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.