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.