is known to all. Equally characteristic are
the _agitation_ and irregular movements in chorea and hysteria;
the _gun-hammer posture_ in cerebrospinal meningitis, and the
_opisthotonos_ in tetanus and strychnine poisoning.
=Station.= Station is the _power_ of standing more or less firmly
on one’s feet. It includes _attitude_ which is the _manner_ of
standing, i.e., the relation of the rest of the body to the erect
position. The carriage of the head and shoulders should be noted; the
shape of the entire body whether bending _forward_, as in “stooped
shoulders” (faulty attitude habit) and in paralysis agitans, or bending
_backward_, as in ascites and abdominal tumors, should be closely
studied and differentiated from the actual lordosis which is seen
in spinal diseases, in advanced pregnancy, in pseudo-hypertrophic
paralysis and in cretinism. The strictest attention should be paid to
the attitude of the lower limbs, their individual shapes and their
relation to each other when the erect position is assumed. The degree
of firmness with which the individual stands should always be taken
into consideration before a final diagnosis is made. _Swaying_ is the
term applied to any departure from the ideally rigid erect attitude and
perpendicular station. The normal individual, with eyes open and heels
close together, sways about one inch forward and three-quarters of an
inch from side to side. In functional and static ataxias, the swaying
may become so extreme as to produce absolute incapacity to stand.
=Gait.= This term means the specific _manner_ of walking. It is a
narrower term than locomotion which is the _power_ of walking. It
is, however, the chief factor in the act of progression and in the
majority of cases it is characteristic enough to stamp itself indelibly
on the normal as well as on the diseased individual. While in character
reading, gait expression may not be as popular as face expression, it
is often more reliable and in certain diseases it is simply invaluable
as an aid in diagnosis.
METHODS OF DIAGNOSIS
=A.--The Observation Method.= This is the usual method of ascertaining
the gait of an individual. It is practised by the average physician and
podiatrist and consists in observing the patient while he or she walks
up and down the room, taking notice of the peculiarities of gait which
may develop. The patient may be allowed to roam freely about the room
or should be directed to follow a carpet seam or a crack in the floor
at right angles to a previous line of vision. This may be varied by
opening or closing the eyes, stretching out the arms, with legs wide
apart, or keeping them close together. Brisk walking should alternate
with a slower gait and the effect of stopping abruptly and turning
sharply at command should be closely observed.
It is best to have the patient uncovered from the hips down. In women,
the nightgown or chemise can be pulled tightly between the thighs and
fastened anteriorly with a safety pin.
=Caution.= Due allowance should be made for nervousness and a careful
watch must be maintained against a serious fall.
[Illustration: Fig. 1
ICHNOGRAM OF A NORMAL GAIT]
=B.--The Ichnogram Method= consists in studying the impressions left by
_both_ soles (previously colored) when walking on paper for a distance
of about twenty-five feet. Ichnograms (from the Greek--_ichnos_--trace,
and _gramma_--to write) as a method of gait diagnosis are more exact
than the method of observation and should supplement it. Besides, they
inform us, at the same time, of the state of the plantar arch as each
_pelmatogram_ (the impression of a single foot) shows more or less
clearly a posterior oval which changes but little, and an anterior oval
as well as toe marks which undergo characteristic contour changes,
depending on the state of the ligaments, of the tarsal and metatarsal
bones and phalanges, and the relation of these structures to the
musculature and innervation of the foot.
Comparatively little has been accomplished along this line of endeavor,
although it offers a vast and fruitful field for podiatric research.
In fact this branch of podiatry deserves a special treatise, and it
will be discussed in fuller detail in our forthcoming book on Podiatry
Orthopedics.
[Illustration: Fig. 2
A. PELMATOGRAM OF A NORMAL FEMALE FOOT
B. MODIFIED PELMATOGRAM SHOWING WEIGHT BEARING POINTS]
[Illustration: Fig. 3
PELMATOGRAM OF A MALE, SHOWING FLAT FOOT]
=Classification of Gaits.= Strictly speaking there are only three types
of gait: (1) the _paretic_, (2) the _ataxic_ and (3) the _choreic_.
In some diseases there may be a combination of the three, while in
others one type of gait predominates during the early stage and another
during the later developments. At times, one comes across a gait that
combines characteristics of the three types and hence is difficult of
classification.
=I.--Paretic Gait.= _Paresis_ means a lessening of the normal motility
of a muscle, while the term _paralysis_ denotes entire absence of motor
power. We may have, therefore, two or three distinct paretic gaits
according to whether the muscle is slightly or severely weakened or
entirely paralyzed:
A.--The mild paretic gait.
B.--The moderate or flaccid paretic gait.
C.--The severe or spastic paretic gait.
=A.--The Mild Paretic Gait= is caused by muscular weakness due to a
large number of etiologic factors. It results in slowing of locomotion,
the steps being shortened on account of an exaggerated flexion at the
knee joint. The following are examples of mild paretic gaits:
(1) _The Pompous Gait._ The upper part of the body leans backward,
the back is hollowed, the abdomen is protuberant, the feet are widely
separated and appear to move with deliberation and dignity, giving the
impression of conscious importance--hence the name. This gait may be
seen in obesity, pregnancy, ascites, large abdominal tumors, cretinism
and rickets.
(2) _The Hobbling Gait._ The pelvis tilts towards the sound side,
while the trunk leans over to the affected side, causing more or
less pronounced _limping_. This gait is seen in people afflicted
with corns, rheumatism, gout, sciatica, plantar neuralgia, Morton’s
neuralgia, metatarsalgia, hip or knee joint disease or injury (recent
or old), sacro-iliac disease, sprains, inflammatory diseases of the
lower extremity, chimatlon, short leg, paralysis of one leg, abdominal
aneurism, and subacute and chronic appendicitis.
(3) _Intermittent Limping_ (disbasia angiosclerotica or intermittent
claudication) may be classified here and is a curious limping gait
which develops in arteriosclerosis of the lower extremities. There
are pain and fatigue on walking, which disappear after a short rest,
to reappear again soon after walking is resumed. The pulse is weak or
absent below the knee.
(4) _The Waddling or Goose Gait._ The pelvis and head of femur are
jerked forward at each step, knee advanced and extended only after
foot is flat upon the ground. There is more lordosis and swinging
of the body from side to side at each step, than in the pompous
gait. It resembles the gait of a goose. The patient cannot stand on
tiptoe. It is seen in: congenital dislocation of both hip joints and
in pseudo-hypertrophic muscular paralysis, a hereditary disease seen
mostly in boys under ten years of age, and characterized by inability
to get up from the floor.
(5) _The Wobbly Gait._ Resembles the above and is due to atrophy or
paralysis of the three glutei muscles and prevents the patient from
climbing. This inability to climb is also seen in those exhibiting the
waddling gait.
(6) _The Tottering Gait._ Seen in those who have taken large doses
of bromides for long periods; also in hydrocephalus, in Korsakoff’s
disease (psychosis polyneuritica) and in idiopathic muscular atrophy.
(7) _The Shuffling Gait_ is the gait seen in normal old age or senility
and is associated with slowly progressive loss of strength and
mentality. It is also seen in general paresis and is the “normal” gait
of the long-term prison inmate. The patient gives the impression of
being too lazy to lift his feet and instead pushes them along with his
legs.
(8) _The “Charlie Chaplin” Gait_ has been erroneously described as
an ataxic gait. It is rather a combination of the “funny part” of
several gaits in which the waddling, shuffling, tottering paretic gaits
predominate and to which some elements of the spastic paretic, as well
as the ataxic gaits, have been added. The inspiration must have come
originally to the celebrated movie star from some waddling cripple whom
he proceeded to imitate and later burlesqued.
=B.--The Moderate or Flaccid Paretic Gait.= In this form of the paretic
gait there is commonly a paresis of a certain group of muscles, usually
the extensors of the foot or the peronei, causing “toe drop” and
apparent lengthening of the affected extremity. It corresponds to the
“wrist drop” of the upper extremity. To compensate for the lengthening
of the limb, overflexion at the hip or knee, or at both joints, takes
place. The limb is flaccid or flabby.
The foot is lifted high up with each step in order to raise it clear
off the ground and avoid tripping. As the foot is brought down, heel
first, this gait may sometimes be confused with tabes and is therefore
sometimes referred to as the pseudo-tabetic gait. It is, however,
easily differentiated from the true tabetic gait by its characteristic
“high action” or “high stepping” quality which made Charcot compare it
to the gait of a horse and hence called it:
(1) _The Steppage Gait_, mostly seen in the chronic intoxications
producing neuritis. It resembles the gait of a man walking through
thick grass or brushwood and stepping over constantly recurring but
non-existent obstacles. The typical steppage gait is seen in arsenical
neuritis with ankle drop, also in alcoholic neuritis, polyneuritis
potatorum (ataxia of drunkards) and in lead neuritis (lead palsy,
plumbism, saturnism), in which first the peroneal muscles are affected,
later the extensor communis digitorum and finally the extensor
proprius hallucis. Phosphorus, copper and grain (ergotism) poisoning
may give rise to a neuritis in the lower extremities and produce the
characteristic steppage gait. Tuberculosis, malaria, diabetes and
diphtheria (motor form) may sometimes produce this gait. It may also
develop as a sequel of sunstroke (thermic fever, insolation) and in
fact following any disease which will cause peripheral neuritis of the
anterior tibial nerve.
(2) _The Prancing Gait_ is an exaggeration of the preceding gait.
It is seen in epidemic anterior poliomyelitis (infantile paralysis)
when the disease affects the anterior horn cells of the lumbar cord,
causing atrophy of the extensor muscles of the foot, resulting in
“foot drop.” It is also seen in acute ascending paralysis (Landry’s
disease), which is probably a form of poliomyelitis, and in progressive
hereditary muscular atrophy of the leg (Charcot-Marie-Tooth type) where
the muscles of the leg, not the foot, are primarily affected, i.e.,
first the peronei become atrophied, later the extensors of the toes
and finally the calcaneal muscles. Finally the prancing may be seen in
connection with certain tumors of the cord, unilateral hip disease,
dislocation or injury and in multiple neuritis and beriberi (epidemic
multiple neuritis).
=C.--The Spastic or Severe Paretic Gait.= The spastic gait is due to
the hypertonicity of the weakened muscles, the resulting stiffness
causing a slowing of locomotion and diminished excursion of the
affected limb. The hypertonicity is produced either by direct
stimulation of the motor cells in the anterior horn of the spinal cord,
as in traumatic myelitis, or by impulses coming down from the cerebral
cortex. The limb is spastic or rigid, due to the tonic spasm. When the
tonic spasm is of long standing, it is termed a _contracture_. The
lower extremity moves as a whole, the toes clinging to the ground,
scraping it and very often “catching.” Contrary to the moderate paretic
gait, this group presents difficulty in flexion which is partly
overcome by the elevation of the pelvis on the side of the swinging leg.
(1) _The Mowing or Hemiplegic Gait._ This is the prototype of
all spastic gaits and is encountered in its simplest form in all
hemiplegias, i.e., in paralysis of one side of the body, which may
be caused by cerebral hemorrhage, embolism, thrombosis, syphilis,
brain tumor, multiple sclerosis of a cerebral hemisphere, meningeal
hemorrhage or suppuration, Raynaud’s disease, general paresis of the
insane; sometimes it may be due to hysteria (functional hemiplegia)
or to uremia (transient hemiplegia). No matter what the cause of the
hemiplegia, there is always the typical mowing gait. This mowing
movement is due to the fact that the spastic limb swings lateralward,
describing an arc of a circle (outward), and strikes the ground in a
flail-like manner. Technically speaking, circumduction takes place by
tilting of the pelvis and the swinging of the foot outward and around
to the front. The patient afflicted with hemiplegia makes the same
movement with his limb as does the reaper with the hand in which he
holds the scythe. _Exception_: the only paralytic gait in which there
is no mowing movement occurs in hysterical (functional) paraplegia,
which is very rare. In this condition the leg is dragged forward
instead of outward.
_Important shoe sign in paraplegia._ The sole of the shoe is worn down
on the inner side.
(2) _The Small-step Gait_ (la marche à petits pas). This gait is seen
in cerebral softening following an apoplectic stroke, especially in
pseudo-bulbar paralysis; the steps are very short and the feet are
lifted from the ground with difficulty, the patient seeming to count
his steps.
(3) _The Cross-legged Gait._ This gait is due to a spasm of the
adductors of the thigh causing the knees to rub against each other,
resulting in cross-legged progression, the lower limbs having a
tendency to cross during locomotion. It is seen in both Little’s
congenital and Erb’s syphilitic form of lateral spinal sclerosis. In
the syphilitic form, a dragging and shuffling gait is often associated
with the cross-legged type.
(4) _The Ill-defined Spastic Gaits._ Ill-defined spastic gaits are seen
in tetany (paroxysmal tonic spasm) from any cause, and in amyotrophic
lateral sclerosis, which is the spastic form of progressive muscular
atrophy (Charcot’s disease). This involution disease, due probably to
developmental defects of the lateral pyramidal tracts, has the combined
symptoms of spastic spinal paralysis, anterior poliomyelitis and bulbar
palsy, hence the difficulty in classifying it. Myelitis (inflammation
of the spinal cord) may be due to trauma, alcoholism, syphilis,
vertebral caries (compression myelitis), tumors, aneurism, hemorrhages
into the cord, etc., and will exhibit various gaits according to
the stage and severity of the disease. It may begin with a mild
paretic gait passing through several stages of the spastic gait or to
complete paraplegia (paralysis of both lower extremities). In complete
paraplegia there is of course no gait, as the patient cannot walk,
there being a loss of the power of locomotion but not of progression (a
patient so afflicted may still move from place to place on his hands).
(5) _The Dragging Gait._ In hemiplegia one foot only is dragged.
Dragging of both feet is seen in multiple neuritis, hereditary peroneal
atrophy, spasmodic spinal paralysis and spinal and syphilitic spinal
paralyses.
(6) _The Dromedary Gait_, so called on account of its resemblance to
the gait of a camel, is seen in children suffering with progressive
torsion spasm (Flatau-Sterling disease).
Finally, spastic paretic gaits are often observed in pellagra (maidism,
Italian leprosy, Alpine scurvy) and in lathyrism (lupinosis), where
the slow toxic spinal sclerosis finally leads to spastic paraplegia
and loss of the power of locomotion; also in caisson disease (divers’
paralysis).
=II.--The Ataxic Gait.= The ataxic gait may be either:
A--The Static ataxic gait, or
B--The Functional ataxic gait
and these are termed either (1) spinal or (2) cerebellar, according to
the location of the lesion.
=A.--The Static Spinal Ataxic Gait= is the most easily recognized gait,
and once seen, is never forgotten. There is an exaggeration of all the
movements of locomotion. The hips are overflexed and rotated laterally,
the foot is raised suddenly and too high, the toes are lifted and the
whole limb is thrown suddenly forward with unnecessary vehemence and is
then brought down heel first or flat-footed, with a stamping sound. The
feet are kept wide apart and while in the air they move in an undecided
manner, as if the patient was doubtful where to put them. The eyes of
the afflicted person are glued to the ground or fixed to the limbs so
as to supplement the lack of muscular and articular sensation by the
sense of sight.
In the cerebellar type of this gait the movement excursion is not as
extensive as in the spinal type. A sudden turning movement or an abrupt
sitting posture is difficult or impossible to assume in this type of
locomotion.
In order to test static ataxia, the patient is made to stand heels
and toes together, whereupon marked swaying takes place. The swaying
is increased when the eyes are closed and the patient looks like a
“chicken on a clothes line.” If there is more than one inch forward
swaying and more than three-quarters of an inch lateral swaying, the
patient is considered ataxic.
In the disease known as tabes dorsalis, or locomotor ataxia of
syphilis, the swaying may be so pronounced as to produce absolute
incapability to stand or to walk.
=B.--The Cerebellar (functional) Ataxic Gaits.= These gaits are
produced by a disturbance of the equilibrium accompanied by vertigo
resulting in a very irregular swaying from side to side, resembling the
gait of an intoxicated person.
The patient makes short steps, keeps his feet wide apart, staggers,
rolls, sways to and fro and reaches a set point by zigzagging toward
it. The swaying is relieved when support is given under the armpits.
(1) _The Titubating Gait_ is a form of functional cerebellar ataxic
gait seen in the following affections: Friedreich’s (disease) ataxia;
hereditary cerebellar ataxia; dementia paralytica; ataxic paraplegia;
labyrinthine disease and to some extent in vertigo; syringomyelia; and
in some cases of general paresis, and various chronic intoxications
like lead or arsenic or alcohol poisoning affecting the cerebrospinal
system.
(2) _The Reeling or Staggering Gait_ is seen in acute alcoholic
intoxication and Mésnière’s disease (disease of the middle cerebellar
lobe).
=III.--The Choreic Gait.= The choreic gait, sometimes called _tremor_
gait, spasmodic or hysterical gait, is very variable in quality
depending on the cause of the tremor. It consists of a series of
quivering or trembling movements of varying intensity, but nearly all
due to clonic spasm and disappearing during sleep or passive motion.
This distinguishes it from the spastic or paraplegic gait in which
the spasm is tonic in quality, lasting from one minute to one month.
The clonic spasm, on the other hand, consists in rapidly alternating
contractions and relaxations of the muscle.
(1) _The Stumbling Gait_ is seen in chorea (St. Vitus’ dance) and
Huntington’s (hereditary) chorea, in Friedreich’s paramyoclonus
multiplex (which is not to be confounded with Friedreich’s ataxia),
in Unverricht’s progressive myoclonus, and in multiple sclerosis
of the spinal cord. The gait resembles that of a schoolboy, who
clownishly stumbles or trips over his heel to attract attention.
Technically it consists of spasmodic adduction, extension and outward
rotation of the legs which soon renders locomotion impossible. When
these abrupt twitchings and jerking movements, which are involuntary
and purposeless, affect only one-half of the body, we speak of the
condition as hemichorea. The patient appears restless, unsettled and
fidgety.
(2) _The Festination Gait_ is typical of the disease known as
paralysis agitans (Parkinson’s disease, shaking palsy) and is an
advanced choreic gait in which there may be observed the curious
phenomena of propulsion and retropulsion, i.e., the impossibility of
stopping, once the patient is pushed either forward or backward. In
some instances, when pulled suddenly backward, the patient will take
a few backward steps with increasing rapidity, also the body remains
in the characteristic posture of paralysis agitans; namely, in the
forward-leaning attitude. In festination “the body tries to overtake
its centre of gravity” (Trousseau).
(3) _The Saltatory Gait_ (“The jumpers”), is a very rare condition
occurring the instant the weight of the body is put upon the feet. It
consists in strong and rapid contractions of the muscles of the thigh
and leg causing the patient to jump up violently. It is probably a
hysterical spasm.
(4) _The Myotonia Gait_ occurs in Thomsen’s disease and consists of
tonic, _painless_ spasms whenever a certain group of muscles begin
to functionate. The steps are first checked and delayed; but this
gradually wears off. This curious condition returns again when the same
group of muscles are called into action. Owing to the tonic spasms,
this gait might have been properly classified as a spastic paretic
gait, were it not for the fleeting and irregular character of the
spasticity.
(5) _The Hysteria Gait_, known also as astasia-abasia, is notable by
the ease with which it may simulate any and all of the gaits described
above, the spastic as well as the flaccid types of paralyses,--even
the cross-legged gait, ending in complete inability to stand or walk.
It differs from all of them, however, in the ability of the patient to
perform all the nervous functions of the limb when lying in bed. The
hysterical gait may also end in:
_Catalepsy_ which is a state of muscular rigidity enabling a limb to
maintain a posture in opposition to gravity for one hour or more (waxy
flexibility). This curious phenomenon of retaining the leg or any other
part of the body in a fixed attitude (given to it by the operator)
is sometimes seen in catatonia, general paresis, brain tumors and,
(rarely) in meningitis.
(The above chapter was especially prepared for “Practical
Podiatry” by Paul Luttinger, M.D., Professor of Bacteriology in
The First Institute of Podiatry. It is the first compilation of
its kind ever published and should prove a valuable aid to both
practitioners of medicine and of podiatry--_Editor_).
CHAPTER XXIV
MISCELLANEOUS FOOT LESIONS
TRENCH FOOT
A foot lesion has arisen during the present war, which, because of the
fact that it appears on the feet of those who have been subjected to
long sieges of service in the trenches, has been called “Trench Foot.”
The condition has been and is being investigated by many medical men
of note, and although the literature available has been rather meagre,
several facts have been established and some of the data has been
classified.
This chapter has been compiled from various papers upon the subject
written by those who are now serving their respective countries in
France, and who have had experience in dealing with the lesion.
Articles by the following writers have been used, and all of the
statements contained therein have been verified: B. Sherwood Dunn,
M.D., of Paris, in _The Medical Record_; “Anonymous,” in the same
publication; H. Oswald Smith, in _The Lennox_, a journal devoted to
dentistry, and several articles in the _Journal of the American Medical
Association_.
Trench foot is a lesion found in the lower extremity and is a result of
exposure to cold and dampness in the trenches. It has been likened to
frost bite, but cases reported during the summer months show that the
parallel is not justified. There are several stages to the disease, and
they are classified by Smith into four groups: (1) Neuritic--producing
acute pain and preventing the patient from walking or sleeping. There
is no swelling or discoloration of the foot. (2) Edematous--without
discoloration, but acute pain is present, produced by the pressure
on the nerve endings. (3) Edematous--with blisters and varying
discoloration of the skin, short of gangrene. (4) Gangrenous--partial
or circumscribed, with edema and blisters and reddening of the skin
involving the lower leg.
=Etiology.= The lesion is found chiefly among men of from twenty to
thirty years of age who have been in continuous service in the trenches
for a minimum of three days. That it is truly the result of trench life
is proven by the fact that men in the artillery, who do not see trench
service, are not thus afflicted.
The constriction of the foot in ill-fitting shoes and stockings with
lack of cleanliness are also etiologic factors. Cold is not accepted
as the cause of trench foot, as the trouble occurs in weather above
freezing and some cases have developed in the summer time. Neuritis,
produced by humidity, is the cause of the lancinating pain.
Raymond and Parisot have stated that the disease is caused by
bacterial invasion. They have isolated the microbe, from the mud of
the trenches, and have reproduced in animals the various symptoms
manifested in trench foot. The microbe was found in the purulent layer
of the vesicles and the injection of these germs into the epidermis
of the rabbit and guinea pig caused the same lesion as is found in
man. They have reached the conclusion that the disease is similar to
mycetoma, the fungus foot of Madura and misnamed by English surgeons
“tuberculosis foot.”
The disease is prevalent among those standing in the soft, slushy mud
or in the muddy water of the trench. The skin of the feet becomes soft
and macerated, and while in such condition offers easy ingress for the
microorganism, especially along the nail grooves or through abrasions
caused by shoe friction.
A committee of United States army surgeons in France, headed by Major
R. P. Strong, are making extensive tests in order to ascertain the
cause of _trench fever_. Their unfinished report (they are still
investigating) shows as follows: (a) the organism causing trench
fever is present in the plasma of the blood; (b) the organism is not
filtrable; (c) the disease is transmitted naturally by the body louse
(pediculis corporis); (d) this method is apparently the important and
common means of the transmission of the disease[7].
=Symptomatology.= The symptoms of trench foot are always the same. The
ball of the great and second toe are swollen and edematous, the skin
is distended and glossy and there are occasional blisters or vesicles.
The edema may extend to the remaining toes and to the ball of the
foot, and, from being white, may become rose-colored or even red and
violet. In grave cases the liquid in the vesicles changes from citron
color to a hemorrhagic hue, the skin becomes blue-black, then livid
and gangrenous. Some of these vesicles may dry and the scab fall off,
leaving no scar; the base of the vesicle may change in color from brown
to black, and this change may extend beyond the borders and cover the
entire area affected by the edema. This change is the forerunner of
gangrene; the vesicle becomes a crust; when it falls off it leaves a
putrid base which may gradually eat into the tendons and articulations
and periosteum. It is not infrequent to have the first crust followed
by a second and third, and when the disease has progressed to this
stage, no medication seems to avail and the member has to be amputated
at a healthy point beyond the parts affected.
There is little if any fever accompanying the lighter forms, but a
temperature of 104 degrees F. may attend the graver forms, with general
disturbances of the nerve trunks. Albuminuria is not infrequent.
The patient complains of lancinating pains which interrupt sleep and
cause difficult locomotion. Walking is accomplished on the heels, with
the toes elevated. The pain is excited at several points, chiefly by
pressure on the heads of the metatarsals. In the lighter forms, the
patient complains of numbness (but only in the affected members) which
at times extends to a condition of anesthesia. The mildest form is
characterized simply by pain and paresthesia.
The trouble appears, as a rule, after the patient has spent his
assigned period in the trenches and manifests itself when he has
retired to the sector for repose and removes his shoes for the first
time in several days.
In the very worst cases there is gangrene accompanied by all of the
dangers of infection, by destruction of tissue and loss of limbs.
There is a tendency to contracture of the foot, usually described as a
turning under of the foot.
=Prognosis.= Trench foot has a duration of from two to three weeks, in
the lighter forms, and from six weeks to three months in the severe
cases. The simpler lesions respond well to treatment, and in the type
in which vesicles have formed, these latter dry and fall off, leaving
no scar. A cure is effected in about one month. In more advanced types,
in which extensive ulceration is present, the toes alone are lost and
the rest of the tissues are saved under proper treatment. When general
septicemia develops, and according to statistics of two thousand cases
treated from October, 1916, to January, 1917, there have been only two
such cases, the patients have immediately succumbed.
Complications are frequent accompaniments of the malady--abscess,
neuritis, lymphangitis, etc. Tetanus has been observed with sufficient
frequency to cause all patients to be injected with antitetanic serum
upon admission for treatment.
=Treatment.= The prophylactic measures that have been adopted since
trench foot has been more thoroughly understood, have eliminated it
to a great extent, and the disability that it caused at that time is
gradually being controlled. The perfection of general sanitary methods
and the construction of better trenches have helped to diminish the
incidence of the condition as well as to reduce disease and disability
in general. The smaller sectors and the greater reserve of men,
allowing for more frequent change, have of themselves, without the
actual preventive methods instituted, reduced both the severity and
the occurrence of trench foot. Where previously the men had to stay in
the trenches for long periods, at present there is a change every few
days.
As a general preventive measure against the lesion, it was found that
the wearing of looser boots, perhaps a size too large, was of great
help. This measure prevents the restriction of the circulation, which
is so large a factor in the causation of trench foot. The general
circulation of the body can be maintained by warmth and by appropriate
movements and exercises. Socks must be changed very frequently and must
be kept dry. Torn socks are especially liable to constrict the blood
vessels and to produce injury to the foot. Foot rags, well paraffined,
have been tried, with more or less success, to obviate the difficulty
of keeping socks whole. If these foot rags are well applied, they are
found to be far more comfortable than socks. Puttees must be loosely
applied. Boots must be thoroughly greased before being put on. Rubber
boots have been extensively used and are looked upon with favor.
Thorough greasing of the feet was tried at the beginning, but was found
to be offensive to the men, and consequently was not conscientiously
carried out.
The newest and apparently most successful method of preventing trench
foot is by means of the so-called “trench-foot washhouses.” Immediately
before returning to the trenches the men go to these washhouses for
treatment. Here they have their feet soaked in warm, not hot, water
and washed with a special soap composed of soft potash soap 1000
parts, powdered camphor 25 parts and borate of soda 100 parts. The
feet are then carefully dried and treated by the regimental surgeon
or podiatrist, and are finally dusted with a mixture of powdered
camphor, talc and borate of soda. In the trenches, the soldiers must
be served with hot food in order to maintain warmth and keep up the
general circulation. No amount of attention to the feet of the soldier
can be too painstaking as regards cleanliness, shoeing and physical
condition. To escape disability as the result of actual war violence
and to acquire it as the result of preventable sanitary conditions,
would be indefensible.
The treatment of the lesion itself, depends upon the severity and the
extent of the condition.
1. =Simple Edematous Form.= In the beginning, the erroneous diagnosis,
and the subsequent treatment directed along the lines of frost bite,
and the taking of potassium iodide, salversan-methylene blue, and the
application of tincture of iodine and copper sulphate, did more harm
than good in some cases, and the results, at best, were irregular. The
statistics of Raymond and Parisot, who have treated more than 2000
cases in a short time, are the best compiled, and as their results have
been excellent they are here given.
At the earliest moment possible the feet of the patient should be
thoroughly soaked in warm water and washed with liberal quantities of
the soap, previously mentioned, and composed of soft soap, camphor and
sodium borate. The cleansing should be thorough, but with care not to
break the skin or to open any existing vesicles. The skin must be dried
carefully with a soft towel and the following applied: cover a layer of
absorbent cotton of the thickness of the hand with gauze; soak this in
a solution of camphor, 1.1; borate of soda, 15, boiled water, 1000, and
apply while still thoroughly wet (being careful to cover the ends of
the toes) to all the edematous surface as far up the leg as it extends.
Cover the whole with oiled silk or rubber sheeting, and fit by adhesive
strips. If a roller bandage is used, it must be applied loosely. The
dressing should be damp when changed the following day.
Renew this dressing daily, until the edema disappears, which should
be from the second to the sixth day; after this, continue the same
dressing for two or three days without the impermeable covering;
following this, camphorated oil is to be applied without rubbing.
When the disease proves obstinate and is accompanied by persistent
pain, some relief is afforded by bathing the feet at the time of the
daily dressing in warm water, using the same liquid soap as at first.
2. =Vesicular Form.= The small vesicles, not larger than a ten cent
piece, should be left undisturbed and will dry up without scar with the
above-described treatment. When they are extensive, and especially when
the contents are hemorrhagic, they should be completely denuded and the
gelatinous base should be carefully removed by aid of a sterile tampon,
and then these denuded surfaces should be covered with compresses
soaked in a solution of camphor, 30, ether, 1000. These compresses and
the whole affected surface are covered by the fomentation previously
described, and should be changed daily.
When the edema subsides, omit the fomentations and continue the
application of camphorated ether solution, and as the denuded surfaces
show improvement, dust them with camphor powder or with boric acid
powder.
3. =The Formation of Crusts.= The foregoing treatment will ordinarily
prevent the formation of crusts or scabs; when these do form, steps
must be at once taken for their removal without undue force or surgical
aid, as they cover the most virulent germ collections, which are liable
to produce a general infection if permitted to contaminate freshly cut
surfaces. On the other hand, if permitted to remain, the germs thus
protected have a tendency to burrow profoundly, involving the tendons
and articulations.
The crusts must be softened and carefully removed from their borders
daily, little by little, by aid of the forceps, the operator being
careful to cause no bleeding. To soften the crusts, the following
are recommended: (1) liberal dressings soaked in camphorated ether
and covered with oiled silk or rubber sheeting; (2) collodial silver
dressings; (3) camphorated oil and borated vaseline. As the crusts are
gradually removed each day, the uncovered surfaces should be treated
with the camphorated ether.
Not infrequently the crusts will re-form, in which event it is well
to treat them with pomade of Reclus, made as follows: vaseline, 200;
boric acid, 3; iodoform, 1; antipyrine, 5; salol, 3; carbolic acid
(crystals), 1; bichloride of mercury, 0.1.
4. =Extensive Invasion.= Where the processes have progressed and
involve a considerable amount of tissue, evidenced by a congested,
violet-red surface, but with little or no erosion or vesicles, we
recognize the presence of the malady in its worst form, and prompt
measures must be taken to save the member. In these cases the germs
have penetrated beyond the surfaces, and in order that they can be
subjected to contact treatment and destroyed, we must reach the hidden
centres of their activity.
After surgical preparation of the surfaces, they are incised by a sharp
pointed bistoury in the long axis of the foot and down to the level
of the infection, indicated by a purulent layer of fetid edema. If a
collection of pus is found, a free and extensive incision is made and
the tissues thus exposed are thoroughly washed out with an antiseptic
solution, by aid of a syringe. The thermocautery should not be applied,
as the results of its use in such cases have been very bad.
When the infected parts are opened they are treated with the previously
mentioned camphorated ether, or with collodial silver dressings or,
in the presence of purulent infiltration, with collodial gold, which
can be varied by the following: eucalyptol, balsam of Peru, guaiacol,
gomenol, camphor, of each 10, in ether, 1,000. Under the influence of
these dressings, the hardened infiltrated surfaces soften and can be
removed little by little by the aid of the forceps, in measure as the
sloughing continues, until the destroyed and contaminated tissues are
eliminated.
In so far as possible, surgical intervention should be avoided; where
the bone is attacked, it is better to permit it to be eliminated
by the progressive destructive action of the disease. Tentative or
conservative operations upon the bone have been followed by extensive
destructive osteitis. If an amputation becomes necessary, it should be
made at a healthy point beyond the infected area.
5. =Reparation Stage.= When the necrosis has been arrested and the
granulations show that the affected parts are disinfected, the usual
emollient applications can be employed to aid the repair; but here, a
treatment brought into use by Rathery and Bauzil is recommended. This
forms an impermeable covering easily applied and changed, and possesses
self-evident advantages. It is composed of naptholate of soda, 2;
essence of thyme, essence of origanum, essence of geranium, of each 3;
vaseline 1,000; paraffin (45°-50°), 5,000. Melt and thoroughly mix by
aid of heat and put aside in pots holding 125 grams each; sterilize for
twenty minutes at 120°.
At the time of the daily change of dressings, place the number of
pots necessary in a bath of boiling water to melt the wax, cover
the affected parts with a single layer of sterile gauze and paint
thoroughly with the melted wax. This dressing hardens as fast as it is
applied. Apply a second and third layer in the same manner, to form a
perfectly occlusive dressing. Cover with cotton and bandage. Dressing
comes off easily and completely without pain, and gives remarkable
results in healing and repair and renewal of the skin to the parts.
6. =General Treatment.= In the cases complicated by septicemia,
subcutaneous injections of camphorated oil in doses of from 5 to 15
c.c. per day, or intramuscular injections of collodial camphor in doses
of 2 c.c. per day, are advisable.
7. =Complications.= The most frequent is tetanus. Every patient should
at once be injected with antitetanic serum, and this should be repeated
every eight days during the period of ulceration and sloughing. It is
even prudent to augment the second injection in those gravely afflicted
(20 c.c. of the Pasteur Institute serum, or 3000 units of the American).
Gaseous gangrene is infrequent with the treatment here indicated. If
present, it can be treated in the usual way.
Smith has employed subcutaneous injections of oxygen in cases of this
condition which have been neuritic, or edematous without discoloration,
edematous with blisters, gangrenous, partial or circumscribed. The
technic of the oxygen treatment is as follows: a Woulfe bottle is
required, with two glass tubes bent at an angle and inserted into a
tightly-fitting cork. To the end of one glass tube is fitted three
yards of red rubber tubing connected with the usual oxygen cylinder; to
the end of the other glass tube is fitted two yards of a finer rubber
tube, and the distal end of the tube has fitted on it a salvarsan
needle. The bottle contains a saturated solution of sodium carbonate.
The needle should be sterilized in boiling oil for each individual
case. The operator, having sterilized his hands, uses iodine on the
proposed sites of the puncture. The needle is inserted into the
subcutaneous tissue at a point midway between the heel and the external
malleolus. The oxygen is allowed to enter slowly until the foot is
filled up. The needle is then withdrawn and inserted midway between
the internal malleolus and the heel. If the toes are black and cold
the needle is inserted in the mid line at the base of the toes. It is
important that the oxygen should be injected slowly. If the part is
almost gangrenous, injection into the deeper tissues is of advantage.
The treatment is based on the conclusion that trench foot is akin to
Raynaud’s disease. The edema produces stasis in the veins of the foot,
impeding or stopping circulation, and the venous blood, if oxygenated,
will help to keep the tissues alive until the serum can be drained
away, while the oxygen helps to drive out the serum, slowly but
steadily, through the puncture holes. Mere puncturing has been found
useless in relieving the edema. The oxygen balloons the subcutaneous
tissue, thus relieving pressure on the blood vessels and lymphatics.
When the oxygen is absorbed and the serum drained away, circulation is
quickly restored to the limb.
There is marked relief to pain at once, and under the eye of the
observer certain changes can be seen taking place. The reddish blue
appearance changes to pink; the redness which often extends up the leg
disappears, and where blackened areas exist, a white line makes its
appearance and any living tissue is noticeable by its pink color. The
white line indicates what would ultimately be the line of demarcation
of gangrene, and it is noted that healthy granulations start from
this white line after injections of oxygen. The destruction of parts
is greatly lessened, and is often confined to the tips of the toes.
Areas of black blood on the dorsum of the foot rapidly undergo change,
becoming grayish white and pink, and more nearly resembling healthy
tissue. In many of the severe cases, recovery of the whole foot has
taken place, and in some the loss of but a single digit has had to be
recorded.
A minor but important point is the treatment of all blisters. They
should be drained by sterilized thread passed through by means of a
straight surgical needle and the ends cut short. The dead skin should
be left in situ as a protective, unless pus is present.
The oxygen causes an increase in the pulse of the posterior tibial
artery. There is no rise in temperature, pain is relieved, and sleep
promoted. Lint, wrung out in 1 per cent. solution of picric acid, is
applied to the parts and renewed every day. No cotton wool should be
employed or disastrous results will ensue. The lint and bedclothes next
day will be found saturated with serum, sometimes clear, and sometimes
blood-stained. The skin will have a peculiar wrinkled appearance,
pointing to the previous state of edema. The foot is warm even at the
toes, and movement will have returned. At the end of the second day
tingling sensations arise. In cases which are semi-gangrenous and
where the edema still persists, a second injection may be given. One
injection is usually found to be sufficient, but picric acid should be
used once or twice a day to keep the part dry and sweet. The effect of
the oxygen on the deep layers of the true skin is notable; a rich red
velvet color persists for several days.
Smith advocates conservative treatment in all cases of trench foot
unless gas gangrene or grave toxemia be present. Repair is slow but
sure and many hopeless looking cases have recovered with useful limbs
and minor loss of structure. The cost of the oxygen treatment is small,
and oxygen is usually available. There is no risk to the patient if
this treatment be intelligently used, but healthy tissue, as far as
possible, should be utilized for injection purposes. The length of time
for repair and recovery of the part is long in the semi-gangrenous and
in the gangrenous cases. The granulation tissue is often indolent with
the epithelial margin heaped up, and here, again, oxygen has been found
to stimulate epithelial growth, a hypodermic needle being utilized in
place of the salvarsan needle.
The conclusion drawn is, that if the edema can be relieved by
withdrawing the serum, the circulation can be re-established, and
during this withdrawal the tissues are supplied with oxygen to keep
them nourished.
GROUND ITCH OR UNCINARIAL DERMATITIS
Prof. Paul Luttinger in addressing the students of his class at The
First Institute of Podiatry gave the following outline of this disease:
“this condition is known as water itch, water pox, water sores, sore
feet of coolies, panighao, mazamorro (Porto Rico), tunnel-digger’s sore
foot. It is an erythematous or papulo-vesicular irritation of the feet,
due to infection with the larvae of the hookworm. These latter gain
entrance through the skin of the lower extremities and cause the very
grave tropical disease known as uncinariasis (hookworm), or tropical
chlorosis.
“The eruption, which is very itchy, appears first as reddish spots
between the toes and on the dorsum of the foot. These spots become
macules and later vesiculate. In some cases blebs may be formed which,
upon rupturing become raw, oozing surfaces accompanied by considerable
local swelling. Pustulation and ulceration may result if these surfaces
become infected with pus producing microorganisms.”
=Treatment.= Under proper treatment, this condition will subside within
a few weeks; otherwise it may take months or until the systemic disease
develops. Sometimes gangrene of the part may result. Cleanliness,
combined with mild antiseptic lotions, is all that is necessary to cure
the disease in its early phase. A three per cent. alcoholic solution
of salicylic acid has been highly recommended by Barlow, who opens the
blebs and applies pledgets of cotton dipped in this solution twice
daily for five minutes.
The proper disposal of excreta in rural communities and the avoidance
of going barefoot in the warm and rainy season, are the best methods of
prevention.
GAS INFECTION AND GAS GANGRENE
Gas infection is a very common condition found in the wounded in the
present war. It is controlled successfully if it is seen and treated
early in its course, but when it has progressively developed it causes
a most dangerous condition called gas gangrene.
=Etiology.= The infecting agent is called the bacillus of Welch, the
bacillus aërogenes capsulatus or the bacillus perfringens. The bacillus
is of the anærobic type, and being lodged in deep wounds with ragged
tissues, recesses and pockets, and completely obstructed by fragments
of broken-down tissues, all of which prevents the air from reaching
them, they multiply rapidly with the formation of gas followed by a
great destruction of tissue.
The bacillus of Welch grows rapidly and it is on that account that
immediate and radical action is essential if loss of life is to be
prevented. Kenneth Taylor has obtained a pure culture in a very short
time as follows: a series of six or more culture tubes are inoculated,
each tube from its predecessor, at intervals of only half an hour.
Even in this short period bubbles of gas became evident in the
successive tubes. By the time the sixth or the seventh tube is reached,
one may obtain a pure culture, so far has the gas bacillus outgrown the
other germs.
=Symptoms.= The rapidity of the development of the bacteria is
responsible for early symptoms of the infection, and Bowlby has
observed well-marked infection with the formation of gas within five
hours, and death of an entire limb has occurred from gas gangrene in
sixteen hours.
The course of the disease varies somewhat, being at first, a _local_
condition; bubbles of gas appear in the discharges from the wound, and
crackling from gas may be felt in the tissues immediately surrounding.
Prompt and radical treatment will prevent further development and will
restrict the lesion to a limited area. Certain muscles will be lost and
with them the corresponding motions, leaving the patient crippled to
that extent, but beyond this, recovery will follow.
A more serious and fatal form, is the _diffuse_ or rapidly spreading
process. The skin is discolored, the limb is extremely swollen and
edematous, gas penetrates the cellular tissues and advances rapidly, so
pressing upon the muscles as to render them useless, and obstructing
vessels and nerves; the pulse is small and rapid, the extremities are
cold; vomiting and hiccough may occur. The patient is profoundly toxic
but he may not feel very ill. If improvement cannot be secured by
thorough exposure of all pockets and excision, death ensues, the gas
spreading rapidly upward to the abdomen, chest, and then to the neck,
causing distressing pressure and finally loss of life.
In other cases the whole limb is involved suddenly, beginning within
a few days of the initial injury. A wound which is doing fairly well
at night may reveal a condition of gangrene--swollen, tense, and
discolored in the morning; the patient, already in collapse, succumbs
before the gas itself has apparently spread far enough to cause death.
=Treatment.= The paramount importance of the earliest possible
treatment during the first stage of rapidly spreading infection,
before the production of gas in any serious quantity has occurred, is
self-evident. Every hour counts against the patient.
Taylor points out clearly what is to be done:
1. Destruction of the bacillus.
2. Removal of the tissues especially favoring its growth, which are the
necrotic muscles.
3. Measures to prevent the destruction of the muscles as a result of
mechanical pressure.
For the destruction of the bacilli, Taylor recommends a one per cent.
solution of chlorhydrate of quinine. Others have found Dakin’s fluid
effective.
All foreign bodies (clothing, etc.) in the wound, must be removed as
they will keep up the anærobic infection; _all_ dead tissue must be
removed, the wounds kept open, and frequent antiseptic dressings used.
Dakin’s fluid or Taylor’s quinine chlorhydrate, when properly used in
connection with the above absolutely necessary means, will enable the
surgeon to conquer the infection at the start if he sees the patient as
early as possible--certainly within the first twenty-four hours.
The muscles should be opened by numerous longitudinal incisions,
incisions of the muscular sheaths, and the excision of all necrosed
tissue. Sometimes single muscles or a group of muscles may need to be
excised. The dead muscle can be distinguished from the living by its
dirty brick-red color, in contrast to the normal purple-brown. The
dead muscles also lose their contractility. The focus of infection,
if known, should be excised. The wound should be dressed with the
chosen antiseptic solution. The incisions should be kept open by light
gauze compresses, wet with this solution. No circular bandages which
can exert the least compression, and so hinder the escape of the gas,
are allowable. Nothing should obstruct the free escape of the gas.
Everything should be done to promote it.
If gas gangrene occurs or has already set in, the same free incision
should be made, unless this has already been done.
Bacteriologic diagnosis in the early stage is most important. Soon the
discoloration of the skin, blebs, and crepitation make the diagnosis
positive, but crepitation often appears late rather than early. The
X-rays may disclose the bubbles of gas in the tissues. On incision,
if the muscular tissue is bloodless, pale, dry, of a brick-red color,
gangrene already exists. The best judgment then will be required to
decide whether free excision of this gangrenous tissue, with suitable
subsequent dressing, or immediate amputation should be done. If the
limb is amputated, it should be by the so-called “guillotine” method,
i.e., without flaps. The wound should be dressed with the end of the
stump entirely uncovered until the infection has been conquered. Then
the skin may be drawn down by lacing or by weights, and sutured as soon
as feasible. The bone may have to be shortened.
=Antitoxin Treatment.= One of the most important contributions to
surgery as a result of the war has recently appeared in the form of
a paper by Carrol G. Bull and Miss Ida Pritchett, of the Rockefeller
Institute. This paper describes a lengthy series of experiments with
the bacilli Welchii, which were cultured from wounds caused by the war.
A very powerful, soluble toxin, produced by the bacilli has been found,
which has killed animals almost instantly. The most important result of
the experiments is that they give promise of an antitoxin which may be
as potent in the prevention of gas gangrene and gas infection as other
antitoxins have been effective in their respective spheres. Among these
are antitetanic, antityphoid and other antitoxins.
(The above material has largely been taken from “The Treatment
of War Wounds,” by Dr. W. W. Keen, and from “Surgical Nursing
in War,” by Dr. Elizabeth R. Bundy).
SYPHILIS
Although syphilis is a disease that is usually considered as of a
systemic nature and manifests itself in every part of the body, the
skin is a very common place for its appearance (syphiloderma), and the
foot is often involved. It then becomes the function of the podiatrist
to diagnose the lesion, and as this necessitates a knowledge of the
general characteristics of the disease, the following should prove of
interest:
=Derivation.= From the Greek _sus_ and _philos_, “a companion of swine.”
=Synonyms.= Syphilis cutanea, lues, syphilis of the skin.
=Definition.= Syphilis is a chronic, specific, contagious, sometimes
hereditary disease, caused by a germ, the spirochaeta pallida,
involving the skin and nervous system, but capable of affecting any
organ or tissue. Inoculation occurs usually at some part of the
genitalia, the first evidence of the disease being the initial lesion
or “chancre,” but inoculation may occur at any other part of the body
forming the so-called “extra-genital chancre.”
=Etiology.= Syphilis may be hereditary, i.e., transmitted by the
parent. In the majority of adults it is acquired directly from an
existing chancre or other lesion, the spirochaeta pallida being
conveyed directly from one to another. Extra-genital chancres are
caused by kissing, by towels, by drinking cups, or by infected
instruments, bites, etc. The extra-genital chancre may occur on the
mucous membrane or at the site of any skin abrasion. It is essential
that infected persons be informed of the danger of transmitting it to
others. The contagious period exists to the end of the second year and
any secretion, from the possible presence of mucous patches, may be
infective.
=Pathology.= Syphilitic deposits are new growths and consist of round
cell infiltration, especially about the vessels, generally endothelial
proliferation, and in the tubercular and some other lesions, a
variable number of giant cells. The initial changes are noted in the
upper part of the corium. The rete, the corium, and, in the deeper
lesions, the subcutaneous tissues, are involved, the retrogressive
steps being by involution, through fatty degeneration and absorption,
or by necrosis and ulceration.
All the various syphilitic lesions are structurally the same, amounting
to an endarteritis of a special kind, slowly obliterating and tending
to the production of hypertrophy of the tissues about it. The coppery
ham-color in syphilitic lesions is due to blood coloring matter from
the extravasated red blood corpuscles and to the sluggish nature of the
inflammation. These exudation processes are found for months after the
process has healed clinically.
=Diagnosis.= Syphilis usually runs a mild course, but occasionally
it is malignant. In some instances its cutaneous symptoms resemble
other skin lesions, and it is on that account that diagnosis is often
difficult. The general points to be observed are the distribution,
color, form, course and duration.
=Distribution.= The secondary lesions are more or less general and
symmetric in distribution. The lesions vary in duration and may show
a preference for certain locations, such as the upper part of the
forehead, anus, palms and soles. The late secondary lesions, and
particularly those of the tertiary period, are usually confined to one
region, are grouped, and are not bilateral in distribution.
=Color.= Syphilodermata are dull coppery-red or ham-color. Exposure to
cold air often makes the eruptions on the body more distinct. Color
alone cannot be depended upon to make certain a diagnosis.
=Form.= The earliest lesions are round or oval, showing no tendency to
grouping. In the late secondary, and in the tertiary stages, grouping
occurs and the lesions may be serpiginous and circinate. This is an
important point in diagnosis.
Early ulcers are superficial and the scars are insignificant. Later
ulcers are deeper, and the scars, often pigmented, are sometimes
diagnostic.
There are many and various forms of syphilis, all of which have
characteristic symptoms, but for the podiatrist, who usually sees the
later lesions, and who cannot make an examination of the entire body,
it will be necessary to recognize those that appear on the foot only.
The nails are occasionally involved in syphilis. Onychia and
paronychia are found in the active secondary stage of the disease.
The inflammation starts in the matrix or in the nail folds, followed
by nutritive disturbances, and subsequent thickening, friability and
opacity, furrows and depressions. The nail is lifted up, as a rule,
and if there is much ulceration, the nail falls off. Such lost nails
are generally replaced by new nails which are ill-formed at first, or
they may remain deformed permanently. The skin surrounding the nail
is swollen and infiltrated. In infants, the ends of the toes become
club-like (syphilitic dactylitis). This condition is rarely seen in
adults. The pain is not severe unless accompanied by further pyogenic
infection or by mechanical disturbance.
[Illustration: PLANTAR SYPHILID]
=Plantar Syphilid.= The plantar surface of the foot is a common site
for dry syphilids. The palm of the hand, and the sole of the foot
are the most common locations for the papulosquamous lesions of the
late secondary stages of the disease. The lesions are not so elevated
and their edges are not so well defined, papules looking more like
macules; infiltration, however, is distinct. The shape may be irregular
and the usual ham-color does not appear on the surface on account of
the scaliness or dry heaped-up epidermis. There is usually a central
brownish, gray, callous-like thickening, surrounded by a partly visible
band of brownish-red, underlying, papular infiltration. The color
is disclosed by removal of the scale. Surrounding the lesion is an
encircling edge of partially detached epidermis with its loose, ragged
edge directed toward the centre. This semi-detached edge is of extreme
value in the diagnosis of plantar syphilids.
The plantar lesions come on slowly and spread gradually. They are
usually limited to one sole, but may be found on both feet. There is
no itching, but they may be painful if fissures are present. If the
plantar lesions are a part of a generalized eruption of the second
stage of the disease, they yield readily to treatment, but if they
are a recurrence of a generalized eruption, they are more obstinate.
Occurring as a late manifestation, they may be extremely rebellious.
Papulosquamous syphilis is the most common lesion of syphilis found on
the foot, and is most apt to be confused with eczema. The latter often
occurs on the soles of the feet; the following table will show the
differential diagnostic points:
PAPULOSQUAMOUS
SYPHILODERM ECZEMA
1. History of syphilis. 1. History of previous outbreaks.
2. Concomitant signs present. 2. No associated signs.
3. Favorite seats, palms and 3. Favorite seats, flexor surfaces.
soles.
4. Itching usually absent. 4. Itching present.
5. Edge of lesion surrounded 5. Scales completely detached.
by detached scales.
6. Scales scanty and dirty-grayish. 6. Scales abundant, and granular.
7. Infiltrated, dull red papules 7. Flat, reddish patches beneath
beneath the scales. the scales.
Eczema can also be differentiated by the more inflammatory aspect,
the involvement of the toes and toe-ends, by its appearance on the
dorsum of the foot as well as on the plantar surface, by the itching,
and by the presence of inflammatory exudation. There is no attempt at
configuration in eczema, while this is characteristic of syphilis. In
addition, some of the elemental lesions of eczema will usually be found
around one of a doubtful nature.
=Blood Tests.= Testing the blood is practised to a great extent for
determining the presence of syphilis, but this method of diagnosis is
not absolute. The Wassermann complement fixation test and the later
modification by Noguchi are of value when they are positive. A negative
reaction is no absolute proof of the absence of the disease. They are
positive during the active secondary stages, but in the first week or
two they are usually negative. In the late stages, when the bacteria
may be encapsulated in a lesion, the reaction may be negative. This
may be made positive by the administration of potassium iodide, which
causes the germs to enter the blood or lymph stream. One should be
able to make a diagnosis without the aid of the blood tests in cases of
syphilis in which there are skin lesions.
The luetin test, a vaccine test, is of most value in the late stage of
the disease.
=Course and Duration.= Secondary lesions appear rapidly and are fully
developed at the end of two weeks, and in time disappear spontaneously.
Palmar and plantar lesions are apt to be more persistent. There is
little tendency to spontaneous disappearance of the tertiary eruption.
=Treatment.= The treatment of syphilis is entirely out of the domain
of the podiatrist, and when such a case is discovered, it should be
turned over to the dermatologist or to the general medical practitioner
at once. Plantar syphilids should be treated with soap and warm
water so as to remove the scales and thickened epidermis, and this
may be followed by an application of salicylic acid ointment, 5 to
10%. Thereafter ointment containing mercury, the white precipitate
(ammoniated mercury) preferred, should be used twice a day.
Constitutional treatment is absolutely essential if the disease is to
be cured, and this should be vigorous during the first few months after
inoculation. The general health must be maintained and nutritious,
plain diet, rest, moderate exercise and abstinence from alcohol
and tobacco must be urged upon the patient. With all of the above
precautions, accompanied by the proper use of remedies, recovery is
usually prompt and the symptoms are limited.
Mercury is the one drug that is used almost exclusively. It is
very dependable, and should be employed freely, up to the limit of
tolerance, during the active stages of the disease. In the tertiary
stage, potassium or sodium iodide, in addition to the mercury, is
administered. These drugs are used in various forms and in various
doses, all of which are of no interest to the practitioner of podiatry.
Recently many practitioners of medicine have been using a complex
compound of arsenic, viz., arsphenamine, (salvarsan). This drug is
injected into the muscles or the veins. Although many have taken up
the use of salvarsan and like chemicals, most practitioners still rely
upon mercury. The newer preparations are used more as adjuvants than
as specifics. Lesions of the mucous membranes disappear rapidly under
treatments with these drugs.
Formerly it was difficult to tell when a case of syphilis had been
cured; however, with the advent of the various blood tests, this has
become a less doubtful matter. When the various reactions of these
tests are negative in uncomplicated cases, toward the end of the second
year, it is safe to say that the disease is cured.
(The above is largely compiled from the lectures of Dr. Andrew
H. Montgomery, Prof. of Dermatology at The First Institute of
Podiatry).
FOCAL INFECTION
Focal infection is the name given to a pathologic condition in the
human body, which manifests itself in a part remote from the original
focus of infection, or from the original lesion.
Up to a few years ago, focal infections were not recognized by even the
most advanced members of the medical profession, and many thousands of
people have suffered and died, due to the fact that lesions of this
type remained undiagnosed.
Thanks to the efforts of Dr. M. L. Rhein, of New York City, and Prof.
Gies, of Columbia University, who drew the attention of the scientific
world to the intimate relationship between tooth infections and
indefinite ailments in the body, including those of the feet, a large
quantity of material has been accumulated on this subject, which throws
an interesting light upon it.
It has now been firmly established that the teeth, the tonsils, the
adenoids, the male and female urethra, the uterus and the gall bladder,
in fact, any part of the body which serves as a portal of entrance
to any infection, may become the reservoir of a chronic pathologic
condition, and cause disease in any other part of the body. So the
teeth, harboring certain microorganisms, have been shown to be directly
responsible for heart, stomach and kidney lesions, as well as arthritis
and other joint and bone diseases.
=Mode of Infection.= The bacteria responsible for focal infections
thrive best upon dead or necrotic tissue. These bacteria, when they
locate in a place where such necrotic tissue is available, such as a
tooth in which some of the dead pulp remains, or in a diseased tonsil
or urethra, develop so that they throw off toxins or poisons without
causing any visible signs of inflammation. These toxins circulate in
the blood stream, and locate in various parts of the body, especially
in those which offer the least resistance to the invasion.
=Relationship Between the Foot and Focal Infection.= The most common
lesion of the foot due to focal infection, is arthritis or inflammation
of the joints. This is due to infection of the teeth, tonsils, nose
or adenoids with the common microorganisms such as the staphylococci,
streptococci, influenza bacilli, etc., that infest the cavity of
the mouth. It may also be due to an infection of the valves of the
heart with the streptococcus viridans, or of the gall bladder with
typhoid bacilli, or of the genital organs with the gonococcus. In some
instances, arthritis of the foot may be traced to an auto-intoxication
of the intestinal tract or of the bladder by the colon bacillus.
Osteomyelitis, or inflammation of the bone marrow, periostitis or
inflammation of the bone covering, and less often, osteitis or
inflammation of the bone proper, may be caused by the typhoid bacillus
or its toxin, which originally manifests itself in the intestinal
tract. These diseases may develop during an acute attack of typhoid,
but usually appear after the acute symptoms have subsided.
=Gonorrheal Heel= is a well defined type of focal infection due
to original invasion of the urethral tract by the gonococcus. The
microorganism, or its toxin, reaches the inferior surface of the os
calcis, at the point where the flexor brevis digitorum muscle arises,
lodges there and causes a chronic inflammation of the periosteum and
the bursa. The process is a mild and slow one, and gradually the
periosteum is absorbed. With their covering removed, the bone cells
increase in number, causing the formation of a spur or exostosis.
Walking upon this growth causes the characteristic pain referred to as
“painful heel.”
=Painful Feet in Women.= Dr. Henry Frauenthal, of New York City, has
recorded a large number of cases of painful heel in women, in which the
foot manifests no signs that would warrant such pains. Investigation
has shown that these women were suffering with leucorrhea. Such cases
often come to the podiatrist’s office, where they may be mistreated for
flat and weak foot by means of mechanical appliances which do no good
and often cause additional pain. Discreet questioning will reveal the
fact that the patient is a sufferer from leucorrhea, and she should be
sent to a physician for treatment.
=Treatment.= Focal infections of all types require treatment at the
initial source of infection and therefore are out of the domain of the
podiatrist. These cases should be referred to the physician or dentist,
as the circumstances warrant. Attempts at local treatment will prove
futile, and bring the podiatrist into bad repute. His duty ceases when
he has recognized such an infection and sends his patient to the proper
person for professional care.
It is a well known fact that the removal of an infected tooth or of a
diseased tonsil has often given immediate relief to one suffering from
foot pains, due to focal infection. It is equally well known that heel
pains, due to gonorrheal causes, have disappeared contemporaneously
with the cure of an old venereal lesion. So fully satisfied are the
authorities in charge of the Clinics of The First Institute of Podiatry
of the utility of such a procedure, that means are now being devised
whereby there shall be in nightly attendance, physicians and dentists,
to whom are to be referred all cases of foot pains, in which, by
exclusion, a diagnosis has been reached that focal infection may be the
cause of the same.
MORTON’S TOE AND METATARSALGIA
Morton’s toe and metatarsalgia are conditions, so common in the
practice of the podiatrist that it is deemed best to discuss them
briefly in this volume, although they will be treated most exhaustively
in “Podiatry Orthopedics,” the next volume of this series.
=Morton’s Toe or Morton’s Neuralgia.= When the foot is kept in a narrow
shoe, the strain placed upon the forefoot is so great, that the fifth
metatarsal bone is forced upward and the fourth one downward, and the
latter bone is made to act as the pillar of the arch. In consequence,
a severe pain is produced, caused by pressure upon one of the plantar
nerves, between the head of the bone and the skin. This condition
is called Morton’s toe, or Morton’s neuralgia, after Morton, of
Philadelphia, who was the first to call attention to it.
=Treatment.= The pain induced by Morton’s toe, as stated, is caused by
direct pinching of a branch of the external plantar nerve, and it is
therefore necessary to relieve the pressure on the head of the bone
which causes this condition. This is accomplished by the application
of a felt pad about one inch long, three-fourths of an inch wide and
three-eighths of an inch thick, properly skived and fastened by some
adhesive substance, reinforced with adhesive plaster strips, well
behind the head of the affected bone. This will raise the head of the
bone so that pressure on the nerve will cease, thus relieving the pain.
It is essential to remember that the pad must be placed behind the head
of the bone, for if it is put too far forward, increased suffering
will result. If the case is one in which it becomes necessary to use
a pressure of this kind for any length of time, the felt should be
discarded, and a plate of metal or some other stable substance should
be substituted, with an elevation at the point at which the pressure is
desired.
In addition to the device for raising the arch to its normal position,
exercises and massage should be prescribed. The exercises should be
those which will strengthen the flexor muscles of the toes. Attempting
to pick up a pencil or other cylindrical object with the toes, if
practised daily for ten or fifteen minutes will ultimately prove
effective. Massage, to help develop these muscles and to stretch the
shortened extensors, will also be of benefit. The patient should be
instructed to wear shoes that are wide enough to allow for the normal
spreading of the anterior part of the foot in walking. The waist of the
shoe, the portion behind the ball of the foot, should be snug.
=Metatarsalgia.= The name applied to this lesion is, literally, a pain
in the metatarsal region, but is particularly relevant to the condition
in which there is a painful depression of the heads of the second,
third and fourth metatarsal bones, the bones that make up the anterior
arch. This condition is readily recognized by the fact that the heads
of the bones are in a straight line instead of forming a concave arc,
when the foot is at rest. Upon weight bearing, the normal anterior arch
is obliterated.
=Treatment.= Metatarsalgia is treated much the same as Morton’s toe,
except that the pad is made large enough to support the three middle
metatarsal bones. The pad should be so shaped that it conforms to the
contour of the normal arch. Metal or other devices may be worn, if
properly fitted, in cases where the pressure is desired for a period
of time. Exercises and massage should be used in these cases as well
as in Morton’s toe, especially the former, for stretching the extensor
muscles.
A tight bandage around the foot just behind the heads of the metatarsal
bones will often give relief in metatarsalgia and Morton’s toe; it acts
beneficially by preventing the heads of the bones from being forced
below their normal level. Adhesive plaster and rubber bands may also
be used for this purpose.
The shoe should have a very low heel and a broad toe, so that only
a little weight is borne at the metatarsophalangeal joints, thus
affording the extensor muscles of the toes a chance to stretch. This
type of shoe will cause the patient to experience a feeling of falling
backwards, particularly in the case of a woman who has been accustomed
to wearing high heels; but this feeling and the strain that is caused
on the calf muscles, will soon pass off.
CHAPTER XXV
X-RAYS IN PODIATRY
Roentgenology is the science that deals with the use of the Roentgen,
or X-rays, in all their applications. The subject is divided into
three parts, each distinct from the other, and with special required
study for each part. The first branch of roentgenology is known as
_roentgenotherapy_ or _actinotherapy_, and comprehends the treatment of
disease by the use of the X-rays or by other radiant energy.
Roentgenotherapy, to be intelligently applied by the practitioner,
requires a thorough knowledge of pathology and is strictly within
the province of the licensed doctor of medicine. The second branch
variously styled _fluoroscopy_, _skiascopy_, _radioscopy_ or
_roentgenoscopy_, is utilized for examining the various parts of
the body by projecting the X-rays through the body and fixating
the shadows cast on the fluoroscope. This branch of the science of
light is of great assistance in diagnosis and is used extensively in
surgery for the location of foreign bodies in the tissues. The third
division of roentgenology is called _radiography_, _skiagraphy_ or
_roentgenography_, and consists of the making of X-ray photographs by
passing the ray through the body in front of a photographic plate.
This branch is of great importance to the podiatrist because of the
value it possesses in the diagnosis of foot lesions, involving the bony
structures; it often clears up a doubt as to the true state of a lesion
when other means have failed. The soft tissues through which the ray
passes readily appear in light shadow, while the bones, because they
are solid, cast a darker shadow on the plate.
Experiments with electricity and with the modifications of the various
currents of electricity, have been responsible for all of the new
discoveries and inventions along these lines, and the same may be said
of the X-rays.
The two divisions of electric current are the direct and the
alternating, named after the direction in which they flow. The direct
current moves in one direction and may be likened to the flow of water
from a faucet, while the alternating current does not maintain a
steady pressure nor does it flow in the same direction continuously.
The alternating current, which is commonly used for lighting purposes,
reverses its direction of flow and pressure 120 times per second. It is
therefore called 60 cycle current, in that it makes 60 complete cycles
per second. The alternating current may be likened to the tide, which
rises and falls every twelve hours. Instead of passing from ebb to
flood and back again each twelve hours, the alternating current, used
for illuminating purposes, does so in one-sixtieth of a second.
The alternating current, is of most value to the sciences, because its
voltage or pressure may be easily changed. Thus it can be raised or
lowered by passing it through special apparatus. One particular form
of alternating current has a voltage of from 30,000 to 120,000 and can
be used for the production of Roentgen rays, if it be transformed into
a so-called pulsative or unidirectional high tension current. This
transformation is easily brought about by modern Roentgen ray apparatus.
The discovery of the X-rays was preceded by an improvement in the
knowledge of alternating currents. Many scientists were experimenting
and looking for new rays and currents, and after the invention of the
air pump and the production of glass globes, from which the air was
removed by means of the pump, Geissler invented the process of sealing
platinum into glass and produced the Geissler air pump, which is used
to the present day. This made it possible to seal electric conductors
into vacuum tubes.
Following this, Faraday and Maxwell developed the electro-magnetic
theory of light and laid the foundation for a theory of the Roentgen
ray, which, although later considerably changed, has proven one of the
most useful adjuvants to the science of physics. The period between
1840 and the discovery of the X-rays was an active one in electric
experimenting. Many men were interested in this work, and their
observations and discoveries were important in the final discovery of
the rays. In fact, Roentgen’s discovery was fully expected, inasmuch
as several investigators, including Sir William Crookes and Roentgen
himself, were convinced that rays existed of which they knew nothing.
The earlier of the two workers, Crookes, had probably produced X-rays,
but overlooked them and it fell to Roentgen to become aware of the
conditions under which they were produced. He called them X-rays or
unknown rays, but after a time, they were named after him, and are
known in science as Roentgen rays. Roentgen wrote and published three
papers on the subject and these have become classics on this topic. All
of the facts announced by him at that time continue to be accepted,
because, notwithstanding all the work done along these lines, they have
never been disproven.
Experiments have been continuous, and gradually the types of generators
and tubes have changed, always improving. Where at first only simple
work could be accomplished, the most wonderful things in this art are
now being done, with probably many more wonderful things still to
come. The dangers to which the earlier workers were subjected have
been gradually eliminated, and today with proper care, the danger from
the X-rays has been reduced to a minor factor. This danger came about
from lack of knowledge of what occurred in the tube when the ray was
being generated. There are three rays produced, one of which causes
destruction of the human tissues, when exposed for a prolonged period
of time. By preventing the passage of this ray, by the use of lead and
lead glass, as protective mediums, the danger has been practically
controlled.
X-RAY APPARATUS
The apparatus used in the generation of the X-rays consists of a
generator, a vacuum tube and an appliance for holding the tube in a
fixed position, called the tube stand.
=The Generator.= The generators used in X-ray work are of three types,
the motor generator, the interrupterless type and the coil generator
with a chemical interrupter.
The function of the Roentgen ray apparatus is to produce high potential
electric discharges in one and the same direction, or what is known
as a unidirectional current. Dependent upon the kind of current used
to start with, distinction can be made between the types of apparatus
previously mentioned. These types are operated by either direct or
alternating current.
Direct current apparatus requires an interrupting device for the
purpose of producing the necessary change of flux of magnetic lines in
the inductive part of the apparatus. Interrupting devices, which are
used in connection with such apparatus, are of three kinds: _first_,
the hammer interrupter; _second_, the mercury interrupter; _third_, the
electrolytic interrupter. The function of any one of these interrupters
is to break up the continuous flow of direct current into small
fragments. Each one of these fragments then produces one impulse of
high potentiality, which is then directed through the tube.
The alternating current, as its name implies, is already interrupted,
but the impulses are alternately changing direction, passing first
in one direction and then in the opposite direction. Hence, if the
alternating current is used as a primary source of electric energy,
then the secondary or high potential impulses will also be changing
their direction alternately. Two methods are used in employing the
alternating current as a primary source of energy. The first consists
of the suppression of one phase (that which would pass in the negative
direction) by means of the so-called rectifier cell. The second
consists of producing high potential impulses which flow in alternate
directions, and to then redirect these impulses so that all of those
passing through the tube are in the one and the same direction.
[Illustration: INTERRUPTERLESS TYPE GENERATOR]
Accordingly, X-ray apparatus can be divided into the three classes
previously mentioned. The coil, consisting of an induction coil
activated by direct current, which is broken into small sections by
the interrupter; or the induction coil which is energized by the
alternating current of which one phase is suppressed through a liquid
rectifier cell, and in which the proper interruptions are again
produced by some interrupting device. The most extensively used type
of apparatus is known as the “interrupterless machine.” This machine
operates on either the direct or the alternating current, but, if
the direct current is used as a primary source, it is transformed
into an alternating current by means of a rotary converter or motor
generator set. The alternating current, therefore, either produced or
already available, passes into the primary coil of a transformer which
changes it into alternating impulses of high potentiality. In order
to transform them into impulses, all of which shall pass in the same
direction, a so-called rectifying system is employed. This consists
of either a disk or of cross-sticks, which are so arranged that they
produce contact with both terminals of the transformer in such a way
that current of the same polarity, the unidirectional current, is
always delivered to the tube. The name “interrupterless machine” merely
implies that the devices used for interrupting the primary current have
been eliminated.
There is one other type of apparatus which is built on the principle of
an electrically oscillating system. Here again a start is made with the
alternating current, obtained either from the line or by changing the
direct current by means of an interrupter. The current is transformed
through a so-called step-up transformer into one of high potentiality
which is then still alternating. This current oscillates over a spark
gap. Parallel to this spark gap a resonator is connected in which
impulses are produced that correspond to the discharges over the gap
and which, if applied to a specially built, so-called high frequency
Roentgen ray tube, will produce X-rays. Since the principle of electric
oscillations of a high frequency is used in this type of apparatus, it
is generally called the high frequency Roentgen ray apparatus.
[Illustration: TUNGSTEN TARGET TUBE]
=Roentgen Ray Tubes.= The various types of apparatus previously
described require special forms of Roentgen ray tubes. For the coils
by virtue of their relatively small capacity, platinum target tubes
are generally employed. The capacity of the interrupterless type being
considerably higher, the use of a material of greater resistance as
a target is necessitated. For this purpose tungsten is generally
employed. For the high frequency, or Tesla coils, a tube which embodies
a rectifying or valve action device is necessary.
The mechanism of the production of Roentgen rays can be described
in the following way: the cathode, or negative terminal of the
tube, consists of a hollow spherical surface of aluminum. When this
electrode is attached to a negative potential, a stream of negative
ions or cathode rays is projected perpendicular to the surface of
the electrode. By reason of its curvature, the electrode is therefore
focused to produce a converging beam of cathode rays, the area of which
is smallest where, in the centre of the tube, the tungsten block or
anticathode is placed.
According to whether the area selected for the location of the
anticathode is small or large, the possibility to distinguish between
fine, medium or broad focused tubes arises. The discharge from the
negative electrode takes place, dependent upon conditions which give
to the discharge either a high or a low velocity. If the velocity is
high, the change from kinetic energy to Roentgen ray energy will be
greater than if the velocity of the cathode ray stream is decreased.
In the latter case, the radiations will have less penetrating power.
The velocity of the discharge must therefore depend upon the magnitude
of the charge on the negative electrode, and also upon the number of
gas particles present in the tube at that time. If there is a large
quantity of gas present, there will be a reduction in the speed of the
ray, due to collision and impact with the gas. The penetration of the
Roentgen rays depends therefore directly upon the potential produced
by the apparatus and inversely on the gas pressure (or directly on the
vacuum) of the tube.
For the purpose of controlling the state of vacuum in the tube, a
regulating system has been improvised which, when an electric current
is passed through it, liberates a certain amount of gas which passes
into the tube proper. This is a convenient device for reducing the
vacuum of the tube. Up to the present time, no one has succeeded in
inventing an efficient method or device for removing gas from the tube,
or a means which would help to increase the vacuum. It is for that
reason that operators should guard against reducing the tube unduly.
It is a simple matter to reduce the vacuum but difficult to increase
it. When a tube becomes low (when the gas content is high), resting the
tube by allowing it to remain in its bracket for a period of time,
will usually suffice to increase the vacuum.
The proper care of the tube is essential for good radiograms. It should
be kept free from dust, and before being used the degree of vacuum
should be determined by the testing apparatus on the generator. If
the tube is dusty or dirty, the passage of the rays through the glass
will be hampered, as these particles tend to deflect the rays from
their straight course. If the vacuum of the tube is too high, it will
affect the quality of the plate, and if it is too low there will be no
penetration and therefore a blank plate.
[Illustration: TUBE STAND]
=The Tube Stand.= The tubes used in Roentgenology are delicate
structures and great care must be exercised so as to prevent breakage.
To guard against such damage it is necessary to securely hold the tube
in a proper device while it is being used. The tube stand should be
so arranged that it is possible to raise or lower the tube, with its
connections, without being compelled to touch the tube itself, to swing
it from side to side, to tilt it forward or backward, or in or out.
This is best accomplished by the modern tube stand which is so arranged
that after having set the tube in its proper place, it is no longer
necessary to touch the apparatus in order to secure all of the above
named motions. A careful study of the accompanying photograph will make
this clear.
=The Roentgen or X-rays.= The rays generated in the apparatus
heretofore described, and named after their discoverer, are of a
peculiar character, and although they have proven a boon to mankind,
serious trouble and even death has come to those who in their ignorance
used the X-rays promiscuously. It has been discovered that there are
three distinct rays generated when the high potential current is passed
through the vacuum tube and they have been named after the first three
letters of the Greek alphabet, namely: the alpha, the beta and the
gamma rays. The _alpha_ ray is the ray that is seen in the tube and is
of no consequence. The _beta_ and _gamma_ rays are invisible and it is
these rays that penetrate the tissues of the body. To the gamma ray
is attributed the harmful effects of Roentgen’s discovery. Although
the X-ray is used as a therapeutic measure it should only be applied
by those who have a thorough knowledge of its properties. Prolonged
exposure will cause severe burns, and in some cases continued contact
with the ray has caused cancer. Their action in this respect is due
to the actinic quality of the gamma rays. The symptoms of a burn do
not manifest themselves until a minimum of a week or ten days after
exposure and, when they do appear, they are usually severe. Sloughing
of the tissues takes place, and the wounds produced do not heal readily
and, in consequence, ugly disfiguring scars remain.
=Radiography.= This branch of Roentgenology is of most interest to the
podiatrist. By means of photographic plates, properly exposed and well
developed, it is often possible to make diagnoses where other means
have failed. It is essential for one who would be correct in diagnosing
X-ray plates, to have a thorough knowledge of the structure of the
bones of the foot and to understand the meaning of the various shadows
cast upon the plate.
When the X-rays penetrate the foot they pass through the tissues, and
when they strike a tissue of great density they cannot penetrate it
as readily as the rays passing through a tissue of less density. The
result is that as the rays pass through the foot they cast a series of
shadows on the sensitized photographic plate beneath, the density of
which depends upon the tissues through which the rays have passed. So,
in reality, the plate when finished is not a photograph, as most laymen
imagine, but a shadowgraph or, as it is variously termed, a radiogram
or skiagram.
For the purposes of producing radiographs that are clear and easily
interpreted, it is necessary to have good materials and to follow
the technic of developing and fixing the plate in every detail. The
photographic plates used in general photography do not, as a rule,
give satisfactory results. Plates, with specially prepared emulsions
that are adapted for radiography, are preferred. These plates are
sensitized with a gelatinous substance containing bromide of silver.
When this substance is exposed to the action of the rays it undergoes
chemical decomposition, the degree of which varies with the amount of
exposure. It is upon this decomposition of the salt that the art of
photography depends and so, too, the science of radiography. The plate
is then developed.
Developing of a photographic plate consists of making visible the
metallic silver which is produced by the decomposition of the silver
bromide. This is accomplished by the use of a mixture of chemicals
called the developer. The plate is put into a tray about two inches
deep and large enough to allow for its easy removal, and the developing
solution is poured over the emulsion. Gradually the exposed portions of
the negative will appear and developing must continue until every such
exposed part has been brought out in its fullest detail. The unexposed
portions are then dissolved by placing the plate in a solution of
sodium hyposulphite, sometimes called the _fixer_ or the fixing bath.
As its name implies, this solution permanently fixes the exposed
silver, and if the plate were not treated in this manner the entire
mass would become blackened upon exposure to light.
The preparation of radiographic plates is carried on in a room that
is protected from light with the exception of a dull, red glow from a
“ruby lamp” which has no effect upon the plate. The plate is placed
into an envelope made of black paper, and this in turn is placed, flap
down, into a second envelope of red paper. This insures protection
from light rays when the plate is brought out of the dark room. After
exposure, the negative must be taken back to the dark room before it is
removed from the envelope. After it has been developed and fixed it may
be brought into the light with safety.
The length of time required in making exposures varies with the
different types of apparatus. When the flow of rays is great, it will
require a proportionately shorter exposure. So, too, the length of
exposure with a certain type of generator varies with the part being
exposed. The bones of the fingers would require less time than those
of the leg, while the bones of the head would require more time than
either of the above for the production of a clear radiograph. It is
essential in all branches of radiography to remember that the part to
be skiagraphed be parallel to and in close proximity to the plate. This
will prevent elongations and foreshortenings of the shadows cast.
[Illustration: SPUR ON THE UNDER SURFACE OF THE HEEL]
DIAGNOSIS OF RADIOGRAPHS
There are several lesions of the foot commonly arising in the practice
of the podiatrist, which are easily recognized by radiographic
examination but which otherwise are difficult of diagnosis. Some of
these cases are shown in the accompanying pictures, which were selected
from a large collection at The First Institute of Podiatry of New
York City. They are characteristic of the lesions they depict, and
it is needless to emphasize their value as an aid to diagnosis. If a
condition involves the bony structure of the foot, clinical symptoms
are never so certain that an absolutely positive diagnosis can be made,
but the X-ray plate readily reveals such disturbances so that there is
no doubt left in the minds of the practitioner as to the exact nature
of the trouble. Periostitis, exostosis, fractures, arthritis, bone
abscesses, bone ulcers, etc., are thus easily distinguished.
=Periostitis.= Periostitis is an inflammation of the periosteum, the
outer covering of the bone. There are two types, the acute and the
chronic, both of which are not really diseases themselves, but are
indications of the reaction of the periosteum to some irritant. In
acute periostitis the X-ray plate shows a slight destruction of the
outer portion of the bone, and a slight thickening of the periosteum,
and if suppuration is present, the lesion is a mild osteomyelitis
rather than a periostitis.
Chronic periostitis causes an increase in the osteogenetic cells of
the periosteum and is common in a great many lesions. Trauma, blows
or contusions cause a chronic thickening of the bone covering with
additional bone formation, as do syphilis and superficial abscesses
in the soft tissues, in the immediate vicinity of long bones. Thus
chronic ulcer of the leg over the shaft of the tibia will produce this
condition. The picture shows that the even line of the bone surface is
lost, and there is a rough, uneven edge, with or without an increase
in the bone cells. The entire shaft of the bone is often thicker than
normal, especially in the metatarsals, and it is quite common to find
one of these bones greatly increased in size. The fourth metatarsal is
the one most usually affected.
=Exostosis.= This lesion is common in the foot, and is a source of
great pain and annoyance. It is usually the result of a chronic
bursitis which has affected the periosteum over a localized area. Due
to the destructive changes brought about by the inflammatory processes,
the periosteum is absorbed and the bone cells beneath protrude in
the form of a spur which shows on the plate. The most common site of
exostosis of the foot is on the inferior surface of the os calcis,
under the calcaneo bursa. The part is somewhat swollen and is extremely
painful when pressure is brought to bear directly over the growth.
The heads of the metatarsal bones on their lateral surfaces are
occasionally affected, especially the outer side of the head of the
first metatarsal. Lateral pressure gives rise to pain in this type of
exostosis. The treatment for all exostoses is purely surgical.
=Fractures.= There are several kinds of fracture, and they are
classified variously, but for the purposes of the podiatrist, the
following types, with the description of each, will prove sufficient:
=Incomplete Fractures=, among which are the greenstick and the fissured
fractures, are those in which there is not a complete separation of the
fragments. The greenstick is really a bending rather than a breaking of
the bone, and is found mostly in children under fifteen and then only
rarely affects the bones of the leg. Fissured fractures are splits or
cracks in the bone which do not separate it into two parts and occur
occasionally in the fibula or in the metatarsals. They are easily seen
in the radiograph by the dark shadow they produce in the region that
would ordinarily appear light. This shadow extends over the entire
length of the break.
=Complete Fractures= are the most common type found in the lower
extremity and are divided according to the line and the seat of the
breach of continuity. Thus we have transverse, longitudinal, oblique
and spiral fractures. The radiograph will reveal the nature of the
break, and a dark shadow will be cast between the fragments of bone.
The most common of these found in the leg are the oblique and the
spiral fractures.
=Comminuted Fractures= are those in which there is extensive
splintering of the bone adjoining the fracture or one of the fragments.
This class of fracture does not occur in the foot.
=Impacted Fractures= are those in which the fragments are driven into
each other, forming a wedge, thus preventing abnormal motion, so common
in other types. This occurs mostly in the neck of the femur.
=Crushing or Compression Fractures= are those in which the bones are
crushed. The spongy portion and the cortical layer are both involved
and in some cases the bones may be pulpified. The tarsal bones are
subject to this type of fractures as the result of falls from heights,
upon the soles of the feet. (See accompanying picture of fracture of
the os calcis.)
=A simple fracture= is one in which a wound of the skin is absent, or
if present, there is no connection between it and the broken bone.
If the bone is broken in two or more places or if two or more
non-adjacent bones are simultaneously broken, the condition is called a
=multiple fracture=.
[Illustration: FRACTURE OF THE OS CALCIS]
=A compound fracture= is one in which the fragments of bone pierce the
soft tissues and protrude beyond the skin.
It is essential in examining a patient who has suffered from a recent
fracture, to obtain a history of the case as well as a description
of the accident. An examination of the part should be made, and the
various symptoms such as deformity, abnormal mobility and crepitus
should be noted. The X-ray picture is then taken and if a fracture is
found, the case should be put in the hands of a competent surgeon for
immediate and proper treatment.
=Sesamoid Bones.= The sesamoid bones which are found in the flexor
tendons under the head of the first metatarsal bones, are subjected to
injury in those who follow vocations in which the ball of the foot is
put to great strains. Among such may be mentioned dancers and acrobats.
The normal position of these bones is directly beneath the head of the
first metatarsal bone, and when this part is put to a great strain, the
bones may become fractured, or they may become displaced. The outer
sesamoid is usually forced outward and the X-ray picture shows it in
the first interosseous space. The inner sesamoid is not affected, but
may also be forced outward, and is then found under the outer side of
the first metatarsal, in the normal position of the outer sesamoid bone.
Fracture of these bones is not unusual and is a result of a severe
injury. The line of division is shown by a dark shadow, much the same
as in other fractures. One or both of the bones may be involved. It is
essential to remember that if the bone is broken, the opposite sides
will fit into each other perfectly, whereas, in cases of a freakish
nature, in which there are four sesamoid bones, this will not be the
case.
=Arthritis.= Arthritis, or inflammation of the joints, may involve
any one or all of the structures which make up joints, viz., bone,
cartilage, ligaments, synovial membrane and fibro-cartilage. The acute
forms of inflammation are not detected by the radiogram, but the
chronic type leaves its characteristic marks which, when present,
are easily seen. The synovial covering of the ends of the bones
is destroyed, and shows a rough, uneven surface. In cases of long
standing, there is complete bony ankylosis, and the shadows of the
joint line are completely obliterated. This is particularly true in the
tarsal joints, in which the joint lines between the bones can hardly be
seen. There is no motion in such joints, and in milder cases, in which
no union has occurred, the sensation of crepitus is conveyed to the
hand if the joints are moved passively. Tubercular arthritis shows a
rarification of the bone with a thickening of the periosteum.
=Arteriosclerosis=, or hardening of the arteries, is often detected
by means of the X-ray picture. Light shadows cast in the normal dark
shade produced by the soft tissues, which appear over the course of the
arteries, are indications of this condition.
This disease of the arteries causes a change in the vessels whereby
there are calcareous salts deposited in the middle coat. These salts,
containing the metal calcium, are not readily penetrated by the ray,
and thus a difference between the artery and other soft tissues is
established.
There are many other conditions in which the X-rays are a valuable aid
in making diagnosis, but these are of no interest to the podiatrist,
being within the exclusive province of the physician and surgeon.
The reader is referred to books which deal with the subject of
Roentgenology exclusively, for further information upon the subject.
[Illustration: HALLUX VALGUS]
CHAPTER XXVI
THE PODIATRIST’S OFFICE
The equipment of an office of a professional man or woman, whether
it be the surgeon, the dentist, the podiatrist or any other of the
practitioners of the allied branches of medicine, cannot be set to an
absolute standard. There are several factors that govern variations,
one from the other, among which are considerations of finance and the
amount of available space. Regardless of these differences, however,
certain fundamental principles must be observed in equipping such
an office, and these depend upon two cardinal requirements: (1)
cleanliness, and (2) the comfort of the patient. Such an office must
be fitted out with the laws of asepsis and antisepsis ever in mind,
otherwise it will prove unsafe for the treatment of patients whose feet
require surgical attention. Again, the patient must feel at ease while
being treated, or revisits will be scarce.
There are other and secondary standards which should be considered
among which is the appeal to the eye. First impressions often are
lasting ones, and an office which makes a favorable impression will
help attract patients. One often hears the thoughtless layman express
himself, “Go to Dr. Blank for treatment, he has a beautiful office.” So
it often occurs that a professional person is judged by the equipment
in his office, and the effects of such an impression should be
considered.
=The Waiting Room.= The waiting or reception room should be furnished
with chairs upholstered in leather or made of solid wood. In waiting
rooms in which many patients must wait at the same time, and space is
valuable, smaller chairs with cane seats are very useful. The table
should be of polished wood, covered with a plate glass top. The wood
work of the room itself should be white, and the walls should be
painted in preference to being papered. Buff is a pleasing color to the
eye, and readily matches all kinds of furniture. The floor should be of
hard wood, and may be covered by linoleum or rugs. Carpets should not
be tolerated, as they are dirty; and even though frequently swept, they
become the repositories of dust and of germs.
=The Operating Room.= The operating room must be scrupulously clean.
As a white background best shows dirt spots, that should prevail in
furniture and in decorations. A door, either of glass and wood or
entirely of wood, should separate the reception room and the operating
room; if hangings must be used, they should be of some washable, white
material, that can be readily changed. The floor should be of tile,
marble or stone; if these materials are not available, hard wood
floors, well polished, are permissible. No covering of any kind should
be used for the floor of this room. The ceilings and walls should be
painted white, and the wood work should be enameled the same color.
Tile or marble walls are preferable to plaster or wood. No curtains
should be used on windows or doors, and if necessary the glass can be
frosted to secure privacy. A wash basin, with running hot and cold
water, should be in the operating room, and the valves should be
controlled by foot levers in preference to hand faucets.
To summarize, everything in the operating room should be of such a
character as to make it possible to wash it daily with soap and water.
Nooks and corners that tend to collect dust and dirt must be thoroughly
cleaned, bearing in mind that disease-producing bacteria will not grow,
unless a breeding place be provided for them. Wall pictures and their
frames should be selected with a view to having them equally sanitary.
=The Equipment.= The equipment of a modern office is divided into three
classes: (1) the furniture, which, when bought, is permanent; (2) the
instruments; and (3) the supplies, which are replenished from time to
time as they are exhausted.
Furniture should consist of the following in the order of their
importance:
Sterilizer
Operating Chair and Stool
Cabinet
Glass-Top Table
Drill
High Frequency Machine
Air Compressor
Galvanic Machine
Wall Cabinet and Extra Accessories.
The authors are not interested in the wares of any manufacturer, and
any equipment that is efficient and well made will answer the purposes
of the podiatrist. There are many styles of chairs, cabinets, electric
machines, etc., on the market and the selection of such furniture and
equipment rests with the finances and the taste of the individual.
Chairs should be roomy and have a suitable rest for the patient’s back
and head. The foot rest should be adjustable and so arranged that the
patient’s foot is made comfortable, regardless of the position in which
it is held. This part of the chair is very important, as upon it often
depends the result of the podiatrist’s work. If the foot and leg are
held so that the patient is uncomfortable or so that muscular cramps
are the result, both patient and operator are at a disadvantage which
it is difficult to overcome.
There are two types of foot-rests on the market which have proven
efficient. One gives support along the entire length of the leg and
allows the foot to hang free at the end, and the other gives support
at the foot proper and is so arranged that it gives this support no
matter in what position the foot be held. The chair itself should be so
constructed that no matter how the weight of the patient’s body may be
distributed, the chair will remain firm, with no danger of spilling
its occupant. It is on this account that a chair with a heavy metal
base or with heavy spreading legs is best. When the chair is placed in
a horizontal position so that the patient is prone, it should be as
firm as with the patient in a sitting posture. The stool should match
the chair and should be adjustable.
The cabinet is the most important part of the podiatrist’s equipment
from an aseptic standpoint, for therein are kept the instruments,
dressings, drugs, etc. There are many styles and shapes from which to
select, but only those that afford proper protection from dust and
dirt should be considered. Drawers should be provided for bandages and
dressings, and one drawer should be divided into compartments for the
various sized shields. This adds to the neatness as well as to the
efficiency of the cabinet. Special movable racks which fit into shallow
drawers should be provided for the instruments, so that, if necessary,
they may be collectively removed, thus avoiding the need for handling
each instrument separately. Instrument compartments of this type should
be so made that the blades of the various instruments are suspended
in the air; moreover such racks and drawers are easily cleaned. Drugs
should be kept in special compartments provided with glass doors,
or, if the cabinet has no such provision, the bottles should fit in
metallic clamps arranged in the rear of the top of the cabinet. Glass
tops on the cabinets are best for they are easily cleaned, but white
enameled metal tops are quite as good. The towels should be kept in a
compartment of the sterilizer, otherwise in a special compartment in
the cabinet, one having a glass door being preferred.
Sterilizers may be heated by gas or electricity and when boiling water
is not available, even formaldehyde gas is better than nothing for
sterilizing purposes. The sterilizer, a necessity and not an ornament,
should be cleaned and polished and the water should be changed daily.
Unfortunately in the past, practitioners of podiatry did not use the
sterilizer with regularity, and one could enter many of these offices
and not even find such a contrivance. This state of affairs, however,
is becoming a memory because the practitioner, as well as the public,
has learned the importance of asepsis and antisepsis. The podiatrist
who fails to observe the needs of this dispensation is unworthy of the
title he bears.
The sterilizer should be kept on a white enameled table with a
detachable metal top, so that boiling water or hot instruments will
cause no damage to it, as might occur on a glass-topped table. This
table should have a glass shelf below, on which may be kept additional
remedial agents for which there is no room in the cabinet.
The surgical drill or rotary file is a valuable asset to the podiatrist
in treating the nails, and should be a part of the equipment. There are
several makes of rotary files, all with the same fundamental structure.
The motors and cables are of one type, and are held either by a wall
bracket or suspended upon a metal hook, resting on a metal pedestal.
When the instrument is kept in only one operating room, the former type
is sufficient, but when the drill is moved from one room to another,
the latter style is necessary.
Other accessories in the office, such as an air compressor, high
frequency coil, galvanic machine, wall cabinet, etc., should be
selected with care as to quality, and with judgment as to their
harmonizing with the other equipment. If space allows, all of these
accessories are desirable because useful, but when quarters are
contracted, care must be taken in arranging the paraphernalia that the
effect is not such as to give the patient the impression that he is in
a podiatry supply shop.
“Cleanliness is next to Godliness,” should be the slogan of every
practitioner of medicine in any and in all of its collateral branches
and the manner in which he conducts his office should be evidence that
such is the belief and the practice of every podiatrist.
FOOTNOTES:
[1] The District of Columbia has now a similar law, passed since the
above was written. Ernest Stanaback, former President of the N. A.
C., and Harry P. Kenison, the present President of the N. A. C., were
potent factors in procuring most of the legislation in the above states.
[2] Podiatrists are advised to refrain from using cocaine on account of
its dangers.
[3] Hypodermic and hypodermatic are synonymous terms although medical
lexicographers, as a rule, give preference to the latter.
[4] _Apothesine_ (Parke Davis & Co.) is a new synthetic preparation
of definite chemical composition. It is ¹⁄₈ as toxic as cocaine, is
very soluble in water and alcohol, and may be sterilized by boiling
for five or ten minutes. It is used in a one per cent. solution and
came into favor during the war, by reason of the scarcity of cocaine
and novocaine. Apothesine is not a habit-forming drug and is therefore
easily obtainable. At The First Institute of Podiatry this preparation
and novocaine are almost exclusively used for producing local
anesthesias.
[5] Apothesine, lately introduced, is proving efficacious and reliable
(see page 148).
[6] These experiments were carried on at The First Institute of
Podiatry under the direction of Monroe Redell and W. H. A. Fletcher,
clinicians, and on the suggestion of Dr. F. Oefele.
[7] (Capt. V. N. Sorapure, R. A. M. C., who has lectured to the
students of The First Institute of Podiatry, has contributed to the
literature on this subject; see Journal of the A. M. A., July 6, 1918).
GLOSSARY
A
=a-, an.= A prefix conveying a negative meaning--without, not, away
from.
=aa.= A sign used in prescription writing to indicate equal parts of
each ingredient so designated.
=ab.= A prefix signifying from, away from, off.
=abdominal.= Relating to the abdomen or belly.
=abduction.= Rotation of the foot outward.
=abnormal.= Not normal, contrary to the rule or type; irregular.
=aboriginal.= Primitive, existing from the beginning.
=abrasion.= A circumscribed removal of the epidermis of skin or mucous
membrane.
=abscess.= A circumscribed cavity in the tissues containing pus.
=absorption.= The taking into the tissues, through the medium of the
lymphatics or blood vessels, of any material in suitable form.
=acetanilid.= An analgesic made from aniline by treating it with acetyl
chloride.
=acetic.= Relating to vinegar; acid.
=acid.= A chemical compound containing replacible hydrogen, having a
sour taste, and neutralizing a base to form a salt and water.
=acidum.= Acid.
=a.= Aceticum, acetic acid; useful as a counter-irritant.
=a.= aceticum glaciale, glacial acetic acid; employed
externally as a caustic.
=a.= boricum, boric acid; dusting powder, antiseptic.
=a.= carbolicum, carbolic acid, phenol; antiseptic.
=a.= chromicum, chromic acid; caustic.
=a.= dichloraceticum, dichloracetic acid; caustic.
=a.= hydrochloricum, hydrochloric acid; escharotic.
=a.= iodicum, a white crystalline powder; antiseptic and
deodorant.
=a.= monochloraceticum, a white deliquescent powder; caustic.
=a.= nitricum, nitric acid; caustic.
=a.= nitricum fumans, fuming nitric acid; caustic.
=a.= nitrohydrochloricum; a fusing corrosive liquid; caustic.
=a.= salicylicum, salicylic acid; disintegrant.
=a.= sulphocarbolicum, sozolic acid; antiseptic and
disinfectant.
=a.= sulphuricum, sulphuric acid, oil of vitriol; caustic.
=a.= tannicicum, tannic acid, astringent.
=a.= trichloraceticum, trichloracetic acid; caustic.
=acquired.= Noting a disease which is not congenital but has taken
possession of one at some period after birth.
=actinic.= Relating to chemically active rays.
=actinotherapy.= The treatment of disease by radiant energy.
=acute.= Of short and sharp duration, not chronic; said of a disease.
=adduction.= Rotation of the foot inward.
=adhesive.= Sticky; causing adhesion.
=adipose.= Fatty; relating to fat.
=adjacent.= Next to; along side of.
=adjuvants.= Agents added to a prescription to assist or increase the
action of the main ingredient.
=adolescents.= Youths, those between the ages of puberty and the
attainment of full growth.
=adrenalin.= A principle obtained from the suprarenal glands having
marked astringent and hemostatic powers.
=agar.= A gelatinous substance prepared from seaweed, and used as a
base for culture media.
=agent.= Anything which produces an effect upon the organism.
=agnail.= Hangnail, whitlow.
=albumin.= A protein contained in the tissues of plants and animals.
=albuminous.= Containing or consisting of albumin.
=albuminuria.= The presence of albumin in the urine as voided.
=alcohol.= One of a series of organic compounds, especially one whose
formula is C_{2}H_{5}OH, and called ethyl alcohol.
=algia.= A suffix indicating pain. (Exam. metatarsalgia--pain in the
metatarsals).
=alignment.= Alinement; the act of bringing into line.
=alkaline.= Relating to an alkali; having the reaction of an alkali.
=alkaloid.= A basic substance found in plants, usually constituting the
active principle of the crude drug.
=alum.= A double sulphate of aluminum; burnt a. alumen exsiccatum.
=aluminum chloride.= A substance used as an astringent in hyperidrosis
and bromidrosis.
=alypin.= A crystalline powder used as a local anesthetic.
=ammoniated mercury.= See unguentum, hydrarg, amm.
=ampere.= The unit of strength of an electric current.
=amyotrophic lateral sclerosis.= A form of progressive muscular atrophy
with increased reflexes due to hardening of the lateral columns of the
spinal cord.
=anærobe.= A microorganism which thrives best or only when deprived of
oxygen.
=analgesic.= An agent which causes analgesia or freedom from pain.
=anastomose.= To open one into the other directly or by connecting
channels; said of blood vessels and nerves.
=anatomy.= The science devoted to the study of the structure of
organized bodies, more especially the human body.
=anemia.= A condition in which the blood is reduced in amount, or is
deficient in red blood cells or in hemoglobin.
=anesthesia.= Loss of sensation, especially of tactile sensibility.
=anesthetic.= 1. Insensible to touch or to pain or to other stimuli. 2.
A drug which produces local or general anesthesia.
=anesthetize.= To induce anesthesia; to render anesthetic.
=aneurism.= A blood-containing tumor connecting directly with the lumen
of an artery.
=angioma.= A swelling or tumor due to dilatation of a blood vessel.
=ankylosis.= Stiffening or fixation of a joint.
=anterior.= In front of, or, in the front part of.
=anterior poliomyelitis.= Inflammation of the anterior horns of the
spine; infantile spinal paralysis.
=antheloticum or remedium heloticum.= Remedy for helomata.
=anti.= A prefix signifying against, opposing. (Exam.
antifebrile--against fever).
=anticathode.= The platinum or other plate in a Crookes tube on which
the cathode rays impinge, giving origin to the X-rays.
=antiphlogistic.= An agent which subdues or allays inflammation.
=antisepsis.= The destruction of germs causing disease, fermentation or
putrefaction.
=antiseptic.= 1. Destructive to the germs of disease, fermentation or
putrefaction. 2. A substance which prevents the action of the germs of
fermentation, decomposition, or disease.
=aperture.= An opening, orifice.
=apex.= The summit or tip.
=apodal.= Without feet.
=apodia.= Congenital absence of feet.
=apoplectic.= Relating to, predisposed to or suffering from apoplexy.
=apoplexy.= A sudden loss of consciousness followed by paralysis, due
to cerebral hemorrhage or blocking of an artery of the brain.
=apothesine.= A synthetic product used to produce local anesthesia,
which came into popular favor at a time when the usually employed local
anesthetics were unobtainable because of war conditions.
=apparatus.= A collection of instruments adapted for a special purpose.
=appendage.= Any part, subordinate in size, attached to a main
structure.
=appendicitis.= Inflammation of the vermiform appendix.
=applicator.= A slender rod of wood or metal by means of which with
cotton, local applications may be made to a part.
=apus.= A monster without feet.
=aqua.= Water.
=aqua cinnamomi.= Cinnamon water.
=aqua fortis.= Nitric acid; see acidum nitricum.
=aqueous.= Watery.
=arch.= In anatomy, any vaulted or arch-like structure.
=argentum.= The metal, silver.
=aristol.= Trade name of thymol iodide, a local antiseptic.
=armamentarium.= In podiatry, all the means (drugs, instruments, etc.)
at the disposal of the podiatrist to fit him for the practice of his
profession.
=arsenic.= A steel-gray metal, one of the elements; arsenic trioxide,
white arsenic.
=arteria.= Artery: a blood vessel conveying blood away from the heart.
=arteries of the foot=:
=a.= communicans; communicating branch of dorsalis pedis (to
plantar surface to join plantar arch).
=a.= digitales dorsales; digital branches of dorsalis pedis
(dorsal surface of the toes).
=a.= dorsalis pedis; dorsalis pedis artery (dorsum of foot).
=a.= metatarsae dorsales; metatarsal branch of dorsalis pedis
(dorsum of foot to metatarsus).
=a.= plantaris lateralis; external plantar artery (plantar
surface, joining communicating branch of dorsalis pedis,
completing the plantar arch).
=a.= plantaris medialis; internal plantar artery (plantar
surface of foot).
=a.= tarsae lateralis; tarsal branch of dorsalis pedis (dorsum
of foot to the tarsus).
=arteriosclerosis.= Hardening of the arteries.
=areolar.= A tissue made up of loose connective tissue, with many
interspaces and found under the skin.
=arsenical.= Relating to or containing any of the salts of arsenic.
=arthritis.= Inflammation of the joints.
=articulation.= A joining or connecting together loosely so as to allow
of motion between the parts.
=articular.= Relating to a joint.
=ascites.= An accumulation of serous fluid in the peritoneal cavity.
=asepsis.= A condition in which living bacteria are absent.
=astasia-abasia.= Inability through muscular incoordination, to walk or
stand, although the muscles functionate normally when the patient is
lying down.
=astragalus.= The ankle bone.
=astringent.= An agent which causes contraction of the tissues or
arrest of the secretions.
=ataxia.= A loss of the power of muscular coordination.
=ataxic.= Relating to ataxia.
=atony.= Lack of tone or tension.
=atrophy.= A wasting of the tissues of a part or of the entire body.
=atypical.= Not typical.
=auto.= A prefix denoting self. (Exam. autogenesis--self-production).
=auto-serotherapic.= Relating to the treatment of certain conditions by
the injection of the patient’s own blood serum.
=axilla.= The armpit (pl. axillae).
=axis.= A straight line passing through a spherical body between its
two poles and about which the body may revolve.
B
=bacillus.= A bacterium; more especially, a rod-shaped or elongated
variety.
=bacillus aërogenes capsulatus.= The specific organism causing gas
infection and gas gangrene. =b. of Welch=, the same; =b. perfringens=,
the same.
=bacteria.= Unicellular vegetable microorganisms, usually those which
produce disease.
=bactericidal.= Causing the death of bacteria.
=bacterium fetidum.= A microorganism producing a stench. =b.
prodigiosus.= A microorganism found on food, but not pathogenic.
=bandage.= A piece of cloth or other material applied to any part of
the body, to make compression, prevent motion and to retain surgical
dressings.
=base.= The lower part or bottom. In pharmacy, the chief ingredient of
a compound. In chemistry, a compound which neutralizes an acid to form
a salt.
=belladonna.= Deadly nightshade. A perennial herb, the leaves and roots
of which are used in medicine.
=beneficent.= The disposition to do good; of help to.
=benign.= Mild in character, said of an illness; not malignant.
=benzine.= A purified distillate of American petroleum.
=beriberi.= Endemic neuritis; a specific polyneuritis occurring in
eastern and southern Asia. It prevails especially in armies, prisons,
ships, etc., wherever large numbers of men are kept together.
=bi.= A prefix denoting two, twice, or double. (Exam. bicuspid--having
two prongs).
=bichloride of mercury.= A chemical compound, HgCl_{2}, called
corrosive sublimate and mercuric chloride. It is used as an antiseptic.
=bifid.= Split or cleft bilateral. Having two sides, biped. Two-footed.
=bismuth subgallate.= A yellowish dusting powder; trade name, dermatol.
=bismuth subnitrate.= A white dusting powder with astringent properties.
=bistoury.= A long, narrow-bladed knife, straight or curved on the
edge, sharp or blunt pointed; employed for opening abscesses, slitting
up sinuses, etc.
=bleb.= A circumscribed area of separation of the epidermis due to the
presence of a clear non-purulent fluid.
=blister.= A bleb.
=blood.= Sanguis, cruor; the red fluid circulating in the arteries,
capillaries and veins. =b. plasma=, the fluid portion of the blood as
it is contained in the vessels. =b. serum=, the fluid which is squeezed
out by shrinkage of a blood clot.
=bones.= The hard substances that make up the framework of the body.
=bones of the foot=:
=astragalus.= Ankle bone.
=cuboid.= In front of the os calcis.
=internal, middle and external cuneiforms.= In front of the
scaphoid.
=metatarsals.= Five; in front of the tarsal bones.
=os calcis.= Heel bone.
=phalanges.= Fourteen; in front of the metatarsals, two in the
great toe and three in each of the four lesser toes.
=scaphoid.= In front of the astragalus.
=boric acid.= A powder, soluble in water used as an antiseptic dusting
powder.
=bromidrosis.= Foul-smelling perspiration.
=buckskin.= A leather made from the skin of the buck.
=buffing.= Polishing by means of some soft material, attached to a
rapidly revolving motor.
=bulb.= Any globular or fusiform structure.
=bulbar palsy.= Paralysis of the tongue and larynx.
=bulla.= A bleb.
=bullous.= Relating to or of the nature of bullae.
=bunion.= An inflammatory swelling of the bursa over the
metatarsophalangeal joint of the great toe.
=bur.= A small disc or bulb, made to revolve rapidly and used by
podiatrists in connection with their employment of the rotary drill, or
file.
=Burow’s solution.= A solution of alum and lead acetate.
=bursa= (plural, bursae). A closed sac or pouch containing synovial
fluid, found over joints and where tendons play over bones.
=bursitis.= Inflammation of a bursa.
C
=caisson disease.= The bends, divers’ paralysis, tunnel disease; a
symptom-complex, occurring in tunnel workers and others working in
places under high air pressure when they return too suddenly to the
normal atmosphere.
=calamine.= Zinc carbonate; a pink powder used as an astringent.
=calcaneoastragaloid.= Relating to the os calcis and the astragalus.
=calcareous.= Chalky.
=calcified.= Hardened by the deposition of lime salts in a part.
=calcium.= A metallic element having a yellow color.
=calibre.= The diameter of a canal or vessel.
=callositas.= Callous, tyloma, a circumscribed thickening of the
epidermic layers of the skin.
=callous.= Callositas.
=callus.= Callosity. The bone-like substance thrown out between and
around the ends of a fractured bone.
=calomel.= Hydrargyrum chloride mite.
=calor.= Heat.
=camphorated soap liniment.= Soap liniment, camphorated tincture of
soap.
=capillary.= One of the microscopic blood vessels forming the capillary
system, intermediate between the arteries and the veins.
=capsicum.= The dried fruit of Cayenne, African or red pepper.
=capsule.= A membranous structure enveloping an organ or any other part.
=carbolic acid.= Phenol.
=carbon.= An element, occurring in the form of the diamond, graphite
and coal.
=carbon dioxide pencil.= A mass of solidified carbon dioxide used for
the destruction of verruca, etc.
=carborundum.= A very hard substance (carbide of silicon) used to
sharpen instruments.
=caries.= Molecular decay of a bone.
=carpal.= Relating to the wrist.
=carpus.= The wrist.
=cartilage.= A connective tissue substance.
=cashmere.= A woolen fabric made from goat hair.
=cast.= An object formed by the solidification of a liquid poured into
a mold.
=castor oil.= Oleum ricini; a fixed oil from the seeds of Ricinus
communis.
=catalepsy.= A morbid state in which there is rigidity of the limbs.
=cataplasma.= A poultice, a soft magma or mush, prepared by wetting or
heating various powders or other absorbent substances.
=catatonia.= Stupor.
=cathode.= The negative pole of an electric current.
=caustic.= Corrosive.
=cautery.= An agent used for scarring or burning the skin or tissues by
means of heat or of caustic chemicals.
=c.c.= Abbreviation for cubic centimeter.
=cell.= A minute structure, the living active basis of all plant and
animal organization, composed of a mass of protoplasm and containing a
nucleus.
=cellulitis.= Inflammation of the cellular or connective tissue.
=centigrade scale.= A thermometer scale, in which there are 100 degrees
between the freezing point and the boiling point of water.
=centimeter.= The hundredth part of a meter or .3937 (²⁄₅) of an inch.
=cerate= (Lat. ceratum). An unctuous solid preparation, containing
sufficient wax to prevent it from liquefying when applied to the skin.
=cerebellar.= Relating to the cerebellum or hind-brain.
=cerebral.= Referring to the brain.
=cerebral cortex.= The external layer of gray matter covering the
hemispheres of the brain.
=cerebral hemisphere.= The large mass of brain substance on either side
of the great longitudinal fissure.
=cerebrospinal.= Relating to the brain and the spinal cord.
=cerebrospinal meningitis.= An acute infectious inflammation of the
brain and spinal cord caused by the meningococcus.
=chamois.= The skin of the goat family, prepared for purposes of
utility.
=chancre.= The initial sore of syphilis.
=characteristics.= The traits which mark a substance or condition, and
differentiate it from others.
=Charcot’s disease.= Amyotrophic lateral sclerosis.
=chauffeur’s foot.= A painful condition of the anterior part of the
foot.
=chilblain.= An inflammation of the skin due to exposure to cold and
dampness.
=chimatlon.= Chilblains, an inflammation of the skin due to exposure to
cold and dampness.
=chiropodical.= Relating to chiropody (podiatry).
=chiropodist.= One who treats the minor lesions of the foot. Originally
probably, chirurg-podist, a surgeon of the foot.
=chiropody.= The study of the minor lesions of the foot. Podiatry.
=chisel.= The podiatrist’s instrument; helotomon.
=chlorine.= An element in nature; an irritating, greenish, gaseous
element used for disinfectant and bleaching purposes.
=cholesterin.= A monatomic alcohol.
=chorea.= A disorder of childhood characterized by spasmodic,
involuntary movements of the limbs and facial muscles; St. Vitus’ dance.
=chromidrosis.= A disease of the sweat glands in which the perspiration
is colored.
=chromium.= A very hard steel-gray element.
=chronic.= Of long duration; noting a disease of slow progress and long
continuance.
=cicatricial.= Referring to scars or scar tissue.
=cicatrix.= A scar.
=circinate.= Circular, ring-shaped.
=circum.= A prefix denoting a circular movement. (Exam.
circumcision--to cut around).
=circumduction.= Movement of a part in a circular direction.
=circumscribed.= A definitely limited area.
=claudication.= Limping.
=claw-foot.= Muscular atrophy with caval contraction of the foot.
=clavus.= Heloma, corn.
=clinic.= An institution in which medical attention is given to
patients who live elsewhere and do not require hospital care.
=clonic.= Marked by alternate contraction and relaxation of muscle.
=clot.= Coagulated blood.
=club-foot.= Talipes.
=coagulation.= Clotting, the process of changing from a liquid state to
that of a soft, jelly-like solid.
=coalesce.= To grow together, to become one.
=coaptation.= The joining together of two surfaces, as in sewing up a
wound or setting a fracture.
=cocaine.= An alkaloid derived from coca and used for producing local
anesthesia.
=cocoon dressing.= A dressing made of absorbent cotton covered with
collodion.
=cohesion.= The power of attraction between the molecules of any
substance, keeping the mass from falling apart.
=collateral.= Secondary or subordinate.
=collodial.= Glue-like. A substance which remains permanently suspended
in a liquid, but does not dissolve.
=collodion= (Collodium). A solution of guncotton in ether and alcohol.
=coma.= A state of profound unconsciousness from which one cannot be
roused.
=comatose.= A state of coma.
=comminuted.= Broken into a number of fragments, as in a multiple
fractured bone.
=compound.= Not simple but made up of two or more parts. In chemistry,
a substance formed by the chemical union of two or more elements.
=compress.= A pad of gauze or other material placed over a part to make
compression.
=concave.= A surface which is evenly curved inward.
=concentrated.= Referring to a solution which has been made strong by
evaporation or other means.
=concentric.= Having a common centre.
=concomitant.= Accompanying; occurring at the same time.
=concrete.= Hardened; solidified into a mass.
=condyle.= A rounded articular surface at the extremity of a long bone.
=configuration.= External form.
=congelation.= Freezing.
=congenital.= Existing at birth.
=congestion.= The presence of an abnormal amount of blood in the
vessels of a part.
=connective.= Binding, joining.
=c. tissue.= The general supporting or uniting tissue of the
body.
=constitutional.= Relating to the system as a whole; not local.
=contact.= The touching or apposition of two bodies.
=contagion.= Transmission of an infectious disease.
=contamination.= Pollution, soiling with infectious matter.
=continuity.= Without a break; absence of interruption.
=contour.= The outline of a part, the surface configuration.
=contra.= A prefix signifying against or opposite. (Exam.
contra-lateral--relating to the other side).
=contra-indicated.= Not indicated, as in the purposed use of a remedy
or in the consideration of a surgical procedure.
=contract.= To shorten.
=contracture.= A permanent muscular contraction, due to tonic spasm or
to loss of muscular equilibrium, the antagonists being paralyzed.
=contused.= Bruised.
=convex.= A surface which is evenly curved outward.
=coordination.= The harmonious working together of several muscles or
groups of muscles.
=core.= The central mass of necrotic tissue in a boil.
=corium.= Cutis vera, true skin; the deeper or connective tissue layers
of the skin.
=corn.= Heloma, an overgrowth of the epidermic layers of the skin,
containing a radix, or nucleus.
=cornification.= Conversion into a horny substance.
=corpuscle.= A primary atom.
=corrode.= To wear away gradually.
=corrosive sublimate.= Bichloride of mercury.
=cortex.= The outer portion of an organ.
=cosmetic.= Relating to the care of a person with a view to improving
the appearance.
=cotton.= The white fluffy fibrous covering of the seeds of the plant,
genus gossypium, used in surgical dressings.
=counterextension.= The resistance, or back-pull, made to extension on
a limb.
=counter-irritant.= An agent which causes counter-irritation.
=counter-irritation.= Inflammation or irritation of the skin excited
for the purpose of relieving an inflammation of the deeper structures.
=coup de fouet.= Rupture of the plantaris muscle; lawn tennis leg.
=c. p.= Abbreviation for chemically pure.
=cramp.= A painful tonic muscular contraction; spasm.
=creosote.= A substance obtained from beechwood tar.
=crepitus.= The sensation (a crackling) felt when the hands are placed
over the seat of a fracture, and the broken ends of the bones are moved
against each other.
=cretinism.= A disease occurring in the first three years of life, and
resulting in the arrest of bodily growth and of mental development.
=crinoline.= A stiff material with a coarser mesh, and heavier than
gauze or cheesecloth.
=criss-cross.= Referring to plaster applied to a part, each strip when
applied being at an angle to the strip previously applied.
=Crookes tube.= See Chapter, “X-rays in Podiatry.”
=croupous.= Marked by a fibrinous exudation.
=crural.= Relating to the leg or thigh.
=crystalline.= Clear, transparent.
=cuboid.= A bone of the tarsus.
=cuneiform.= Three bones of the tarsus.
=curettage.= Scraping the interior of a cavity for the removal of the
abnormal tissues, with the curette.
=cutaneous.= Relating to the skin.
=cuticle.= Epidermis or outer horny layer of the skin.
=cutis.= The skin.
=cylinder.= A geometric figure formed by the revolution of a rectangle
around one of its sides.
=cylindrical.= Relating to or the shape of a cylinder.
=cyst.= An abnormal sac containing gas, fluid or a semi-solid material.
=cytoplasm.= Protoplasm, the substance of the cell, exclusive of the
nucleus. It is composed of spongioplasm and hyaloplasm.
D
=D.= Abbreviation in prescription writing for da, give, detur, let
there be given.
=dactyl.= A finger or toe.
=Dakin Solution.= A solution compounded by Dr. Dakin for the treatment
of wounds by means of chlorine gas in solution, applied directly to the
parts affected or injured.
=dancer’s foot.= A painful condition of the great toe joint.
=decay.= Slow destruction of an organic substance.
=débris.= Fragments; broken rubbish.
=deformity.= A deviation from the normal shape or size, resulting in
disfigurement.
=degeneration.= Deterioration; sinking from a higher to a lower level
of a type.
=dehydrating.= Losing water; being deprived of water.
=deliquesce.= To become damp or liquid by absorbing water from the
atmosphere.
=delirium.= A condition of extreme mental excitement, marked by
confused ideas.
=demarcation.= A setting of limits, determining a boundary. =Line of
d.=, a zone of inflammatory reaction separating a gangrenous area from
healthy tissue.
=dementia paralytica.= General paresis, or paralysis, of the insane.
=denuded.= Deprived of a covering; bared.
=deodorant.= An agent which destroys odors, especially disagreeable
odors.
=depressed.= Flattened from above downward. as in fractures of that
type.
=derma.= The connective tissue layer of the skin; the true skin.
=dermatalgia.= Skin pain.
=dermatitis.= Inflammation of the skin.
=dermatitis calorica.= Inflammation of the skin resulting from the
action of cold or heat.
=dermatol.= Trade name of bismuth subgallate.
=dermatorrhea.= Excessive skin secretion.
=dermosynovitis.= Perforating ulcer of the foot.
=desiccant.= A skin-drying agent.
=desiccation.= Drying.
=desquamation.= The shedding of the cuticle in scales or shreds.
=developer.= A solution of chemicals used to develop photographic and
X-ray plates.
=devitalized.= Deprived of vitality or energy.
=dexter.= Right, in contradistinction to sinister, left.
=diabetes.= A disease in which sugar is excreted in the urine, and is
also present in the blood. There are two types, insipidus and mellitus.
The latter is the diabetes in which sugar is excreted. In the former,
large quantities of pale urine are excreted.
=diachylon.= Lead plaster.
=diagnosis.= The determination of the nature of a disease.
=diapedesis.= The passage of the blood cells through the unruptured
walls of the blood vessels.
=diathesis.= A constitutional state predisposing to any disease or
group of diseases.
=digit.= A finger or toe.
=diet.= Food and drink in general. A prescribed course of eating and
drinking.
=dietetics.= The therapeutics of food and drink in relation to health
and disease.
=diffuse.= Spread about; not confined.
=dioxygen.= Trade name for hydrogen peroxide.
=diphtheria.= A specific infectious disease caused by the
Klebs-Loeffler bacillus.
=direct cautery.= Actual fire or heat applied to a part to destroy it.
=disbasia angiosclerotica.= A disease characterized by intermittent
limping.
=disease.= Illness, sickness; an interruption of the function of any
part of the body.
=disintegration.= Separation of the component parts of a substance.
=dislocation.= A disturbance of the relation of the bones entering into
a joint.
=dissection.= The act of cutting apart or separating the tissues of
the body in the study of anatomy. In an operation, to separate the
structures along natural lines. In podiatry, to remove a growth in its
entirety and as a whole.
=disseminatum.= Widely scattered, referring to heloma d., which is so
scattered.
=distal.= Farthest from the centre or median line. Opposed to proximal.
=distension.= The act of stretching.
=dorsal.= Referring to the upper or posterior surface, or the back of
any part.
=douche.= A current of water or other fluid, directed against the
surface or projected in a cavity.
=drain.= To draw off the fluid from a cavity.
=dressings.= The materials applied to a wound for the purpose of
excluding the air, stimulating repair, etc.
=drop-foot.= Paralysis of the dorsal flexor muscles of the foot.
=dropsy.= An excessive accumulation of clear watery fluid in any of the
tissues or cavities of the body. (Latin--hydrops).
=duck shield.= A dressing for heloma molle, devised by Alfred Ahrens.
=duct.= A tubular structure giving exit to the secretion of a gland, or
conducting any fluid.
=ductility.= The quality possessed by some metals to spread and
elongate without breaking.
=dys.= A prefix meaning bad or difficult. (Exam. dysphasia--an
impairment in the sense of touch).
=dyspnea.= Shortness of breath, difficult respiration.
E
=ebullition.= Boiling.
=ecchymosis.= A purplish patch of the skin caused by extravasation of
blood.
=ectrodactylia.= A congenital malformation in which one or more fingers
or toes are absent.
=eczema.= Salt rheum, tetter; an inflammation of the skin,
characterized by weeping and itching.
=edema.= An abnormal amount of clear watery fluid in the lymph spaces
of the tissues.
=edematous.= Dropsical, marked by edema.
=effusion.= Escape of fluid from the blood vessels or lymphatics into
the tissues or a cavity.
=electrode.= One of the two poles of an electric battery or of the ends
of the conductors connected therewith.
=electrolysis.= Decomposition of the tissues by means of electricity.
=eleidin.= A deeply staining substance forming the granules of the
stratum granulosum of the epidermis.
=element.= A simple substance which has not been subdivided.
=elephantiasis.= Barbados leg. Hypertrophy of the skin and subcutaneous
tissues.
=eliminants.= Agents promoting the removal of waste.
=emaciation.= Extreme loss of flesh.
=embolism.= Obstruction of a vessel due to a clot or foreign matter,
which has been transported to it, usually from a thrombus.
=emollient.= Soothing to the skin.
=emphysema.= The presence of air in the spaces of the connective
tissues of a part.
=empiric.= Founded on experience; the treatment of disease based on
experience; opposed to rational.
=encapsulated.= Inclosed in a sheath or capsule.
=encysted.= Encapsuled; surrounded by a closed membrane.
=endarteritis.= Inflammation of the inner coat of an artery.
=endemic.= Noting a disease common to a region.
=endo.= A prefix signifying within. (Exam. endotoscope--a form of ear
speculum).
=endosmosis.= Osmosis in a direction towards the interior of a cavity.
=endothelium.= A layer of flat cells lining serous cavities, blood
vessels, etc., and cavities not exposed to the air.
=enervation.= Failure of nerve force.
=engorgement.= Distension with fluid or other material; congested.
=enucleate.= To remove in its entirety.
=epidemic.= Noting a disease which attacks, nearly simultaneously, a
large number of people in a community.
=epidermis.= The epithelial layer of the skin; the scarf skin or outer
skin.
=epithelioid.= Resembling epithelium.
=epithelioma.= A cancerous growth originating from squamous epithelium.
=epithelium.= The purely cellular, non-vascular layer covering all
cavities and surfaces exposed to the air, such as the epidermis, mucous
membrane, etc.
=eponychium.= The skin adherent to the nail at its root; the nail skin.
=eradicated.= Removed.
=ergot.= Spurred rye, rye smut; a drug made from rye.
=erosion.= A wearing away.
=erysipelas.= An acute spreading inflammation of the skin and
subcutaneous tissues.
=erythema.= A redness of the skin; rose-rash.
=erythematous.= Relating to or marked by redness.
=eschar.= A slough following a burn or cauterization of the skin.
=escharotic.= Caustic, corrosive; an agent producing an eschar.
=Esmarch’s bandage.= A rubber bandage wound tightly about a limb in
order to exsanguinate the member preparatory to offering a bloodless
field for operation.
=essence of geranium.= A solution of the volatile oil of geranium.
=essence of thyme.= A solution of the volatile oil of thyme.
=ether.= An organic oxide, more especially ethyl ether
(C_{2}H_{5})_{2}O.
=ethics.= The principles of correct professional conduct as they relate
to the public, to the practitioner, and to his fellow-practitioners.
=ethyl bromide.= A colorless liquid employed as a local anesthetic.
=ethyl chloride.= A colorless liquid employed as a local anesthetic, by
spraying.
=ethylate of soda.= A reddish yellow powder, employed in aqueous
solution in the treatment of lupus and other skin diseases.
=etiology.= The causes of disease.
=eucalyptol oil.= Oleum eucalypti; an oil distilled from the leaves of
the Eucalyptus globulus.
=evaporate.= To change from liquid to vapor form.
=evaporation.= A change from liquid to vapor form.
=eversion.= A turning outward.
=ex.= A prefix denoting out of, from, away from. (Exam. excision--to
cut out).
=excavator.= A spoon-shaped instrument used to scrape out pathologic
tissue.
=excision.= The operative removal of a limb, organ or other part.
=excrementitious.= Relating to any cast-out waste material.
=excrescence.= Any outgrowth from the surface, especially a pathologic
growth.
=excretion.= The process whereby the waste material is thrown out of
the body.
=excretory.= Relating to excretion.
=exfoliate.= To strip off in layers or sheets, noting especially a form
of desquamation.
=exostosis.= A bony tumor springing from the surface of a bone.
=expansion.= Spreading out; an increase in size.
=exsanguinate.= To make bloodless.
=exsiccant.= A dusting or drying powder.
=extension.= The act of extending a limb; the position of a limb that
is extended.
=extr. cannabis indica.= A soft solid (Indian hemp) of blackish-green
color.
=extravasated.= Exuded from, or passed out of a vessel into the tissues.
=exuberant.= Copious, plentiful, as exuberant granulations.
=exudate.= To exude; a fluid, or formed elements of the blood, which
enters the tissues or any cavity.
F
=F.= Abbreviation for Fahrenheit temperature.
=fabella.= One of two small fibro-cartilages or sesamoid bones in the
tendons of the gastrocnemius muscle.
=fabric.= The structure of anything.
=fabrics.= Materials constructed for manufacturing purposes.
=facet.= A small smooth area on a bone or other firm structure.
=Fahrenheit scale.= The degree markings on the F. thermometer in which
the freezing point is 32° and the point of boiling water is 212°.
=faradic.= Relating to induced electricity.
=fasciculi.= Small bands or bundles of fibres, usually of muscle or
nerve tissue.
=fascia.= A sheet of fibrous tissue enveloping the body beneath the
skin and also enclosing the muscles.
=fatty degeneration.= A retrogressive change associated with
the appearance of fat in the cells and formed within them. =f.
infiltration.= A deposit of fat in abnormal quantity between and in the
cells, and not formed within them.
=felon.= Paronychia, inflammation around the nail. Whitlow.
=felt.= Matted wool, unwoven. Used for podiatry dressings.
=femur.= The thigh bone.
=fermentation.= A chemical change induced in an organic compound by the
action of a ferment.
=ferrum.= The metal iron; the basic ingredient of tincture of the
subsulphate of iron.
=festination.= The peculiar acceleration of gait noted in paralysis
agitans and some other nervous affections.
=fetid.= Foul-smelling; having a rank odor.
=fibre.= A filamentous element; an elongated cell or cell process.
=fibrillae.= Minute fibres.
=fibrin.= An elastic filamentous substance derived from the blood after
coagulation.
=fibroblast.= A cell produced by the connective tissue in the formation
of fibrous tissue.
=fibula.= The external and smaller of the two bones of the leg.
=filament.= A fibril, a fine fibre, or thread-like structure.
=fish skin.= A preparation used as a covering to wounds, etc.; a
substitute for oil-silk.
=fissure.= A furrow, cleft or slit.
=fistula.= A sinus leading from an abscess cavity to the surface.
=flaccid.= Relaxed; flabby; without bone.
=flail-like.= Resembling an instrument used for thrashing or beating.
=flat foot.= Pes planus; a foot in which the arch is sunken.
=flax-seed.= Linseed. Used in making poultices.
=flexion.= Bending; bending of a joint so as to approximate the parts
they connect.
=fluctuation.= A wave-like motion felt on palpating a cavity containing
fluid.
=fluffy.= Feathery.
=fluoroscope.= An apparatus for rendering visible the effects of the
X-rays.
=fluoroscopy.= Examination of the inner parts of the body by means of
the fluoroscope.
=flux.= Flow of electricity or other substance.
=focal infection.= An infectious process which starts at a point remote
from the part where the symptoms manifest themselves.
=follicle.= A simple tubular gland.
=fomentation.= The application of warmth and moisture in the treatment
of disease; poulticing.
=foot.= Pes; the lower, pedal, extremity of the leg.
=forceps.= An instrument for seizing anything and for making
compression or traction.
=formaldehyde.= An antiseptic gas with a pungent odor. The water
solution, formalin, is used in podiatry.
=fracture.= A break, especially of a bone.
=friction.= Rubbing.
=Friedreich’s ataxia.= Hereditary spinal ataxia.
=frost bite.= Inflammation of the skin and deeper tissues due to
exposure to severe cold. Chimatlon severe.
=fulguration.= Lightning stroke. Treatment of tumors by means of the
sparks of the high frequency current.
=function.= The special action or physiologic property of a part.
=fusiform.= Spindle-shaped; tapering at both ends.
=fusion.= Liquefaction by heat; melting.
G
=G.= Abbreviation for gram.
=gait.= Specific manner of walking; manner of stepping.
=gallic acid.= A yellowish-white substance used as an astringent.
=gallstone.= A concretion, chiefly of cholesterin, formed in the gall
bladder or bile-duct.
=galvanic.= Constant current electricity produced by chemical action.
=gangrene.= Death of the soft tissues, en masse.
=gas gangrene.= Gangrene caused by the bacillus of Welch; gaseous
gangrene.
=gastric.= Relating to the stomach.
=gastrocnemius.= One of the calf muscles.
=gastro-intestinal.= Referring to the stomach and the intestines.
=gauze.= A thin loose-meshed cloth employed for dressings, bandages,
etc.
=genitalia.= The genitals.
=genu.= The knee.
=germ.= A rudiment. A microbe.
=germicide.= An agent which destroys germs or microorganisms.
=ginglymus.= A hinge joint.
=glands.= Secreting organs or excreting organs, such as the sebaceous
or sweat glands.
=gliomatous.= Relating to a tumor formed of the nerves of the brain and
spinal cord.
=glucose.= Grape sugar.
=gluteal.= Relating to the buttocks.
=glycerin.= Glycerinum; a sweet, oily fluid obtained by the
saponification of fats and fixed oils.
=golfer’s foot.= A painful condition of the dorsum of the foot.
=gomenol.= A germicidal, ethereal oil obtained from a plant.
=gonococcus.= The specific organism causing gonorrhea.
=gonorrheal heel.= A focal infection of the heel caused by an original
urethral infection with the gonococcus.
=Goulard’s extract.= A solution of lead subacetate.
=gout.= A disease of metabolism characterized by recurrent attacks of
arthritis, particularly in the metatarsophalangeal joint of the great
toe, though any joint may be attacked, by deposits of sodium biuret
in and around the affected joints, and by inflammation of fibrous
structures elsewhere (Stedman).
=grain.= A unit of weight, ¹⁄₆₀ dram.
=gram=, =gramme=. A unit of weight equal to 15.4 grains.
=granulation.= The formation of minute, rounded, fleshy projections on
the surface of a wound in the process of healing.
=gross.= Large, coarse, macroscopic in contradistinction to microscopic.
=growth.= The increase in size of a living being or any of its parts.
=gt.= (plural gtt.). Abbreviation of drop or drops.
=gumma.= An infectious granuloma, the characteristic lesion of late or
tertiary syphilis.
=guncotton.= Pyroxylin.
=gutta percha.= The dried milky juice of a Malay tree.
=gypsum.= Calcium sulphate. =Dried g.= Calcii sulphas exsiccatus,
plaster of Paris.
H
=hair follicle.= A cylindrical pit dipping down through the corium and
containing the root of the hair.
=hallux.= The great toe; the first digit of the foot.
=hallux dolorosus.= Painful toe.
=hallux flexus.= Hammer toe.
=hallux rigidus.= Stiff toe.
=hallux valgus.= A deformity in which the great toe is bent outwards.
=hallux varus.= Deviation of the great toe to the inner side of the
foot away from its neighbor.
=hammer toe.= A condition of permanent flexion of the mid-phalangeal
joint of one or more of the toes; hallux flexus.
=heloma (plural, helomata).= Corn; clavus; an overgrowth of the
epidermis, with a central core or nucleus.
=heloma durum.= Hard corn.
=heloma miliare.= Seed corn.
=heloma molle.= Soft corn.
=heloma neurofibrosum.= Corn containing nerve fibres.
=heloma vasculare.= Vascular corn.
=helosis.= The condition of having heloma.
=helotomeia.= The surgery of helomata.
=helotomon.= The knife for cutting helomata.
=hematidrosis.= The excretion of sweat stained with blood.
=hematocele.= A blood cyst; hematocist.
=hemi.= A prefix signifying one-half. (Exam. hemiplegia--half
paralysis).
=hemichorea.= Chorea involving the muscles of one side, only.
=hemiplegia.= Paralysis of one side of the body.
=hemoglobin.= The coloring matter of the blood.
=hemorrhage.= Bleeding; a flow of blood.
=hemorrhoids.= Piles; a varicose condition of the external hemorrhoidal
veins causing painful swellings at the anus.
=hemostatic.= Arresting hemorrhage; styptic.
=hereditary.= Transmitted from parent to offspring.
=hermetically.= In an air-tight manner; noting a vessel closed or
sealed in such a way that air can neither enter it nor issue from it.
=hidrosis.= Sweating, especially heavy sweating; hyperidrosis;
sudoresis.
=high frequency.= An electric current with a high voltage, and a rapid
change in direction from one pole to the other.
=hirsute.= Hairy; pertaining to hair.
=histology.= The branch of anatomy which deals with the cells and the
minute structure of the tissues; microscopic anatomy.
=homogeneous.= Of uniform structure or composition throughout.
=homo heloticus.= The person having helomata.
=hone.= A flat stone or a piece of leather used to sharpen knives.
=hookworm.= A worm of the genus ankylostoma or uncinaria.
=hornification.= Conversion into horn; cornification.
=Huntington’s chorea.= Hereditary chorea.
=hydrocephalus.= A condition, usually congenital, marked by an
extensive effusion of serum into the cerebral ventricles.
=hydrochloric acid.= See acidum.
=hydrogen.= An odorless, colorless, tasteless gaseous element, the
lightest substance known.
=hydro-therapeutics.= The treatment of disease by the use of water, in
a scientific way; hydrotherapy.
=hygiene.= The science of health.
=hyper.= A prefix denoting excessive. (Exam. hyperidrosis--excessive
sweating).
=hyperemia.= The presence of an increased amount of blood in a part;
congestion.
=hyperesthesia.= Excessive sensibility to touch, to pain or to other
sensory stimuli.
=hyperidrosis.= Hyperhidrosis; excessive sweating.
=hyperporosis.= Excessive formation of callus after fracture of a bone.
=hypertonicity.= A greater degree of tension.
=hypertrophy.= Overgrowth; general increase in a part, not due to tumor
formation.
=hypodermatic.= Hypodermic; under the skin.
=hysteria.= A chronic neurosis or psycho-neurosis, characterized by
disorders of the will, and partial cessation or exaltation of the
individual functions of the brain.
I
=iasis.= See osis.
=ichnogram.= An imprint of the soles of the feet, showing a series of
steps.
=ichorous.= Relating to a thin watery discharge from an ulcer.
=ichthyol.= Ichthyolum; a brownish oil, used in medicine and in
podiatry because of the sulphur (from fossil fish) which it contains.
=ichthyosis.= A congenital rough skin due to hypertrophy of the horny
layer of the epidermis with diminished sweat and sebaceous secretion;
fish-skin disease.
=idiopathic.= Noting a primary disease, one originating without
apparent extrinsic cause.
=idiosyncrasy.= An individual mental or physical characteristic or
peculiarity.
=immersion.= The placing of a body under water or other liquid.
=immobility.= Incapability of moving; the fixed position of a part.
=immune.= Free from the possibility of infection.
=impacted.= Pressed closely together so as to be immovable as in
=impacted= fracture.
=impermeable.= Impervious.
=impervious.= Impassable, impenetrable, to fluids.
=impingement.= Used in podiatry to denote the pinching of tissues
between two adjacent or opposite bones or muscles.
=incipient.= Just beginning.
=incision.= A cut; a division of the soft parts made with a knife.
=incompatible.= Not capable of being mixed without undergoing radical
changes.
=incoordination.= Lack of harmonious action, as of muscles.
=indentation.= The act of notching or pitting.
=indolent.= Inactive; sluggish; painless, or nearly so.
=induction.= Production or causation.
=induction coil.= An apparatus for the induction of a secondary
electric current.
=induration.= Hardening.
=inert.= Slow in action, sluggish.
=infant.= A child during the first two years of life; a babe.
=infection.= Invasion by living pathogenic bacteria of a part of the
body where conditions are favorable to their growth and whence they act
injuriously upon the tissues.
=infiltration.= The act of passing into or interpenetrating a cell or
tissue; said of gases and fluids.
=inflammation.= The reaction of the tissues against injury or bacterial
invasion, characterized by heat, redness, pain, swelling and impaired
function.
=inflation.= Distension of a part by a gas or a liquid.
=inflection.= An inward bending.
=influenza.= The grip; an acute infectious disease caused by Pfeiffer’s
bacillus.
=in-footed.= Pigeon-toed; standing or walking with toes turned in.
=ingrown toe nail.= Onychocryptosis.
=inhibition.= The diminution or arrest of function in an organ.
=injection.= The introduction of a substance in fluid form into the
tissues or cavities of the body.
=innervation.= Distribution of the nerves in a part.
=innocuous.= Harmless.
=inoculate.= To introduce the virus of a disease into the tissues or
blood vessels.
=in situ.= In position.
=instep.= The arch, or highest part of the dorsum of the foot.
=instrument.= A tool or implement.
=integument.= The enveloping membrane of the body; the skin.
=inter.= A prefix denoting between or among. (Exam.
interdigital--between the fingers or toes).
=intercellular.= Between or among cells.
=interosseous.= Between bones.
=interphalangeal.= Between the phalanges.
=intertrigo.= Dermatitis occurring between two folds of the skin.
=intestinal.= Relating to the intestine or belly.
=intima.= The inner coat of a blood vessel.
=intoe.= Hallux valgus.
=intoxication.= Acute alcoholism; drunkenness.
=inunction.= The administration of a drug in ointment form by rubbing
it into the skin.
=inversion.= Bending inward.
=involuntary.= Independent of the will; not volitional.
=involution.= The return of an enlarged organ to normal size.
=iodine.= A non-metallic element occurring in lustrous steel-gray
crystals, soluble in water and alcohol and used externally as a
counter-irritant and antiseptic.
=iodoform.= Iodoformum; a yellow crystalline powder having a strong,
disagreeable odor; employed as an antiseptic dusting powder to wounds
and syphilitic sores.
=ions.= A group of atoms carrying an electric charge.
=irritation.= Extreme reaction of the tissues to an insult or injury;
incipient inflammation.
=ischemia.= Local anemia due to mechanical obstruction of the blood
supply.
=ischidrosis.= Suppression of the perspiration.
=ist.= An affix denoting an agent. (Exam. podiatrist).
=itis.= A suffix grown to mean inflammation of. (Exam.
osteitis--inflammation of bone).
J
=jaborandi.= See pilocarpin.
=joint-capsule.= Capsular ligament of a joint.
=joint-muscle.= A muscle which causes motion at a joint.
K
=kakidrosis.= Bromidrosis.
=keloids.= Lesions of a skin disease marked by patches of a whitish
color surrounded by a purplish border.
=keratin.= A scleroprotein present in hair, in nails, in horn, etc.
=keratogenesis.= The production of horny cells or tissue.
=keratohyalin.= Eleidin.
=keratoma.= A horny tumor.
=keratosis.= Circumscribed overgrowth of horny tissue.
=kilogram.= One thousand grams weight.
=kinesiatrics.= The therapeutic employment of movements; movement-cure.
=kinetic.= Relation to motion or muscular movements.
=Kneipp method.= The treatment of disease by water; hydrotherapy.
=knock-knee.= Genu valgum.
=kolionychia.= Spoon-nail; a malformation of the nails in which the
outer surface is concave.
=Korsakoff’s disease.= Polyneuritic psychosis.
=kyllosis.= Club-foot.
L
=labyrinthine.= Perplexing, intricate, involved.
=laceration.= A tear or torn wound.
=laity.= Non-professional persons.
=lamb’s wool.= A material used in shielding.
=lamelia.= In osteology, a thin sheet or scale of bone.
=lancet.= A surgical knife with a short, sharp pointed, two-edged blade.
=lancinating.= Noting a sharp cutting or tearing pain.
=Landry’s disease.= Acute ascending paralysis.
=Langerhans’ cells.= Star-shaped cells in the deeper part of the
stratum germinativum of the epidermis.
=lanolin.= An oily substance extracted from the wool of sheep; adeps
lanae.
=larynx.= The organ of voice production.
=larvae.= The worm-like forms of insects on issuing from the egg.
=Lassar’s paste.= An ointment containing salicylic acid, talcum, zinc
oxide and vaseline; it is used for eczema.
=lateral.= On the side, as distinguished from medial.
=lathyrism.= Lupinosis; poisoning by flour adulterated with chick-pea.
=lead.= A metallic element.
=lead and opium wash.= A solution of lead acetate and tr. opium in
water; used to allay pain.
=lead neuritis.= Inflammation of the nerves, due to poisoning by lead.
=lead palsy.= Paralysis of the extensor muscles of the wrist, due to
poisoning by lead; wrist drop.
=leprosy.= A chronic disease believed to be due to the presence of
the bacillus leprae, or Hansen’s bacillus. It occurs in two forms;
tubercular, affecting the skin; anesthetic, affecting the nerves.
=lesion.= A more or less circumscribed pathologic change in the tissues.
=lethal.= Fatal, mortal, causing death.
=leucocyte.= A white blood cell.
=leuconychia.= The occurrence of white spots or patches under the nails.
=leucorrhea.= A discharge from the vagina of a white, viscid fluid
containing mucous and pus cells.
=leverage.= The mechanical power gained by using a lever.
=lichen planus.= A skin disease occurring on the soles of the feet.
=ligaments.= Bands of fibrous tissue connecting two or more bones.
=ligation.= The application of a ligature.
=ligature.= A thread, wire or piece of catgut, tied tightly around a
blood vessel, a pedicle or a tumor in order to constrict it.
=limewater.= A solution of calcium hydroxide.
=line of demarcation.= A zone of inflammatory reaction separating a
healthy from a gangrenous area.
=liniment.= A solution of a medicament in mucilage, starch or other
substance, in combination with the white of egg.
=linseed.= Flaxseed; used in making poultices.
=lint.= A soft, absorbent material used in surgical dressings.
=lipoma.= A tumor of fatty tissue.
=liquor ferri subsulphate.= Monsel’s solution.
=liquor potassae.= A 5% solution of potassium hydroxide.
=lisle.= A material woven from cotton and silk.
=liter.= A measure of capacity equal to a trifle over a quart; 1000
cubic centimeter.
=lithemia.= The presence of uric acid, in excess, in the blood.
=Lobstein’s disease.= Constitutional fragility of the bones, fractures
being produced by slight injuries.
=locomotion.= Movement from one place to another.
=longitudinal.= Running lengthwise; in the direction of the long axis
of the body.
=lordosis.= Curvature of the spine with the convexity looking
anteriorally.
=lues.= A plague or pestilence; specifically, syphilis.
=luetin skin reaction.= The reaction of the skin in a specific test for
syphilis.
=lumen.= The space in the interior of a tubular structure, such as an
artery.
=lunula.= The opaque whitish semi-lunar area near the root of the nail.
=lycopodium.= Vegetable sulphur. A yellow tasteless powder used as a
dusting powder.
=lymphangitis.= Inflammation of the lymphatic vessels.
=lymph.= A clear light, straw-colored fluid, which circulates in the
lymph spaces or lymphatic vessels of the body.
=lymphatics.= A series of vessels acting as auxiliaries to the venous
system, and containing the lymph.
=lysis.= The gradual subsidence of the symptoms of an acute disease.
=lysol.= Trade name of a mixture of soaps and phenols, used as a
disinfectant dressing and hand-wash.
M
=M.= Abbreviation for (1) mille, a thousand; (2) in prescriptions, for
misce, mix; (3) minim, a drop; (4) meter, French measure.
=macerate.= To soften by soaking or steeping.
=maceration.= Softening by the action of a liquid.
=mackintosh.= A waterproof cloth or tissue used for surgical dressings.
=macrodactylism.= Abnormal size of a finger or of a toe.
=macroscopic.= Observable to the naked eye, in contradistinction to
microscopic.
=maculae.= Small spots or patches on the skin, not elevated above the
general surface.
=Madura foot.= Mycetoma; a disease occurring in the East Indies,
characterized by large subcutaneous tubercles and nodules which break
down and discharge pus.
=mal.= A prefix meaning bad. (Exam. malposition--bad position).
=malalignment.= Not in normal position.
=malaria.= A disease caused by the presence of a protozoan parasite
(plasmodium) of the red blood cells.
=malignant.= Resistant to treatment; occurring in severe form; tending
to grow worse, and (in the case of a tumor) to recur after removal. Not
benign.
=malingerer.= One who feigns disease.
=malpractice.= Mistreatment of a patient’s ills through carelessness,
ignorance or criminal intent.
=malleolus.= One of the two rounded prominences on either side of the
ankle joint.
=manicure.= To care for the hands and finger-nails, cosmetically.
=marasmus.= Extreme emaciation occurring in children.
=massage.= A scientific method of manipulation of the body by rubbing,
pinching, kneading, tapping, etc.
=masseur.= A male who massages.
=masseuse.= A female who massages.
=massotherapy.= The therapeutic uses of massage.
=materia medica.= The branch of medicine which treats of the origin,
preparation, doses and modes of administration of drugs.
=matrix.= The formative portion of a nail.
=maximum.= The highest limit, the greatest amount possible in
contradistinction to minimum, the least limit.
=M.Cp.= Abbreviation of Master of Chiropody.
=mechanotherapy.= Treatment of disease by means of apparatus or
mechanical appliances.
=medicament.= A medicine; a remedy.
=medicine.= The art of preventing or curing disease. A drug.
=medullated.= Having a soft marrow-like structure, especially in the
centre of a part.
=megalodactylism.= Abnormal size of a finger or toe.
=membrana propria.= The basement layer of the epidermis, and separating
it from the true skin.
=membrane.= A thin sheet or layer of tissue serving as a covering or
envelope of a part.
=meningeal.= Relating to the meninges or membranous envelope of the
brain and spinal cord.
=menthol.= A camphor obtained from oil of peppermint.
=mercuric chloride.= Corrosive sublimate.
=mercury.= An element (quicksilver), compounds of which are used in
podiatry.
=metabolism.= Tissue change, the sum of the chemical changes whereby
the function of nutrition is regulated.
=metacarpal.= Referring to the long bones of the hand between the
carpus and the phalanges.
=metacarpophalangeal.= Relating to the metacarpus and the phalanges.
=metamorphosis.= A change in form, structure, or function.
=metastasis.= The shifting of a disease from one part of the body to
another.
=metatarsal.= Relating to the bones in front of the tarsus, and called
the metatarsal bones; they are five in number.
=metatarsalgia.= Pain in the metatarsal region.
=metatarsophalangeal.= Between the metatarsal and phalanx.
=meter.= A measure of length the equivalent of 39.4 inches.
=methyl.= The radical of wood alcohol.
=methylene blue.= A compound of methylene, used as a caustic in
treating verruca.
=microbe.= A minute one-celled creation, animal or vegetable; a
microorganism.
=microorganism.= A microscopic plant or animal, a bacterium or
protozoan.
=microscopic.= Of minute size, visible only through a microscope; the
reverse of macroscopic.
=miliaria.= An eruption of minute vesicles due to retention of fluid at
the mouth of the sweat glands.
=miliary.= Representing a millet seed in size.
=milligram.= One-thousandth of a gram--1-65 grain.
=milliliter.= One-thousandth of a liter--about 15 minims.
=millimeter.= One-thousandth of a meter 1-25 inch.
=milliampere.= An electric unit of current-strength, the thousandth of
an ampere.
=milliamperemeter.= An instrument used for measuring milliamperes of
electric current.
=millet seed.= A small seed of the millet plant; a grain.
=minim.= One-sixtieth of a fluid drachm, equivalent to about one drop
of water.
=misce.= Mix; the character which directs the druggist to mix the
ingredients of a prescription.
=mistura.= A pharmacal mixture.
=mobility.= The quality of being movable.
=molecular.= Relating to the smallest possible unit of existence of any
substance.
=moleskin.= An adhesive substance used in shielding.
=mollifying.= Calming; softening.
=mono.= A prefix denoting the participation of a single element or
part. (Syn. uni). (Exam. monodactyl--a single finger or toe).
=Monsel’s solution.= Liquor ferri subsulphatis.
=morbid.= Diseased; pathologic.
=morphine.= The chief active principle of opium.
=morphologic.= Relating to the structure of the tissues of the body.
=morphology.= The science which treats of the external configuration or
the structure of animals and plants.
=Morton’s disease.= Morton’s neuralgia.
=Morton’s neuralgia.= A pain in the metatarsophalangeal joint of the
fourth toe; also called Morton’s toe.
=motile.= Having the power of spontaneous movement.
=mucous.= Relating to mucous or to the mucous membrane (m. membrane),
a membrane which secretes mucus, and lines the cavities connected with
the outer air.
=multiple.= Occurring in several parts at the same time.
=mummification.= Dry gangrene, shriveling.
=muscle.= One of the contractile organs of the body, by which the
movements of the various organs and parts are effected.
=muscle-corpuscle.= The nucleus of a muscle-fiber.
=muscle-fiber.= One of the cylindrical fibers, an inch or more in
length and about 1-500 inch in diameter, composing voluntary muscle
tissue.
=muscle-plasma.= The fluid portion of muscle tissue.
=musculature.= The arrangement of the muscles in a part or in the body
as a whole.
=musculus.= Muscle. Important muscles of the foot.
=m.= Abductor hallucis.
=m.= Abductor obliquus hallucis.
=m.= Adductor transversis hallucis.
=m.= Extensor digitorum brevis.
=m.= Extensor digitorum longus.
=m.= Extensor hallucis longus.
=m.= Flexor accessorius.
=m.= Flexor brevis hallucis.
=m.= Flexor brevis minimi digiti.
=m.= Flexor digitorum brevis.
=m.= Flexor digitorum longus.
=m.= Flexor hallucis longus.
=m.= Gastrocnemius.
=m.= Interosseous dorsalis.
=m.= Interosseous plantaris.
=m.= Lumbricalis (4).
=m.= Peroneus brevis.
=m.= Peroneus longus.
=m.= Peroneus tertius.
=m.= Plantaris.
=m.= Soleus.
=m.= Tibialis anticus.
=m.= Tibialis posticus.
=mustard.= The dried, ripe seeds of the white or black mustard plant.
=mycetoma.= Madura foot; a disease of the foot occurring in the East
Indies.
=myelitis.= Inflammation of the spinal cord, or of the bone marrow
(osteomyelitis).
=myeloma.= A tumor due to hyperplasia of the bone marrow.
=myocellulitis.= Inflammation of muscle and cellular tissue.
=myoclonia.= Any disorder characterized by muscular twitching.
=myocyte.= A muscle cell.
=myodynia.= Muscle pain; myalgia.
=myology.= The branch of science which deals with muscles and their
accessory parts.
=myositis.= Muscle inflammation.
=myotonia.= Any disorder characterized by tonic spasm or temporary
rigidity of a muscle.
N
=naevus.= A congenital mark or discolored patch of the skin; a mole.
=nafalan.= A proprietary remedy containing Caucasian naphtha in a soap
base.
=nail.= Unguis; the horny plate covering the dorsal surface of the
distal half of the terminal phalanx of each finger and toe.
=nail bed.= A portion of the distal phalanx covered by the nail.
=nail fold.= A groove in the skin in which lie the margins and the
proximal edge of the nail.
=nail groove.= A groove in the distal phalanx in which the nail lies.
=nail plate.= The horny substance which makes up the nail proper.
=nanomelous.= Having very small extremities.
=narcosis.= Stupor or general anesthesia produced by some narcotic drug.
=narcotic.= Relating to or causing narcosis; an agent which produces
narcosis.
=navicular.= One of the bones of the tarsus of the foot.
=nebulizer.= An atomizer; a vaporizer; an apparatus for throwing a
liquid in a fine spray.
=necrosis.= Local death; the death of more or less extensive groups of
cells.
=neo.= A prefix noting new or recent. (Exam. neoplasm--new growth).
=neoplasm.= A new growth; tumor.
=nephritis.= Inflammation of the kidney.
=nerve.= A collection of fibres in the form of a whitish cord through
which stimuli are transmitted from the central nervous system to the
periphery, or the reverse.
=nervousness.= A condition of unrest and of irritability to the nervous
system.
=nervus.= Nerve; a whitish cord made up of nerve fibres.
=nerves of the foot=:
=n.= musculocutaneus; musculo-cutaneous nerve (dorsal surface
and in front of leg).
=n.= plantaris externus; external plantar nerve (plantar
surface).
=n.= plantaris internus; internal plantar nerve (plantar
surface).
=n.= saphenus externus; external saphenous nerve (dorsal
surface and in front of leg).
=n.= tibialis anticus; anterior tibial nerve (dorsal surface
and in front of leg).
=n.= tibialis posticus; posterior tibial nerve (back of leg).
=neuralgia.= Nerve-pain; pain of a severe, throbbing or stabbing
character in the course of a nerve.
=neurasthenics.= Those suffering from neurasthenia, or nervous
exhaustion.
=neuritis.= Inflammation of the nerves.
=neuro-fibrous.= Containing nerve fibres; said of an heloma.
=neuroma (plural neuromata).= A tumor made up of nerve tissue.
=N. F.= Abbreviation for National Formulary, a book issued by the
American Pharmaceutical Association containing formulas of preparations
not official in the Pharmacopeia.
=nitric acid.= HNO_{3}. Employed as a caustic for verrucæ.
=nodule.= A small node or circumscribed swelling.
=Noguchi test.= A test for tabes dorsalis depending upon an albumin
reaction of the spinal fluid; a test for syphilis--a modification of
the Wassermann test.
=non.= A latin prefix denoting a negation or absence of the quality or
fact expressed in the word to which it is prefixed.
=non-medullated.= Without a medulla or medullary substance.
=non-striated.= Without stripes or bands.
=normal.= Typical; usual; healthy.
=nostrum.= A quack remedy.
=novocaine.= A synthetic local anesthetic.
=noxious.= Injurious; harmful.
=nucleus.= The centre of functional activity of a cell; the central
portion of an heloma.
=nutrient.= Carrying nourishment.
O
=obesity.= An abnormal increase of fat in the subcutaneous connective
tissues; corpulence; fatness; general adiposis.
=obliterated.= Destroyed by the effects of time; effaced.
=occlusive.= Noting a dressing which excludes the air.
=official.= Authoritative; noting a drug or chemical found in the
Pharmacopeia.
=ohm.= The unit of electric resistance.
=oid.= A suffix denoting resemblance to the thing indicated by the
other part of the word. (Exam: osteoid--resembling bone).
=oil stone.= A hone upon which oil is used.
=oiled silk.= A waterproof substance used in surgical dressings.
=ointment.= A medicated fatty mixture with the consistency of butter,
and employed externally.
=oligodactylia.= A deformity marked by fewer than five fingers or toes
on each hand or foot.
=ology.= A suffix denoting a special branch of study. (Exam:
podology--the branch of medical science which has to do with the feet
in all their relations).
=oma.= A suffix noting a tumor or neoplasm. (Exam: neuroma--a nerve
tumor).
=onychatrophia.= Atrophy of the nails.
=onychauxis.= Hypertrophy of the nails.
=onychia (onychitis).= Inflammation of the nail bed or matrix.
=onychocryptosis.= Ingrown toe nail.
=onychogryphosis.= Hypertrophy of the nails with curvature or deformity.
=onychoid.= Resembling a nail in structure or in form.
=onycholysis.= Loosening or shedding of the nails.
=onychoma.= A tumor arising from the nail bed.
=onychomalacia.= Absence of rigidity of the nails; hapalonychia.
=onychomycosis.= Any parasitic disease of the nails, such as tinea or
favus.
=onychotrophy.= Nutrition of the nails.
=onychopathy.= Any disease of the nails; onychosis.
=onychophag.= A victim of the nail-biting habit.
=onychophosis.= Calloused nail groove.
=onycophyma.= Swelling or hypertrophy of the nails.
=onychoptosis.= Falling off of the nails.
=onychorrhexis.= Brittle nails.
=onyx.= The greek word for finger-nail or toe nail.
=oozing.= Flowing slowly; gradually escaping.
=operation.= Any surgical procedure.
=opisthotonos.= A tetanic spasm in which the spine and extremities are
bent with convexity forward, the body resting on the head and heels.
=organ.= Any part of the body exercising a specific function.
=origin.= The less movable of the points of attachment of a muscle.
=orthoform.= A white crystalline powder used as a local anesthetic and
antiseptic.
=orthopedics.= A branch of surgery which has to do with the treatment
of chronic diseases of the joints and spine, and the correction of
deformities.
=orthopedist.= One who practices orthopedics; orthopaedist.
=os.= A bone.
=os calcis.= The calcaneus; the heel bone.
=oscillate.= To vibrate.
=osis.= A suffix noting an Increase. (Exam. tuberculosis--an increase
in tubercles).
=osmidrosis.= (See bromidrosis).
=osmosis.= The passage of certain fluids through an animal membrane or
other porous substance.
=ossification.= The formation of bone.
=ossiferous.= Containing bone.
=ostealgia.= Bone pain.
=osteanabrosis.= Bone atrophy.
=osteanaphysis.= Bone reproduction.
=osteotomy.= Surgical removal of bone.
=osteitis.= Bone inflammation.
=osteoarthritis.= Inflammation of the articular extremity of a bone
involving the contiguous joint structure.
=osteochondritis.= Inflammation of a bone and its cartilage.
=osteogenesis.= The formation of bone.
=osteoma.= A bone tumor.
=osteomyelitis.= Inflammation of the bone marrow.
=osteopsathyrosis.= Bone fragility; fragilitas ossium.
=osteotomy.= Bone cutting, usually by means of a saw or a chisel.
=ounce= (abr. oz.). A weight containing 48.0 grains, apothecaries’
weight.
=oxidation.= A combination with oxygen.
=oxygen.= A gaseous element, symbol, O.
=ozone.= A condensed form of oxygen, containing three atoms in a
molecule.
P
=pachyacria.= A bulbous thickening of the extremities of the fingers or
toes.
=pachydactylous.= Abnormal thickness of fingers or of toes.
=pachydermia.= Elephantiasis.
=pachypodous.= Having large thick feet.
=pacinian.= Named after Filippo Pacini, an Italian anatomist, and
noting especially the Pacinian body or corpuscle found in the skin, and
which is a touch organ.
=palliative.= Mitigating; reducing the severity of; noting a method of
treatment of a disease or of its symptoms.
=pallor.= Paleness.
=palpate.= Examining by feeling and pressing with the palms of the
hands and with the fingers.
=pan.= A prefix implying all, entire. (Exam: panhidrosis--perspiration
of the entire body).
=panaris.= Paronychia.
=papilla.= A conical elevation found beneath the epidermis, and
containing capillary loops and nerve endings.
=papillary layer.= The outer connective tissue layer of the true skin,
and made up of numbers of papillæ.
=papilloma.= A circumscribed overgrowth or hypertrophy of the papillæ
of a cutaneous or mucous surface.
=papoid.= A digestive enzyme from the fruit of the pawpaw, resembling
papain.
=papule.= A small circumscribed elevation of the skin containing no
fluid; a pimple.
=papulosquamous.= Relating to both papules and scales.
=para.= A prefix denoting (1) a departure from normal; (2) an
involvement of like parts. (Exam: (1) parachroma--abnormal coloration
of the skin or other parts; (2) paraplegia--paralysis of both lower
extremities).
=paraffin.= A white solid hydrocarbon, having the consistency of wax.
=paralysis.= Palsy; loss of power of voluntary movement in a muscle
through injury or disease of its nerve supply; loss of any function.
=paralysis agitans.= Parkinson’s disease; shaking palsy; a disorder
marked by muscular weakness, stiffness and tremor.
=paralysis, pseudo-bulbar.= Paralysis of the lips and tongue due to a
cerebral lesion.
=paralyzant.= Causing paralysis; any agent causing paralysis.
=paramyoclonus multiplex.= An affection characterized by sharp,
frequently repeated clonic, muscular contractions.
=paraplegia.= Paralysis of both lower extremities and also of more or
less of the trunk.
=parasite.= An animal or vegetable organism which lives on or in
another from which it draws its nourishment.
=parasiticide.= Destructive to parasites.
=paresis.= Cortical paralysis.
=paresthesia.= An abnormal sensation, such as burning, pricking,
numbness, etc.
=paretic.= Relating to, or suffering from paresis.
=paronychia.= Inflammation of the tissues around the nail, felon;
panaris; whitlow.
=parresine.= A paraffin preparation used for burns.
=passive.= Not active.
=pathogenic.= Causing disease.
=pathognomonic.= Characteristic of a disease, noting certain typical
symptoms.
=pathology.= The science that deals with the change in function or in
structure of an organ or tissue in a diseased state.
=pedal.= Relating to the feet.
=pedarthrocace.= Joint disease in children.
=pediculis corporis.= The body louse.
=pedicure.= One who treats the feet cosmetically.
=pedunculated.= Stalked, having a peduncle; not sessile.
=pellagra.= An affection characterized by gastro-intestinal
disturbances and mental disorders.
=pelma.= The sole of the foot.
=pelmatogram.= An imprint of the sole of the foot made by resting the
inked foot on a sheet of paper, or by pressing the greased foot on a
plaster of Paris paste.
=pelvis.= Any basin-like or cup-shaped cavity.
=pemphigus.= An infection of the skin characterized by the production
of bullae.
=per.= A prefix denoting through. (Exam: perennial--lasting through
several years).
=perforating.= Piercing with one or more holes.
=peri.= A prefix denoting around or about. (Exam: periosteum--around
the bone).
=periarthritis.= Inflammation of the parts surrounding a joint.
=periodic.= Recurring at regular intervals.
=perionychia.= (See paronychia.)
=periosteum.= The thick fibrous membrane covering the entire surface of
a bone except its articular cartilage.
=periphery.= The outer part or surface; away from the centre.
=periphlebitis.= Inflammation of the outer coat of a vein or of the
tissues surrounding a vein.
=pernio.= Chilblains; chimatlon mild.
=perodactylus.= A monster with defective fingers and toes.
=peronei.= Relating to the peroneus muscles.
=peropus.= A monster with defective feet.
=peroxide of hydrogen.= Oxygenated water, H_{2}O_{2}, used as an
antiseptic and deodorant.
=perspiration.= The excretion of fluid by the sweat glands. The fluid
excreted by the sweat glands; transpiration.
=perverted.= Turned from what is normal or proper.
=pes=, =gen. pedis=, =pl. pedes=. The foot.
=pes cavus.= Hollow-foot.
=pes planus.= Flat foot.
=petrogen.= The proprietary name of refined mineral oil, used as a base
for remedial agents. =p. iodine.= Iodine mixed with petrogen.
=petrolatum.= Vaseline; a yellowish mixture of the softer members of
the paraffin or methane series of the hydrocarbons, obtained from
petroleum as an intermediate product in its distillation.
=phadena.= A sloughing ulcer.
=phagocytosis.= The process of ingestion and digestion by the cells;
the substances ingested are other cells, bacteria, bits of necrosed
tissue, foreign particles, etc.
=phalanges.= Long bones of the fingers or toes, fourteen in number, two
on each great toe and three on each of the remaining toes.
=phenol.= Carbolic acid.
=phenomenon.= A symptom; any unusual fact or occurrence.
=phlebitis.= Inflammation of a vein.
=phlegmon.= Acute suppurative inflammation of the subcutaneous
connective tissue.
=phosphoridrosis.= Phosphorescent sweating.
=physical.= Relating to the body as distinguished from the mind.
=physics.= The branch of science which deals with the phenomena of
matter.
=physiology.= The science that treats of the functions of the organs
and tissues of the human body.
=picric acid.= A yellowish, crystalline powder used in burns and eczema.
=pigment.= Coloring matter; the coloring matter found in the epidermis.
=pilocarpin.= An alkaloid obtained from the leaves of pilocarpus; used
externally to stimulate the growth of hair.
=pit.= Any natural depression on the surface of the body.
=pityriasis.= A dermatosis marked by branny desquamation; =p. rubra
pilaris=, an eruption of papules surrounding the hair follicles.
=plantar.= Relating to the sole of the foot.
=plantar flexion.= A term used to indicate extension of the foot
forward at the ankle joint.
=plaster.= A solid preparation which can be spread when heated and
which becomes adhesive at the temperature of the body.
=plaster of Paris.= Gypsum, calcium sulphate; used in podiatry for
dressings and to make casts.
=plasticity.= The capability of being formed or moulded.
=platinum.= A silver white metal.
=pledget.= A small mass or tuft of wool, cotton or lint.
=plexiform.= Resembling a plexus or network.
=plexus.= A network or interjoining of structures in the body,
especially of veins, nerves or lymphatics.
=pliability.= The capability of being pliable or flexible.
=plumbism.= Lead poisoning.
=podagra.= Gout, especially of the great toe.
=podalgia.= Pain in the foot.
=podarthritis.= Inflammation of any of the tarsal or metatarsal joints.
=podiatrist.= One who practises podiatry.
=podiatry.= The scientific care of the foot in health and in disease.
=poisoning.= Administering of poison; state of being poisoned.
=policeman’s heel.= A painful condition of the inferior surface of the
os calcis.
=poliomyelitis.= Inflammation of the grey matter of the spinal cord.
=poly.= A prefix conveying the notion of multiplicity. (Exam.:
polyarthritis--simultaneous inflammation of several joints).
=polydactylism.= More than five digits on either the hand or the foot.
=polyneuritis.= Multiple neuritis.
=polynuclear.= Multinuclear, having more than one nucleus.
=pompholyx.= An inflammatory eruption of the skin of the hands and
feet, accompanied by itching and burning.
=popliteal.= Relating to the posterior surface of the knee.
=positive pole.= Anode; the chemically active pole of an electric
battery, the one connected with the electronegative element.
=pore.= One of the minute openings of the sweat glands of the skin.
=post.= A prefix denoting after. (Exam.: postmortem--after death).
=posterior.= Behind or after.
=post-operative.= Following a surgical operation.
=posture.= The term applied to the position of the body in space.
=potassium hydroxide.= Caustic potash, a white crystalline mass used in
solution form to treat verruca.
=potassium iodide.= A white, crystalline powder used in the internal
treatment of syphilis.
=potassium permanganate.= A violet substance used as a deodorant in
bromidrosis.
=potential cautery.= A caustic; an agent such as potassium hydroxide
which forms an eschar without the agency of actual fire.
=potentiality.= A state of tension in an electric source.
=poultice.= Cataplasma; a soft mush prepared by wetting absorbent
substances with fluids and usually applied hot to the surface.
=pre.= A prefix to words formed from Latin roots, denoting anterior or
before. (Exam.: prepatellar--in front of the patella or knee cap).
=precursor.= Forerunner.
=predisposing.= Affecting the body in such a way as to render it
vulnerable to the action of the exciting cause.
=pregnancy.= Gestation; the state of a female after conception until
the birth of the child.
=prescription.= A written formula for the preparation and
administration of any remedy or remedies.
=process.= A projection or outgrowth.
=profuse.= Exuberant; liberal to excess.
=prognosis.= The foretelling of the probable course of a disease.
=progression.= Advance; the act of walking.
=proliferation.= Exuberant growth by reproduction of similar cells.
=prophylaxis.= The prevention of disease.
=propulsion.= The tendency to fall forward that causes festination in
paralysis agitans.
=protonuclein.= Trade name of a nuclein preparation derived from
lymphoid tissue.
=protoplasm.= Living matter, of which animal and vegetable tissues are
formed.
=prototype.= The primitive form.
=proud flesh.= Exuberant granulations; a fungus growth from a
granulating surface which shows no tendency toward cicatrization.
=proximal.= Nearest the trunk or point of origin; opposed to distal.
=pruritus.= Itching.
=pseudo.= A prefix denoting a resemblance, like. (Exam.:
pseudomania--pretended insanity).
=pseudoarthritis.= Hysteric joint inflammation.
=pseudoankylosis.= False ankylosis, fibrous ankylosis.
=pseudo-hypertrophic paralysis.= Progressive muscular atrophy, a
disease of childhood in which fat takes the place of wasted muscle.
=pseudo-tabetic (pseudataxic).= False wasting; false locomotor ataxia.
=psoriasis.= A skin disease characterized by the formation of white
scales over rounded, red patches. It appears mostly on the extensor
surfaces of the elbows and knees.
=psychosis.= A disorder of the mind; =p. polyneuritica=, psychosis
associated with polyneuritis characterized by failure of memory,
hallucinations, and imaginary reminiscences.
=pterygium.= A forward growth of the eponychium with adherence to the
surface of the nail.
=puncture.= To make a hole with a small pointed object, such as a
needle.
=purpura.= An affection characterized by hemorrhage into the skin.
=purulent.= Suppurating, containing or forming pus.
=pus.= A fluid product of inflammation, consisting of exuded serum,
leucocytes and the débris of dead cells.
=pustule.= A small circumscribed elevation on the skin, containing pus.
=puttees.= Leather leggings worn by soldiers and others who ride horses.
=putrefaction.= Decomposition; the cleavage or splitting up of the
molecules of a protein, resulting in the formation of other substances
of less complex constitution, accompanied by the formation of ammoniac
and sulphur gases.
=pyemia.= The presence of pus in the blood.
=pyogenic.= Pus-forming; relating to pus formation.
=pyrogallic acid.= A substance obtained from gallic acid; used in
podiatry in the treatment of verruca.
=pyrogallol.= Pyrogallic acid.
=pyroxylin.= Gun cotton, an ethereal solution of which makes collodion.
Q
=quinine and urea hydrochloride.= A mixture of quinine, as its name
indicates, used as a local anesthetic.
R
=radical.= As a radical operation, one which removes every trace of
possibly diseased tissue, or makes recurrence impossible.
=radiograph.= An X-ray machine.
=radiogram.= An X-ray picture.
=radiography.= The science of obtaining X-ray pictures.
=radioscopy.= Fluoroscopy.
=radix.= The hard, usually central portion of a corn, root. =r.
unguis.= The root of the nail.
=rancid.= Characterizing an oil or other fat which is decomposing.
=rational.= Reasonable; not delirious or comatose.
=rays.= Lines of light, heat or other forms of radioactivity. =alpha
rays.= Rays charged with positive electricity. =beta rays.= Rays
charged with negative electricity. =gamma rays.= Waves of motion not
charged with electricity.
=Raynaud’s disease.= Symmetrical gangrene of the extremities.
=receptacle.= A storage place.
=R.= The abbreviation of the latin word recipe--take, used as the
superscription of a prescription.
=recumbent.= Lying down.
=recurrent.= Returning; applied to symptoms.
=redintol.= A paraffin preparation used for burns.
=reduce.= To replace, as a fracture or a dislocation.
=redundant.= Exuberant, more than normal.
=reenforcement.= Augmented enforcement, as of a bandage or a dressing.
=reflex.= A reaction; an involuntary movement or exercise of function
in a part.
=ankle r.=, ankle-jerk; a sudden contraction of the calf
muscles, extending the foot when the tendo Achillis is tapped,
the subject kneeling on a chair with the foot hanging loosely.
=Babinski’s r.=; extension of the toes follows tickling of the
sole; usually a sign of organic disease of the pyramidal tracts.
=patellar r.=, a sudden contraction of the anterior muscles of
the thigh from a tap on the patellar tendon, which brings up
the foot, the subject being seated on the edge of a chair with
legs loosely crossed; knee-jerk.
=plantar r.=; a flexion of the toes following scratching or
tickling the sole of the foot.
=tarsophalangeal, r.=; flexion of the 2nd and 3rd (sometimes
2nd to 5th) toes when the dorsum of the foot is lightly tapped,
indicating an organic lesion of the motor nerve-centres.
=tendo Achillis r.=; a contraction of the calf muscles when the
tendo calcaneus is sharply struck.
=toe r.=; strong passive flexion of the great toe excites
contraction of the flexor muscles in the leg; sudden passive
extension causes rhythmical contraction of the great
toe--toe-clonus.
=regeneration.= Reproduction or repair of lost or injured parts.
=relapse.= Return of a disease after it has once spent its force.
=relax.= To loosen; to slacken.
=remedy.= An agent applied to cure a disease or to alleviate its
symptoms.
=renal.= Relating to the kidneys.
=repair.= Restoration after injury.
=resect.= To cut off, especially to cut off the articular ends of a
bone or bones forming a joint.
=resin.= The residue after the distillation of turpentine.
=resolution.= The arrest of an inflammatory process without
suppuration; the absorption or breaking down and removal of the
products of inflammation.
=resonator.= An apparatus for producing sounds.
=resorcin.= A phenol derivative used for ulcers.
=respiration.= A function common to all living plants or animals,
consisting in man in the taking in of oxygen and the throwing off of
the products of oxidation.
=resorption.= Removal of an exudate, a blood clot, pus, etc., by
absorption.
=rete Malpighii.= Stratum germinativum, the lowest layers of cells of
the epidermis; the reproducing cells of the epidermis.
=reticular layer.= The inner layer of the corium, composed of
connective tissue bundles.
=retrogressive.= Degenerative; a reversal of metabolic changes.
=retropulsion.= An involuntary backward running or walking occurring in
certain nervous affections; a pushing back of any part.
=reversed.= Turned backward or in an opposite direction.
=rheostat.= A resistance coil; an instrument used to regulate the
degree of resistance in an electric current.
=rickets.= Rachitis, a disease occurring in infants and young children;
it is characterized by softening of the bones, etc.
=ridge.= A linear bone elevation.
=rigid.= Stiff; inflexible.
=rigor.= Rigidity.
=rigor mortis.=; stiffening of the body from one to seven hours
after death.
=Roentgen rays.= X-rays.
=roentgenography.= Radiography.
=roentgenoscopy.= Fluoroscopy.
=roentgenotherapy.= The treatment of disease by the X-rays.
=root.= In anatomy, the base, foundation or beginning of any part;
radix.
=radix unguis=; the root of the nail.
=rotary file.= An instrument used for grinding nails.
=rubefacient.= A mild counter-irritant which reddens the skin.
=rubor.= Redness; one of the classical symptoms of inflammation.
=ruby lamp.= A lamp colored red, and used in the dark room for
developing purposes. It does not affect the sensitized plates.
=runaround.= A superficial paronychia.
=rupture.= A tear or solution of continuity.
S
=S.= Abbreviation of Latin, signa, remark, the usual introduction to
the directions in a prescription.
=sac.= A pouch, a bursa; the capsule of a tumor, the envelop of a cyst.
=sacro-iliac disease.= A disease occurring in the region of the sacrum
and ilium.
=salicylic acid.= An acid derived from the oil of wintergreen. Largely
used in podiatry to remove helomata and verrucæ.
=saline solution.= A solution of sodium chloride and water in the
proportion in which it exists in the blood.
=salol.= Phenyl salicylate.
=saltatory.= Relating to or marked by dancing or leaping.
=salvarsan.= Trade name of Ehrlich’s 606, employed in the treatment of
syphilis.
=salve.= An ointment, ceratum, unguentum.
=sandal.= An old form of footgear.
=sanguineous.= Relating to the blood.
=sapo.= Soap.
=saponaceous.= Soapy; resembling soap.
=sapremia.= Septicemia.
=sarcoma.= A malignant connective tissue neoplasm.
=saturated.= Impregnated to the greatest possible extent; said of a
solution; a liquid holding all of a given solute that it can dissolve.
=saturnism.= Lead poisoning.
=scab.= A crust formed by the drying of the pus on the surface of an
ulcer or excoriation.
=scalloped.= Cut in curves.
=scalpel.= A pointed knife with a convex edge.
=scarfskin.= Epidermis.
=scar tissue.= White fibrous tissue formed in the healing of wounds;
cicatrix.
=scarify.= To make a number of superficial incisions in the skin.
=scarlet red.= An organic dye-stuff used in ointment form as an
antiseptic and as a stimulant in the treatment of ulcers.
=sciatic.= Relating to sciatica.
=sciatica.= Sciatic neuritis. Neuralgia of the sciatic nerve.
=sclerodactylia.= Scleroderma affecting the digits of the hands or feet.
=scleroderma.= A hardening and thickening of the skin with loss of
elasticity.
=scleronychia.= Induration and thickening of the nails.
=sclerosis.= Induration or hardening, of chronic inflammatory origin.
=scoliosis.= Lateral curvature of the spine.
=scorbutus.= Scurvy.
=scrofula.= A constitutional state, occurring in the young and marked
by a lack of tissue resisting power.
=scurvy.= A disease marked by inanition, debility, anemia, edema of the
dependent parts; a spongy condition, sometimes with ulceration of the
gums and hemorrhages into the skin and from the mucous membranes.
=sebaceous.= Carrying or producing sebum.
=sebum.= The fluid excreted by the sebaceous glands of the skin.
=seborrhea.= Overaction of the sebaceous glands.
=secondary.= One of the symptoms of syphilis, following the development
of the chancre.
=secretion.= The product (solid, liquid or gaseous) of cellular or
glandular activity. A secretion is stored up in or utilized by the
animal or plant in which it is produced, thereby differing from an
excretion which is intended to be expelled from the body.
=secretory.= Relating to secretion or to the secretions.
=sedative.= An agent which quiets nervous excitement.
=semi.= A prefix denoting one-half or partly. (Exam.
semi-flexion--midway between flexion and extension).
=semis.= One-half; noted in prescription writing as ss.
=senility.= Old age.
=sensitized.= Rendered sensitive.
=sensory.= Relating to sensation.
=septic.= Unclean, contaminated with bacteria.
=septicemia.= A systemic disease caused by the presence of
microorganisms or their toxins in the blood; sepsis.
=septum.= A thin wall dividing two cavities or masses of softer tissue.
=sequestrum.= A piece of necrosed bone which has become separated from
the surrounding healthy osseous tissue.
=serofibrinous.= Noting an exudate composed of serum and fibrin.
=sero-purulent.= Containing both serum and pus.
=serous.= Relating to, containing or producing serum.
=serpiginous.= Noting an ulcer or other cutaneous lesion which extends
gradually over the surface on one side while usually healing on the
other.
=serrated.= Notched, toothed.
=serum.= A clear, watery fluid that moistens the surface of serous
membranes. The fluid portion of the blood obtained after coagulation.
=sesamoid.= Resembling in size or shape a grain of sesame; an oval
nodule of bone or fibro-cartilage in a tendon playing over a joint
surface; most common in the metacarpo and metatarsophalangeal
articulations and other joints of the fingers and toes.
=sessile.= Having a broad base of attachment, not pedunculated.
=sheath.= Any enveloping structure, such as the membranous covering of
a muscle, nerve or blood vessel.
=sheepskin.= Prepared skin of the sheep, used for shields.
=shield.= An agent used in podiatry to protect a part from friction or
pressure.
=shock.= A sudden physical or mental disturbance.
=silver.= Argentum; a metal of lustrous white color.
=s. nitrate=; largely used in podiatry as a caustic, escharotic
and stimulant.
=s. stick=; fused silver nitrate in stick form.
=sinew.= Tendon.
=sinister.= Of evil import, of bad prognosis; Latin for left, in
contradistinction to dexter, meaning right.
=sinistrapodeal.= Left footed.
=sinuous.= Tortuous, bending in several directions.
=sinus.= A tortuous tract opening on a free surface and leading down to
an abscess cavity.
=sirenomelia.= A monstrosity having two lower limbs fused in one.
=skiagram.= A print made from a photographic plate exposed to the
action of the X-rays.
=skiagraphy.= Radiography.
=skiascopy.= Fluoroscopy.
=skin.= The membranous covering of the body, cutis, integumentum.
=skin grafting.= The placing of bits of epidermis or larger strips of
the entire skin on a denuded surface in order to supply defects or to
stimulate a new skin growth.
=skiving.= The process of thinning shields at their borders.
=skiving knife.= An instrument used for skiving.
=slough.= Necrosed tissue separated from the living structure.
=sodium.= A metallic element. The following salts of sodium are used in
podiatry.
=s. bicarbonate=; used as a dusting powder in acidity of the
skin.
=s. borate=; (borax) used as an antiseptic.
=s. chloride=; (common salt) used as an antiseptic.
=s. ethylate=; used as a caustic in verruca.
=s. hydroxide=; (caustic soda) used as a caustic.
=s. sulphide=; used to remove superfluous hair.
=soggy.= Soaked; wet.
=sole.= The under part of the foot, the plantar surface.
=solution.= The incorporation of a solid or gas in a fluid.
=spasm.= An involuntary convulsive muscular contraction; cramp.
=spastic.= Spasmodic, convulsive.
=spatula.= A flat blade used for spreading plasters and ointments.
=spatulate.= Shaped like a spatula.
=specific.= Relating to an individual infectious disease, one caused by
a special microorganism; in a special restricted sense, syphilis.
=sphacelous.= Necrotic, gangrenous, sloughing.
=spheroidal.= Resembling a sphere.
=spica.= A form of bandage with overlapping turns.
=spinal.= Relating to the vertebral column.
=spiral.= Coiled; winding around a center.
=spiritus (spirit).= An alcoholic solution of a gaseous or volatile
substance.
=Spirochaeta pallida.= The protozoan which when present in the blood
indicates syphilis.
=splay-foot.= Flat foot, talipes valgus.
=splint.= An apparatus for rendering a part immobile, as in fractures.
=spontaneous.= Occurring without external stimulation.
=sporadic.= Occurring singly; neither endemic nor epidemic.
=spur.= A dull spine or projection from a bone.
=staphylococcus.= A group of cocci in which the individuals are
arranged in irregular masses somewhat resembling a bunch of grapes.
=stasis.= Stagnation of the blood or other fluids.
=static.= In a state of equilibrium or rest; not in action.
=static ataxia.= Inability to preserve equilibrium in standing through
loss of the deep sensibility.
=station.= Power of standing more or less firmly on one’s feet.
=stereognosis.= Ascertaining the form of an object by means of touch.
=sterile.= Surgically clean; free from bacteria.
=sterilization.= The act of making a person or thing sterile.
=sterilizer.= An apparatus for making anything aseptic or germ free.
=stimulant.= An agent that arouses organic activity.
=stimulation.= The arousing of the body or any of its parts or organs
to increased functional activity.
=stovaine.= A local anesthetic, used especially to induce spinal
anesthesia.
=stratum.= Layer.
=streptococcus.= A group of cocci in which the arrangement resembles
chains.
=streptococcus viridans.= A form of streptococcus which grows in green
colonies and is not hemolytic; the bacterium responsible for most focal
infections in the teeth.
=striated.= Striped.
=stroma.= The framework made of connective tissue.
=strychnine.= An alkaloid of nux vomica.
=stump-foot.= Club-foot.
=styptic.= Astringent, hemostatic.
=sub.= A prefix denoting beneath, less than normal or typical;
inferior; corresponds to hypo. (Exam. subastragular--under the
astragalus).
=subacute.= Not frankly acute, yet not chronic, noting the course of a
disease.
=subcutaneous.= Beneath the skin.
=subluxation.= An incomplete luxation or dislocation.
=sudamina.= Minute vesicles due to retention of fluid at the mouth of a
sweat follicle.
=sudoriferous.= Carrying or producing sweat.
=sulphur.= Brimstone; a chemical element; used in ointment form as a
stimulant.
=super.= A prefix signifying in excess, above, superior, same as supra
and hyper. (Exam. supertension--extreme tension).
=superficial.= Near the surface; cursory, not thorough.
=superfluous.= More than sufficient.
=supernumerary.= More than normal in number.
=supersaturated.= Said of a solution which holds more than a normal
quantity of a solute, and caused by heating the liquid.
=suppurate.= To form pus.
=supra.= A prefix denoting a position above. (Exam. supracostal--above
the ribs).
=surgery.= The branch of medicine which has to do with the treatment of
disease by means of operative procedures.
=suture.= The surgical uniting of two surfaces by means of stitches,
with silk thread, catgut, wire, etc., the material by which the two
surfaces are held in apposition.
=swab.= A tuft of cotton or other like material attached to the end of
a stick or wire; used for cleansing cavities or applying remedies.
=sweat gland.= One of the tubular coil-glands in the corium and
subcutaneous connective tissue, secreting sweat.
=swell-foot.= Swelling and redness of the metatarsus, with pain and
disability, due to sprain of the ligaments which are frequently
detached from the bones.
=symptomatology.= The science of the symptoms of disease.
=symptoms.= Any morbid phenomenon or departure from the normal in
function, appearance or sensation experienced by the patient and
indicative of disease. =Objective s.=, one which is evident to the
observer. =Subjective s.=, one apparent only to the patient.
=synarthrosis.= A fixed articulation.
=syndactylous.= Having webbed fingers or toes.
=synonyms.= Words having the same meaning as others.
=synovia.= A clear fluid secreted by a synovial membrane and used to
lubricate the joints.
=synovial membrane.= The lining membrane of a joint, secreting the
synovia.
=synthetic.= Relating to the formation of chemical compounds by the
union of simpler compounds.
=syphilide.= Any skin lesion of syphilitic origin.
=syphilis.= An infectious disease spread by inoculation, usually by
sexual intercourse, and due to the spirochaeta pallida.
=syphiloderma.= Syphilis of the skin.
=syringe.= An instrument for injecting fluids.
=syringomyelia.= The presence of cavities in the spinal cord due to the
breaking down of gliomatous new formations.
=systemic.= Relating to the entire organism as distinguished from any
of its individual parts.
=systremma.= A muscular cramp in the calf of the leg.
T
=tabes dorsalis.= Locomotor ataxia, a disease of the spinal ganglia and
roots usually found in middle age and often the sequel of syphilis.
=tactile.= Relating to touch or to the sense of touch.
=talipes.= Kyllosis; club-foot in general.
=t. calcaneovalgus=; t. calcaneus and t. valgus, combined;
=t. calcaneovarus=; t. calcaneus and t. varus, combined;
=t. calcaneus=; permanent dorsal flexion of the foot, so that
the weight of the body rests on the heel, only;
=t. cavus=; hollow-foot, an exaggeration of the normal arch of
the foot.
=t. equinovalgus=; t. equinus and t. valgus, combined;
=t. equinovarus=; t. equinus and t. varus, combined;
=t. equinus=; permanent extension of the foot so that only the
ball rests on the ground;
=t. percavus=; an extreme degree of t. vagus;
=t. planovalgus=; t. valgus;
=t. planus=; flat foot, splay-foot--a condition in which the
arch of the foot is broken down, the entire sole touching the
ground;
=t. spasmodicus=; a temporary distortion of the foot, usually
t. equinus, due to muscular spasm;
=t. vagus=; permanent eversion of the foot, the inner side
alone of the sole resting on the ground;
=t. varus=; inversion of the foot, the outer side of the foot
only touching the ground.
=talus.= Ankle bone, astragalus.
=tampon.= To plug a canal with gauze, cotton wool or other substance;
the substance used for the above purpose is also known by the same name.
=tangent.= A straight line that touches or meets a circle or curve, but
does not cut it.
=tannoform.= Trade name of a compound of tannin with ferric aldehyde.
=tarsal.= Relating to a tarsus in any sense.
=tarsalgia.= Podalgia; policeman’s disease; pain in the tarsus usually
due to incipient flat foot or to a shortening of the tendo Achillis.
=tarsometatarsal.= Relating to the tarsal and metatarsal bones of the
foot or region.
=tarsophalangeal.= Relating to the tarsus and the phalanges.
=tarsus.= The root of the foot, or instep.
=T. B. C. (tuberculosis).= A specific disease caused by the presence of
bacillus tuberculosis; it may affect almost any tissue or organ of the
body, the most common seats of the disease being the lungs and joints.
=teat.= Any nipple-like protuberance.
=technic.= The manner of performance of any surgical operation.
=temper.= Elasticity or hardness in steel.
=tenalgia.= Pain referred to a tendon.
=tendo Achillis.= The tendon of insertion of the gastrocnemius and the
soleus muscles into the tuberosity of the os calcis.
=tendon.= A fibrous cord or band which connects the muscle to its bony
attachment.
=tenotomy.= The surgical division of a tendon.
=tension.= The act of stretching.
=tepid.= Lukewarm, for a bath, 86°F.
=tertiary.= The final stages of syphilis.
=tetanus.= An infectious disease marked by painful tonic muscular
contractions; caused by the toxin of bacillus tetani acting upon the
central nervous system.
=tetany.= A disorder marked by intermittent tonic muscular contractions.
=tetradactyl.= Having only four fingers or toes on a hand or foot.
=therapeutic.= Relating to the treatment of disease; curative.
=thermal.= Relating to warmth or heat.
=thermocautery.= The actual cautery; destruction of tissue by heat.
=Thiersch’s solution.= An antiseptic solution containing boric acid and
salicylic acid.
=Thomsen’s disease.= Myotonia congenita. An hereditary disease marked
by momentary tonic spasms which occur when a voluntary movement is
attempted.
=thrombosis.= Formation or presence of a thrombus.
=thrombus.= A plug more or less completely occluding a blood vessel or
one of the cavities of the heart.
=tibia.= Shin-bone; the inner and larger of the two bones of the leg.
=tinctura.= An alcoholic solution or extract of a non-volatile
vegetable substance; a tincture.
=t. arnicae=; used for sprains and bruises;
=t. benzoini comp.=; used for sunburn, chimatlon, etc.;
=t. calendulae=; used for sprains and bruises;
=t. cresolis saponata=; used as an antiseptic;
=t. ferri chloridi=;
=t. iodi=;
=t. iodi (Churchill)=;
=t. iodi decolorata=;
=t. saponis viridis=.
=tinea unguium.= Ringworm of the nail.
=tip-foot.= Talipes equinus.
=tissue.= A collection of cells or of cell derivatives forming a
definite structure.
=titubation.= A staggering or stumbling in trying to walk, due to
spinal lesion; restlessness.
=toe.= Digitus pedis, one of the digits of the feet.
=great t.=, the toe on the inner, tibial side of the foot
corresponding to the thumb.
=hammer t.=, permanent flexion at the mid-phalangeal joint.
=toe drop.= A drooping of the anterior portion of the foot, due to
paralysis.
=toe separator.= An instrument used for separating the toes.
=toe webs.= The skin at the base of the toes.
=tonic.= In a state of continuous, unremitting action, noting
especially a muscular contraction. Increasing physical or mental tone
or strength, invigorating. A remedy given or applied to tone up the
system.
=touch corpuscles.= Special bodies found in the true skin, especially
at the ends of the fingers, and used for the sense of touch.
=tourniquet.= An instrument for arresting the flow of blood through a
part.
=toxemia.= Blood-poisoning; the presence of toxins in the blood.
=toxic.= Poisonous. Relating to a toxin.
=toxin.= A poisonous substance of undetermined chemical nature,
developed during the growth of pathogenic bacteria.
=transient.= Not permanent; coming and going.
=transition.= Passage from one condition or one part to another.
=trauma.= A wound or injury.
=traumatic.= Relating to or caused by a wound or injury.
=tremor.= Trembling, shaking; a disorder of the muscular tonus or loss
of equilibrium, the normal inappreciable tonic contractions being
exaggerated.
=trench foot.= A disease of the present war. See full description in
the body of the book as per index.
=tropacocaine.= An alkaloid obtained from Java coca leaves; a local
anesthetic.
=trophic.= Relating to or dependent upon nutrition.
=tuberculosis.= A specific disease caused by the bacillus tuberculosis;
it may affect any tissue of the body.
=tumor.= Neoplasm; a circumscribed growth, not inflammatory in
character.
=tungsten.= A metallic element, symbol W, atomic weight 184, occurring
as a gray powder of metallic lustre. A form of incandescent electric
lamp is made of a tungsten filament.
=turpentine.= Terebinthina. Prepared in the form of oil and of spirit
for external applications.
=tyloma.= Callosity, tylosis.
=tyroma.= A caseous (cheese-like) tumor.
=typhoid.= Typhus-like; stuporous from fever; same as typhoid fever.
U
=ulcer.= A circumscribed open sore which shown no tendency to heal;
ulcus.
=uncinariasis.= Hookworm disease.
=undertoe.= Displacement of the great toe beneath the second toe.
=ungual.= Relating to the nail.
=unguentum.= Ointment, salve.
=u.= acidi borici, boric acid ointment; used in burns and
abrasions.
=u.= acidi salicylici, salicylic acid ointment; used as a
disintegrant.
=u.= acidi carbolici, carbolic acid or phenol ointment; used in
burns and in superficial wounds.
=u.= balsam Peruvianum, balsam of Peru ointment; stimulating.
=u.= camphorae, camphor ointment; stimulating.
=u.= cantharidis, cantharidal ointment; rubefacient.
=u.= capsici, capsicum ointment; rubefacient.
=u.= creosoti, creosote ointment; applied to chilblains,
indolent ulcers and various skin affections.
=u.= diachylon, Hebra’s lead ointment; employed in hyperidrosis.
=u.= hamamelidis, witch hazel ointment; a soothing application.
=u.= hydrargyri ammoniati, white precipitate ointment; applied
in chronic skin conditions and in tubercular syphilides.
=u.= hydrargyri oxide rubri, red precipitate ointment; used in
the treatment of indolent ulcers.
=u.= ichthyoli, ichthyol ointment; emollient.
=u.= iodi, iodine ointment; used in chilblains and in glandular
enlargements.
=u.= picus compositum, compound tar ointment; employed in
wounds and in burns.
=u.= plumbi acetatis, lead acetate ointment; astringent
application to burns and superficial inflammations.
=u.= resorcini compositum, “soothing ointment”; astringent and
antiseptic.
=u.= scarlet red, scarlet red ointment; stimulating.
=u.= sulphuris, sulphur ointment; used in scabies.
=u.= zinci oxidi, ointment of zinc oxide; a soothing mild
astringent application in skin diseases, burns and abrasions.
=unguis.= Nail; a thin, horny, transparent plate covering the dorsal
surface of the distal end of each terminal phalanx of fingers and toes.
=Unverricht’s progressive myoclonus.= See Thomsen’s disease.
=uric acidemia.= See lithemia.
=uridrosis.= The excretion of urea or uric acid in the sweat.
=union.= The joining together of the opposing parts of a wound.
=unofficial.= Not official; said of a remedial agent not described in
the pharmacopeia.
=uremia.= An auto-intoxication occurring in certain cases of nephritis
or in anuria from any cause.
=U. S. P.= Abbreviation for the United States Pharmacopeia.
V
=vacuum.= A space from which the air has been practically extracted.
=valgus.= Bending outward; noting a condition of the great toe, in
which it is bent outward; knock-knees; see talipes valgus.
=vanadium chloride.= A yellowish substance used in bromidrosis.
=varicose.= Relating to or affected with large and tortuous veins.
=variola.= Smallpox.
=varix.= An enlarged and tortuous vein, artery or lymphatic vessel.
=vascular.= Relating to or containing blood vessels.
=vasoconstrictors.= Agents which cause narrowing of the blood vessels;
nerves, stimulation of which cause vascular constriction.
=vasodilators.= Agents which cause dilatation of the blood vessels; a
nerve, stimulation of which results in dilatation of the blood vessels.
=vasomotor.= The nerves which have the power of dilating or
constricting the blood vessels.
=vein.= A blood vessel conveying blood towards the heart. Lat. vena.
=veins of the foot=:
=v.= plantaris interna; internal plantar vein (plantar surface,
deep).
=v.= plantaris externa; external plantar vein (plantar surface,
deep).
=v.= saphena brevis; external or short saphenous vein (dorsal
surface, superficial).
=v.= saphena longa; internal or long saphenous vein (dorsal
surface, superficial).
=v.= tibialis anticus; anterior tibial vein (dorsal surface,
deep).
No veins on the superficial plantar surface.
=verbatim.= Word for word.
=vermiform appendix.= A blind sac of the intestine, extending from the
head of the cecum.
=verruca.= A circumscribed overgrowth of the layers of the skin,
including those of the derma (plural, verrucæ).
=vertebral caries.= Molecular death of the bones of the spinal column.
=vertigo.= Dizziness, giddiness.
=vesicant.= An agent which when applied to the skin produces a blister.
=vesicle.= A small circumscribed elevation on the skin, containing
non-purulent fluid; a blister.
=vesicular.= Relating to a vesicle; containing vesicles.
=vibration.= A shaking, oscillation.
=vice versa.= The terms in the case being reversed.
=virulent.= Extremely poisonous.
=vocational.= Referring to occupation.
=volatile.= Not permanent; evaporating spontaneously.
=voltage.= The electromotive force of a current expressed in volts.
=vulcanizing.= Adhering rubber by means of heat.
W
=wart.= A circumscribed hypertrophy of the papillæ of the corium. (See
verruca).
=Wassermann test.= A diagnostic test for syphilis, based upon the
theory of complement fixation.
=web.= The skin found at the base of the fingers or toes.
=wheal.= An acute, circumscribed elevation of the skin due to edema in
the derma.
=whitlow.= Felon, paronychia, inflammation of the tissues around the
nail.
=whorl.= A set of organs arranged in a circle around an axis.
=wick.= A piece of gauze or other material used for draining cavities.
=wipe.= A piece of gauze or cotton used in wiping instruments.
=wool fat.= Adeps lanae. Used as an embrocation in podiatry. Lanolin.
=Woulfe’s bottle.= A bottle with two or three necks, for working with
gases (washing, drying, etc.).
=wound.= Loss in continuity upon the surfaces of the body.
=wrist drop.= Paralysis of the extensors of the wrist and fingers.
X
=X-rays.= Roentgen rays.
=xystus.= Scraped lint; lint made by scraping linen with a sharp
instrument.
Z
=Zander’s system.= Treatment by means of mechanical apparatus giving
passive movements.
=zinc oxide.= A white powder used as an astringent.
=zinc stearate.= A white powder used as an antiseptic dusting powder.
=zymotic.= Relating to fermentation; noting an infectious disease.
* * * * *
(We are obligated to Stedman’s Practical Medical Dictionary for many of
the definitions of medical terms above noted--Editor).
CROSS REFERENCE INDEX
A
Acetanilid, 296
Acetic acid, 191
Acriflavin, 34
Actinotherapy, 385
Adenoids, 379
Adipose tissue, 14
Advent of foot clothing, 47
Alcohol, 27, 131, 198, 215, 218, 225, 228, 250, 253, 273, 275, 301,
331, 334
Aluminum acetate, 219, 224, 225, 289, 295
Aluminum chloride, 301
Alternate foot bath, 53, 299
Alternating current, 386
Alypin, 144
Ambrene, 70
Ammoniated mercury, 29, 221, 254
Anidrosis, 303
definition of, 303
derivation of, 303
etiology of, 303
symptoms of, 303
synonyms of, 303
treatment of, 303
Anterior arch, 184
Antisepsis, 19, 20, 21, 24, 33
Antiseptics, general, 24
chlorinated lime, 26
formaldehyde, 25
heat, 25
lime, 25
sublimed sulphur, 26
sunlight, 24
Antiseptics, local, 26
alcohol, 27
balsam of Peru, 27
borate of sodium, 27
borax, 27
boric acid, 27
boroglycerine, 27
bichloride of mercury, 29
calomel, 29
Dakin solution, 27
di-chloramin-T, 28
glycerinum, 28
hydrogen dioxide, 28
peroxide, 28
iodoform, 29
iodine, 28
liquor alumini acetatis, 27
cresolis compositas, 29
lysol, 30
mercuric chloride, 29
mercurous chloride, 29
peroxide of hydrogen, 28
potassium permanganate, 30
sulphur, 30
phenol, 29
thymol, 30
thymol iodide, 30
unguentum hydrargyri, 29
hydrargyri ammoniatum, 29
sulphuris, 30
Apothesine, 148
Applicators, 91
Areolar tissue, 14
Aristol, 30, 220, 249, 262, 320, 332, 334
Arsphenamine, 378
Arteriosclerosis, 404
Arthritis, 402
Asepsis, 19, 32
Aseptic gauze, 62
Atrophy of the nails, 244
B
Bacillus aërogenes capsulatus, 369
Baking, 273
Balsam of Peru, 27, 180, 193, 198, 199, 221, 247, 262, 277, 295, 320,
327, 332, 335
Bandage scissors, 89
Bandages, description of, 75, 76, 77
Bandaging, 73
Belgian hone, 92
Belladonna, 298, 299
Benzoated collodion, 69
Bichloride of Mercury, 29, 199, 218, 273, 274, 289, 318, 328, 334
Bismuth subgallate, 220, 249, 262, 313, 332
Bismuth subnitrate, 220, 249, 262, 313, 332
Blebs, 248, 251, 289, 333
treatment of, 334
Blisters, 248, 251
definition of, 251
etiology of, 251
pathology of, 252
prognosis of, 256
treatment of, 253
ordinary conditions, 252
broken conditions, 254
usual points of location of, 252
Bones of the foot, 50
borate of sodium, 27, 362
Borated gauze, 63
Borax, 27, 362
Boric acid, 27, 220, 225, 239, 273, 275, 302, 303, 318, 320, 334
Boroglycerine, 27, 312
Brilliant Green, 35
Bromidrosis, 302
definition of, 302
derivation of, 302
etiology of, 302
pathology of, 302
symptoms of, 302
synonyms of, 302
treatment of, 302
Buckskin, 97
Bullae, 248, 251, 289
Burns, 248, 256
definition of, 256
pathology of, 257
treatment of, 257
Burnt alum, 226
Burow’s solution, 318
Burs, 91
Bursitis, 263
definition of, 263
characteristics of, 265, 266
etiology of, 264
location of, 264
pathology of, 265
removal of pressure for, 268
rest for, 268
strapping of, 269
symptoms of, 265
objective, 265
subjective, 265
treatment of, 266
non-radical, 267
palliative, 267
radical, 267
C
California College of Chiropody, 5
Callositas, 182
definition of, 182
derivation of, 182
diagnosis of, 183
etiology of, 182
pathology of, 183
prognosis of, 183
symptoms of, 182
synonyms of, 182
treatment of, 184
Callosity, 182
Callous, 182
Callous ulcer, 306, 314
differential diagnosis, 316
etiology of, 315
general causes, 315
local causes, 315
symptoms of, 315
treatment of, 317
cleansing, 318
sterilization, 318
Calloused nail groove, 205, 237
definition of, 205
etiology of, 206
symptoms of, 206
treatment of, 206
surgical, 207
medical, 208
Callus, 182
Calomel, 29, 320
Calamine lotion, 302
Camphor, 361, 362, 363
Camphorated oil, 365
Camphorated soap liniment, 290
Cannabis indica, 277
Capsicum, 279
Carbon dioxide pencil, 179, 191, 203
Carbon dioxide snow, 145
Carrel method, 21
Catalepsy, 355
Chamois, 97
Chauffeur’s foot, 340
etiology of, 340
treatment of, 341
Chicago School of Chiropody, 5
Chilblains, 283
Chimatlon mild, 283
definition of, 283
derivation of, 283
diagnosis of, 286
differential diagnosis of, 288
etiology of, 283
pathology of, 285
predisposition to, 284
prognosis of, 288
symptoms of, 284
synonyms of, 283
treatment of, 288
Chimatlon severe, 291
definition of, 291
derivation of, 291
diagnosis of, 293
etiology of, 291
pathology of, 292
prognosis of, 294
recurrence of, 294
symptoms of, 292
synonyms of, 291
treatment of, 294
Chiropodists of America, 2
Chisel, 81
Chlorazene, 37, 168
Chlorinated lime, 26
Chromic acid, 301, 303
Chromidrosis, 304
definition of, 304
Clippers, 86
Cocaine, 143
Cocoon dressing, 65, 184, 335
Cold applications, 271
Collodial silver, 363
gold, 364
Collodion, 68
benzoated, 69
ichthyolated, 69
iodized, 69
medicated, 68
salicylated, 70
Colorado Pedic Society, 9
Connecticut Pedic Society, 9
Copper sulphate, 320
Corium, 13
Corns, 149
Corrosive sublimate gauze, 62
Cotton, 64
Counter-irritation, 270, 278
Creolin, 318
Cutaneous manifestations of super-acidity, 329
characteristics of, 329
definition of, 329
etiology of, 330
Cuticle scissors, 89
D
Dancer’s foot, 341
treatment of, 341
Dakin solution, 21, 27, 35, 168, 318
Deodorant, 26
Derma, 13
blood supply of, 14
Dermatitis calorica, 291
Dermatitis congelationes, 283
Dermatol, 220, 320, 334
Diachylon, 300
Diagnosis of radiographs, 397
Di-chloramin-T, 28, 37
Direct cautery, 191, 202, 222, 224
Direct current, 386
Disinfectant, 26
Dressings, 60, 218, 258
moist, 60
evaporating moist, 60
non-evaporating moist, 60
occlusive, 61
dry, 61
ointment, 61
Drill, 90
Dry dressings, 61, 220, 312
Duck shield, 173
E
Electric experiments, 385
Electricity, 270, 280, 296
Electrolysis, 178, 191, 200
Ephidrosis, 297
Epidermis, 12
Epithelioma, 189
Ergot, 298
Erythema pernio, 283
Ethyl bromide, 145
Ethyl chloride, 145
Ethylate of soda, 196
Evaporating moist dressings, 60
Excavator, 84
Excessive sweating, 297
Excision, 191, 198, 222
Exostosis, 399
F
Fabrics for dressings, 62
Faradic Current, 281, 290, 296, 304
Felon, 239
Felt, 98
Felt, adhesive, 99
Ferri subsulphate, 227, 232
Ferric chloride, 232
Fish skin, 73
Fissured toe webs, 171
Fissures, 248, 330
definition of, 248
etiology of, 248
treatment of, 248, 331
technic, 249
Flat foot, 340
symptoms of, 340
treatment of, 340
Flavin, 34
Fluoroscopy, 385
Focal infection, 379
modes of, 380
relationship between the foot and, 380
treatment of, 381
Foot care of adolescents, 55
Foot care of adults, 56
Foot care of infants, 53
Foot care of soldiers, 57
Footgear, modern, 47
Forceps, 85, 88
Formaldehyde, 25, 44, 299, 301
Formalin, 319
Fractures, 399
comminuted, 400
complete, 400
compound, 402
compression, 400
crushing, 400
impacted, 400
incomplete, 399
multiple, 400
simple, 400
Freezing method of anesthesia, 146
Frost bite, 291
Fulguration, 177, 191, 199
G
Gall bladder, 379
Gallic acid, 298, 332
Galvanic current, 304
Gangrene, 293, 294
Gas gangrene, 365, 368, 369
Gas infection, 369
antitoxin for, 372
bacteriologic diagnosis, 372
destruction of bacillus, 371
etiology of, 369
removal of necrotic tissue, 371
symptoms of, 370
treatment of, 370
Gauze, 62
borated, 63
corrosive sublimate, 62
iodoform, 62
plain aseptic, 62
squares, 63, 64, 219, 314
uses of, 63
Geissler air pump, 386
Glands, 14
Glossary, 411
Glycerinum, 28
Golfer’s foot, 341
Gonorrheal heel, 380
Ground itch, 368
treatment of, 369
Guaiacol, 290
Gutta percha tissue, 72
H
Hard corn, 150
Heat, 25
Heloma, 149
definition of, 150
derivation of, 149
synonyms of, 150
Heloma disseminatum, 179
definition of, 179
diagnosis of, 180
etiology of, 179
pathology of, 180
prognosis of, 180
symptoms of, 179
treatment of, 179
Heloma durum, 150
diagnosis of, 154
etiology of, 151
pathology of, 152, 153
prognosis of, 155
symptoms of, 150
treatment of, 156
dissection, 160
non-radical, 159
palliative, 157
preventive, 156
operative, 158
radical, 158
shaving, 159
Heloma miliare, 179
Heloma molle, 169
definition of, 169
diagnosis of, 170
etiology of, 170
pathology of, 170
prognosis of, 171
symptoms of, 169
treatment of, 172
Heloma vasculare, 174, 190
diagnosis of, 175
etiology of, 174
pathology of, 174
prognosis of, 175
symptoms of, 174
treatment of, 175
Helotomon, 81
Hematidrosis, 304
definition of, 304
Hemorrhage, 31
Hidrosis, 297
High frequency current, 177, 199, 281, 290, 296
High heels, 48
Honing, 92
Hookworm, 368
Hot applications, 270, 304
Hydradenitis, 305
definition of, 305
Hydrogen dioxide, 28
Hydrogen peroxide, 28, 218, 228, 289
Hydrocystoma, 304
definition of, 304
Hydrotherapy, 270
Hygiene of the foot, 51-59
Hyperidrosis, 297
definition of, 297
derivation of, 297
etiology of, 297
pathology of, 297
prognosis of, 298
symptoms of, 298
synonyms of, 297
treatment of, 298
Hypodermic method of anesthesia, 145
Hypodermic syringe, 90, 146
uses of, 147
I
Ichthyol, 180, 193, 198, 199, 251, 254, 262, 276, 290, 295, 296, 320,
332
Ichthyolated collodion, 69
Idrosis, 297
Illinois College of Chiropody, 5
Illinois Pedic Association, 8
Impervious coverings, 72
Incorporated Society of Chiropodists (England), 6
Indolent ulcer, 306, 314
etiology of, 315
symptoms of, 315
Infection, 213
treatment of, 227
Infected heloma, 167
Inflammation, symptoms of, 177
Ingrown nail clippers, 86
Ingrown nail forceps, 85
Ingrown toe nail, 205, 210, 237
Instruments, 78
applicators, 91
burs, 91
care of, 92
chisel, 81
excavator, 84
helotomon, 81
history of, 79
honing of, 92
Belgian hone, 92
oil stone, 93
Swatty hone, 93
technic, 93
hypodermic syringe, 90
ingrown nail clippers, 86
forceps, 85
iris tooth forceps, 88
nail chisel, 82
clippers, 86
file, 91
groove gouge, 83
scraper, 84
polishing, 94
rotary file, 90
scalpel, 80
scissors, 88
bandage, 89
cuticle, 89
selection and care of, 7
skiving knife, 92
soft corn spoon, 83
spatula, 84
special, for ingrown nail, 85
standardization of, 80
thumb forceps, 86
toe separators, 91
wiping of, 95
Iodoform, 29, 320
Iodoform gauze, 62
Iodine, 28, 215, 295
Iodized collodion, 69
Iris tooth forceps, 88
J
Jaborandi, 304
L
Lamb’s wool, 99
Lanolin, 276
Lassar’s paste, 320
Laws governing chiropody
New York, 3
California, 8
Lead and opium wash, 273, 275, 318
Lewi, Maurice J., 4
Lime, 25
Lint, 66
shielding, 67
Liquor alumini acetatis, 27, 273, 274
Liquor cresolis compositas, 29
Lister, Joseph, 22
Local anesthesia, 143, 158, 198
reaction of, 148
technic of, 145
Locomotion as an aid in diagnosis, 343
classification of gaits, 347
Ataxic gait, 352
static ataxic, 352
static spinal ataxic, 353
cerebellar, 353
titubating, 353
reeling or staggering, 354
Choreic, 354
festination, 354
hysteria, 355
myotonia, 355
saltatory, 355
stumbling, 354
Paretic gait, 347
mild, 347
Charlie Chaplin, 349
hobbling, 347
intermittent limping, 348
pompous, 347
shuffling, 348
tottering, 348
waddling, 348
wobbly, 348
moderate or flaccid, 349
prancing, 350
steppage, 349
spastic or severe, 350
cross-legged, 351
dragging, 352
dromedary, 352
ill-defined spastic, 352
mowing or hemiplegic, 351
small step, 351
elements of, 343
gait, 344
posture, 343
station, 344
methods of diagnosis, 345
ichnogram, 345
observation, 345
Lymphatics, 15
Lysol, 30, 318
M
Massage, 250, 270, 279, 289, 296, 304
Mazamorro, 368
Medicated collodion, 69
Menthol, 276
Mercuric chloride, 29, 273, 274
Mercurous chloride, 29
Mercury, 378
Metatarsalgia, 139, 141, 382
treatment of, 383
Methylene blue, 196
Miliaria, 304
definition of, 304
Miscellaneous foot lesions, 357
Moist dressings, 60, 270, 273
Moleskin, 195
Moleskin, adhesive, 97
Monochloracetic acid, 191
Monsel’s solution, 227, 232
Morton’s neuralgia, 382
Morton’s toe, 139, 140, 382
treatment of, 382
Muscles, 15
Mustard, 279
N
Nail chisel, 82, 215
Nail clippers, 86
Nail file, 91
Nail groove gouge, 83
Nail matrix, 16
Nails, 16, 50
Nail scraper, 84
Naked foot, 46
National Association of Chiropodists, 3, 9, 10
Necrosis, 293
Nerves, 15
medullated nerve fibres, 15
non-medullated nerve fibres, 15
Nitric acid, 176, 191, 194, 225
Non-evaporating moist dressings, 60
Novocaine, 144, 198, 216
O
Occlusive dressings, 61
Office, 405
accessories, 409
cabinet, 408
chair, 407
cleanliness of, 405
comfort of patient, 405
equipment, 406
operating room, 406
rotary file, 409
sterilizer, 408
waiting room, 405
Office equipment, 405, 406
Ohio College of Chiropody, 5
Oil stone, 93
Oiled silk, 72
Ointment dressings, 61, 220, 270, 275, 313
Onychatrophia, 244
derivation of, 244
diagnosis of, 246
etiology of, 244
pathology of, 245
treatment of, 246
Onychauxis, 241
derivation of, 241
diagnosis of, 242
etiology of, 241
pathology of, 242
treatment of, 243
palliative, 243
radical, 244
Onychia, 238
derivation of, 238
diagnosis of, 238
etiology of, 238
pathology of, 238
treatment of, 238
Onychitis, 238
Onychocryptosis, 210, 237
definition of, 210
derivation of, 237
etiology of, 210
complications, 212
prognosis of, 229
treatment of, 214
allowing nail to grow long, 234
complicated cases, 221
excision, 222
method of procedure, 223
no lateral cutting, 235
palliative method, 216
proper boots and hosiery, 235
packing, 233
prophylaxis, 230
radical method, 216
uncomplicated cases, 215
Onychophosis, 237
Onychoptosis, 247
Onychorrhexis, 247
Onychygrophosis, 241
Orthoform, 320
Osmidrosis, 302
Oxygen, 300, 366
P
Painful feet in women, 381
Panaris, 239
Panighao, 368
Papillary layer, 13
Papilloma, 185
Paraffin No. 7., 70
Paraffin No. 7-11., 70
Paraffin preparations, 70, 258
application of, 71
conclusions, 261
precautions in using, 258
removing dressings of, 259
Parresine, 71
Paronychia, 239
derivation of, 239
diagnosis of, 240
etiology of, 239
pathology of, 240
synonyms of, 239
treatment of, 240
Paronychitis, 239
Pasteur, 22
Pasteur serum, 365
Pedic items, 2
Pedic Society, State of California, 7
Pedic Society, New York State, 1
officers, 1
Perforating ulcer, 324
characteristics of, 325
etiology of, 324
prognosis of, 327
symptoms of, 326
treatment of, 326
Periostitis, 397
Pernio, 291
Peroxide of hydrogen, 28
Petrogen camphor, 280
iodine, 280
Phenol, 29, 198, 289, 302
Pilocarpin, 304
Plaster, 105, 106, 107, 117, 120
Plaster of Paris bandage, 74
Podiatrist, 2
Podiatrists office, 405
Policeman’s heel, 341
treatment of, 341
Polyidrosis, 297
Potassium hydroxide, 176, 184, 191, 195, 196, 209, 225
Potassium iodide, 378
Potassium permanganate, 30, 301, 303
Potential cautery, 191, 192
Poultice, 272
Pressure method of anesthesia, 146
Proflavin, 34
Protonuclein, 320
Proud flesh, 213, 216, 221, 251
Pruritis, 333
Pyrogallic acid, 191, 196
Q
Quinine and urea hydrochloride, 144
R
Radiography, 385-395
Radioscopy, 385
Redintol, 71
Reticular layer, 14
Rhode Island Chiropody Society, 9
Roentgenography, 385
Roentgenology, 385
Roentgenoscopy, 385
Roentgenotherapy, 385
Rotary file, 90, 149
S
Salicylated collodion, 70
Salicylic acid, 173, 176, 181, 184, 191, 197, 208, 232, 277, 378
Salvarsan, 379
Sandal, 47
San Francisco Chiropody Association, 6
Scalpel, 80
Scarlet red, 221, 277, 314, 320, 327, 332
School of Chiropody of New York, 4
Scissors, 88
Sebaceous glands, 14, 15, 17
Seborrhea, 305
definition of, 305
Seed corn, 179
Sesamoid bones, 402
Sheep skin, 98
Shields and shielding, 96, 173, 269
adhesive substances, 104
aperture for, 101
definition, 96
location of parts to be shielded, 100
manufacture of, 99
materials, 96
adhesive felt, 99
adhesive moleskin, 97
buckskin, 97
chamois, 97
felt, 98
lamb’s wool, 99
sheepskin, 98
method of skiving, 103
preparation of, 99
skiving of, 101
strapping of, 105, 107
thickness of, 100
Shielding, specific, 107
dorsal surfaces, 138
fifth toe, 120
built up, half-moon, 127
dorsal surface, 120
strapping for, 121, 126
lateral surfaces, 128
strapping for, 128
interdigital surfaces, 128
strapping for, 128
great toe, 107, 113
interdigital surfaces, 118, 119
strapping for, 120
intermediate toes, 113
dorsal surfaces, 113, 115
ends of, 116
strapping for, 117
lateral borders, 137
lateral plantar half-moon, 136
metatarsalgia, 139, 141
Morton’s toe, 139, 140
metatarsophalangeal articulation, 130
oval, 130
half-moon, 131
modified half-moon, 132
os calcis region, 137
plantar surfaces, 132, 133
strapping for, 134, 135
Silver nitrate, 191, 195, 226, 231, 248, 249, 250, 256, 290, 319,
320, 332
Simple ulcers, 306, 311
treatment of, 311
Skiagraphy, 385
Skiascopy, 385
Skin, 11
anatomy of, 12
layers of, 12
physiology of, 17
Skiving, 101, 103
Skiving knife, 92, 104
Spatula, 84
Sodium bicarbonate, 332
Sodium hydroxide, 191
Soft corn, 169
Soft corn spoon, 83
Soft soap, 362
Sterilization, 39
dressings, 40
field of operation, 30, 40
hands of operator, 41
instruments, 39
Sterilizing apparatus, 42
Sterilizers, 42, 408
Strapping, 105, 106, 107, 117, 120, 121, 128, 134, 269
Stratum corneum, 12
Stratum granulosum, 12
Stratum lucidum, 12
Stratum mucosum, 13
Subcutaneous areolar tissue, 14
Sublimed sulphur, 26
Sudamen, 304
definition of, 304
Sudorrhea, 297
Sudatoria, 297
Sudoriferous glands, 15, 17, 49
Sulphur, 30, 33, 299, 335
Sunlight, 24
Sutures, 198
Swatty hone, 93
Syphilitic ulcer, 327
symptoms of, 327
treatment of, 328
Syphilis, 189, 241, 373
blood tests for, 377
Wassermann, 377
Noguchi, 377
luetin, 378
color of, 374
course and duration of, 378
definition of, 373
derivation of, 373
diagnosis of, 374
differential diagnosis of, 377
distribution of, 374
etiology of, 373
form of, 374
pathology of, 373
plantar syphilide, 375
synonyms of, 373
treatment of, 378
T
Tannic acid, 248, 332
Tannoform, 249, 332
Teeth, 379
Temple University, 5
Tetanus, 365
The First Institute of Podiatry, 5
Thiersch’s solution, 318
Thumb forceps, 86
Thymol, 30
Thymol iodide, 30, 220, 249, 262, 312, 332, 334
Tr. Benzoin Comp., 249, 251, 289, 331
Tr. Iodine, 184, 278
Toe separators, 91
Tonsils, 379
Trench fever, 358
Trench foot, 357
complications in, 365
crust formation in, 363
etiology of, 358
extensive invasion in, 364
general treatment of, 365
prevention of, 361
prognosis of, 360
reparation stage of, 365
simple edematous, 362
stages of, 357
symptoms of, 359
treatment of, 360
vesicular, 363
Trichloracetic acid, 191, 194
Turpentine, 279
Tyloma, 182
Tylosis, 182
U
Ulcers, 306
callous, 306
definition of, 306
etiology of, 306
exciting causes of, 308
granulation of, 310
indolent, 306
pathology of, 308
perforating, 306
predisposing causes of, 307
simple, 306
syphilitic, 306
varicose, 306
Uncinarial dermatitis, 368
Ung. Acidi borici, 313
Ung. Acidi tannici, 313
Ung. Balsam of Peru, 314
Ung. Eucalypti, 314
Ung. hydrargyri, 29
Unguentum hydrargyri ammoniati, 29, 221, 313, 332
Unguentum sulphuris, 30, 221, 262, 276
Ung. zinci oxidi, 314
University of Massachusetts, 5
Urethra, 379
Uric acid diathesis, 212
Uric acid and the nails, 335
changes in size and shape, 336
treatment of, 337
discoloration, 335
treatment of, 335
prognosis, 337
texture changes, 336
treatment of, 336
Uridrosis, 304
definition of, 304
Uterus, 379
V
Vanadium chloride, 300
Varicose ulcer, 321
bandaging for, 324
etiology of, 321
symptoms of, 322
treatment of, 322
Vascular corn, 174
Venereal warts, 190
Verruca, 185
definition of, 185
derivation of, 185
diagnosis of, 189
etiology of, 185
pathology of, 187
prognosis of, 190
synonyms of, 185
treatment of, 191
varieties of, 188
where found, 187
Verruca arida, 185, 188
Verruca humida, 185, 189
Verruca vulgaris, 188
Vibration, 281
Vocational foot disorders, 339
W
Walking, 57
Water, 52
properties of, 52
Water itch, 368
Water pox, 368
Water sores, 368
Weak foot, 339
appearance of, 339
symptoms of, 339
treatment of, 339
Welch bacillus, 369
Wet dressings, 60, 218, 239, 270, 273, 311
White precipitate, 29, 221, 254, 378
Whitlow, 239
X
X-ray apparatus, 388
generator, 388
coil, 390
interrupterless, 390
tubes, 391
vacuum regulators, 392
tube stand, 394
X-ray plates, 394
developing of, 396
fixing of, 396
X-rays, 300, 385, 394
dangers of, 387
discovery of, 386
experiments leading up to, 387
Z
Zinc oxide, 261, 313, 320
Zinc stearate, 313
Zinc sulphate, 320
PRACTICAL PODIATRY
is the second volume of a series of books known
as a complete System of Podiatry.
The first volume
SURGERY
WITH
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many progressive physicians.
PODIATRY ORTHOPEDICS
will be the next volume of the System to be
published and will be followed by other books
along special lines bearing upon a knowledge
of foot lesions and their care.
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