Surgery, with Special Reference to Podiatry Part 17

The disease is commonest after punctured wounds or lacerated ones of the hands or feet, and before it appears, a wound is apt to suppurate or slough, but in some instances the wound is found soundly healed.

Teta.n.u.s is due to infection by a bacillus (first described by Nicolaier, and first cultivated by Kitasato), the toxic properties of which, absorbed from the infected area, poison the nervous system precisely as would dosing with strychnine.

+Symptoms.+ The onset is usually within nine days of an accident. At first, the neck feels stiff and there is difficulty in swallowing, and then the jaw also becomes stiff. The neck becomes like an iron bar, and the jaws are rigid as steel. If the injury is on the foot, that extremity usually is found to be rigid. Opisthotonos is present and spasms are very marked. Swallowing in many cases is impossible. The mind is entirely clear until near the end, one of the worst elements of the disease.

+Treatment.+ Careful antisepsis will banish it. Every wound must be disinfected with the most scrupulous care. Every punctured wound is to be incised to its depth and thoroughly cleaned and drained. Large doses of the bromide of pota.s.sium, at least sixty grains, should be given every four to six hours. Teta.n.u.s ant.i.toxin should be given (5000 units), and repeated in twenty-four hours if no improvement is seen.

Recently a saturated solution of magnesium sulphate has been given intraspinally, with very good results. In all suspicious cases, a prophylatic injection of teta.n.u.s ant.i.toxin is to be recommended (1000 units).

+Erysipelas.+ Erysipelas is an acute, contagious disease, characterized by a peculiar form of inflammation of the skin. It is caused by the streptococcus of erysipelas, which grows and multiplies in the smaller lymph channels of the skin and its subcutaneous cellular layers, and in serous and mucous membranes.

The disease is a rapid spreading dermat.i.tis, accompanied by a remittent fever, due to the absorption of toxins, having a tendency to recur. It is always due to a wound. The involved area may or may not suppurate.

+Symptoms.+ The onset is sudden, with a high fever, and at the time of febrile onset, spots of redness appear on the skin. These spots run together, and a large extent of surface is found to be red and a little elevated. This combination of redness and swelling extends, and its area is sharply defined from the healthy skin. The color at once fades on pressure and returns immediately the pressure is removed. In the hyperemic area, vesicles or bullae form, containing first serum and later possibly sero-pus. Edema affects the subcutaneous tissues, producing great swelling in the regions where these tissues are lax.

+Treatment.+ Isolate the patient; asepticize the wound; and give a purge. If a person is debilitated, stimulate freely.

Tincture of iron and quinine are usually administered. Nutritious food is important. For sleeplessness or delirium, use the bromides; for light temperature, cold sponging and antipyretics. Locally, strict antiseptic treatment of existing wounds or other lesions; cold compresses to relax the skin; rest; elevation of the limb; and incisions, only if pus forms.

Where the disease is spreading, good results are obtained by spraying the affected surface with a weak solution of corrosive sublimate in ether, or painting the borders of the affected area with contractile collodion. The affected part may also be painted with a 50 per cent.

ichthyol and water solution. Alcohol, Burow's solution, and a great many other liquid applications are recommended. Antistreptococci serum is also to be recommended; an initial dose of 20 c.c. followed by doses of 10 c.c., as often as necessary, being the usual procedure.

+Cellulitis.+ In cellulitis, redness of the skin is not very p.r.o.nounced and is late in appearing, following swelling, and not preceding it. It is essentially the same condition as a mild form of erysipelas. Its spread is heralded by red lines of lymphangitis, ascending from a wound (infected), swelling of glands, and fever.

In slight cases, the lymphatics may dispose of the poison, and suppuration fails to occur. In severe cases septicema arises.

Cellulitis is usually a result of infection not only with streptococci, but also with other pyogenic cocci.

+Treatment.+ Incise and curet the wound and apply one of the wet dressings. (See chapter on same).

+Actinomycosis.+ This is an infectious disease characterized by chronic inflammation, and is due to the presence in the tissues of the actinomyces, or ray fungus. At the point of inoculation arises an infective granuloma, around which inflammation of connective tissues occurs; suppuration eventually taking place. Inoculation in the mouth is by way of an abrasion of mucous membrane or through a carious tooth. The fungi may pa.s.s into the bones and joints, causing inflammation of the parts. The bones in actinomycosis enlarge and become painful; the parts adjacent are infiltrated and soften; pus forms and reaches the surface through fistulae and the skin is often involved secondarily. In actinomycosis the adjacent lymphatic glands are not involved.

+Treatment.+ Free incision, if possible, otherwise incision, cauterizing with pure carbolic acid, and packing with iodoform gauze. Internally, large doses of iodide of pota.s.sium should be given, as this drug alone has cured many cases.

+Trench Foot.+ This results from exposure to wet and cold in the trenches, and soldiers who were compelled to have their feet immersed in water for any length of time and were then exposed to cold, are afflicted with this condition. The symptoms are similar to frost bite and the prevention of frigorism (Trench Foot) is as follows: adequate feeding; perfect circulation; moderate exercise; good general health; and warm clothing, which all tend to give the body its maximum power of resistance to cold.

It is obvious that anything that tends to impair the circulation and the nutrition of the tissues is favorable to the occurrence of frigorism. Tightness of the clothing of the extremities, such as tight boots, leggins, etc., is particularly detrimental. Heavy clothing and other equipment, by increasing fatigue, also has a predisposing influence.

With regard to the protection against cold water, it is necessary that the external covering should be impervious to and not affected by water. India rubber stockings, waders, and boots have been used by men working in water, not only as a protection against wet, but also against cold. The best results have been obtained by the use of a waterproof covering that can be worn inside the boot, not because it is the only, or even the best possible method, but because it appears to be the simplest and most practical. A waterproof top boot, so devised as to leave a fairly wide air s.p.a.ce between the boot and the greater part of the foot, ankle, and lower part of the leg, would be more efficient and probably more convenient, provided the material used was soft and light, and did not interfere with movements. To obtain this result a new type of boot would be required.

The treatment of trench foot is similar to that of frost bite.

+Motorman's Foot.+ This is a condition caused by occupation, and the symptoms found are usually those of a flat foot combined with enlarged veins. The chief complaint is that of pain in the calf of the legs, which is increased upon standing for any length of time. The treatment is that for flat foot and enlarged veins.

+Chauffeur's Foot.+ This is a condition also caused by occupation. On account of the position a.s.sumed in driving an automobile, the tendons and muscles of the leg are usually affected and a tendosynovitis very frequently occurs. The symptoms and treatment have already been described. Rest is without doubt the best therapeutic measure.

+Bicycle Foot+ is another occupational disease. The chief symptoms are those of cramps in the calves of the leg, and pains of a severe neuritic character.

At times the onset is very sudden, and the cramps are so severe that it is impossible to extend the leg without causing great pain. Flat foot is usually a.s.sociated with the above condition. The treatment is rest and the administration of the salicylates for the relief of pain.

Bicycling is ordinarily a beneficial exercise for the foot muscles.

When bicycle foot results from this exercise it is usually evidence that the bicyclist had an abnormal condition of his foot muscles and foot joints before he took up the exercise in question.

CHAPTER XIV

+VERRUCA (WART), CALLOSITY, HELOMA (CORN OR CLAVUS)+

+DISEASES OF THE NAILS-INGROWN NAIL+

+VERRUCA OR WART+

+Definition.+ A verruca is a circ.u.mscribed overgrowth of all the layers of the skin, varying in size from a pin's head to a small nut. These growths may be single or multiple, and may come and go without any special reason. _Verruca plantaris_, or plantar wart, is observed on the sole of the foot; it may be single or multiple. It is very painful; it may be the size of a pea and is often mistaken for a callosity, from which it may be distinguished by the pain on pressure, and the tendency to bleed when the h.o.r.n.y layer is removed.

Verrucae are probably contagious, but the pathogenic agent has not been isolated. They sometimes disappear spontaneously, and they will recur if their removal is not complete.

+Treatment.+ Certain chemical substances (see "_escharotics_") destroy tissue and can be employed with safety only after much experience.

These drugs when allowed to spread on the normal skin often occasion painful and persistent lesions. They must therefore be applied directly and sparingly to the growth itself and not be left in contact too long.

The daily removal of a thin layer is possible in this way without causing pain or erosion.

The chemical agents that are employed for the removal of verruca are notably nitric acid, acetic acid, monochloracetic acid, trichloracetic acid, nitrate of silver, sodium hydroxide and salicylic acid. The treatment with these drugs is alike in all cases, with the exception of the last three named.

The procedure, when using liquid acids is as follows: render the growth and the surrounding parts aseptic; by means of a tapering gla.s.s rod or a wooden toothpick, apply a drop of the acid so that it will spread over the growth only, making certain that every part of the outer surface has been treated. If pain becomes excessive, apply a neutralizing agent. Dress the part with a s.h.i.+eld that is holed-out, so that when the foot-covering is in place there will be no pressure over the tissues treated. This treatment should be repeated every other day until there is sloughing at the base of the growth. The pocket produced is drained, and balsam of Peru or some other stimulant should be applied and held in place by an appropriate dressing. Five or six treatments will ordinarily suffice to remove the growth.

Many pract.i.tioners find nitrate of silver a serviceable remedy in cases of verruca. The pure stick, moistened, is gently applied to the surface of the growth, which later becomes blackened. The patient returns two days later when the scab, that will have formed, is removed and the original treatment is repeated. Ordinarily from six to ten such applications will suffice. Those who favor the use of salicylic acid for the removal of verruca, usually apply a 60 per cent. ointment of this drug, over the growth only, protecting the surrounding parts with collodion or gelatine. A holed-out s.h.i.+eld is applied over the growth and an appropriate bandage is made to hold it and the ointment in place. The patient is advised to return at the end of ten days and, as a rule, when the dressing is removed, it will be found that the growth is sufficiently loosened to admit of removal by means of forceps and scissors.

Sodium hydroxide is used in these cases in a saturated solution. It is best applied by means of a wood toothpick, wound about with cotton, and should be used sparingly, much after the manner in which liquid acid applications are made and as above described. A slight stinging sensation indicates that the drug has penetrated the tissues near the nerve-endings in the underlying papillae. Such symptoms render it necessary to neutralize the sodium hydroxide. According to Dr. Joseph Renk of New York City, ordinary vinegar contains just the degree of acidity necessary to neutralize the action of the sodium hydroxide, without adding a new irritating element.

Verrucae may also be removed by the high frequency spark, or by electrolysis. Both of these methods are superior to cutting operations, but are equally as painful unless a drop of anesthetic solution is injected into the base of the growth, before treatment is commenced.

+CALLOSITY+

+Definition.+ A callosity is a circ.u.mscribed thickening of the _stratum cornium_. The condition is usually acquired, occurring on parts exposed to intermittent pressure with counterpressure from an underlying bony prominence, as on the toes, soles, and heel of the foot, from ill-fitting shoes.

Callosities are dirty-yellow to brown in color; their extent depending upon the cause; they are thickest in the centre and pa.s.s gradually into the healthy skin. Sensation is usually lost, or at least diminished, over these areas.

They may interfere with movement and may have painful fissures and become infected, giving rise to abscesses, lymphangitis, gangrene, or erysipelas. Hyperidrosis is often a.s.sociated with this condition.

+Treatment.+ The permanent cure of callosities depends exclusively upon the removal of their causation. The position of the foot in the shoe may be faulty because of excessively high or low heels, causing callous skin to appear upon the weight-bearing surface. Occupations requiring constant standing, and deformities, also enter as causative factors which must be considered.

The palliative cure rests for its efficacy on the removal of the h.o.r.n.y tissue down to, but not into, the papillary layer.

+HELOMA+