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+*** START OF THE PROJECT GUTENBERG EBOOK 79224 ***
+
+
+
+
+                           PRACTICAL PODIATRY
+
+                                   BY
+
+                              ALFRED JOSEPH
+
+     _Senior Professor of Podiatry, The First Institute of Podiatry;
+     Ex-President, Nat’l. Ass’n. Chiropodists; Editor, Pedic Items._
+
+                              E. K. BURNETT
+
+    _Professor of Clinical Podiatry, The First Institute of Podiatry;
+  Vice-President, Nat’l. Ass’n. Chiropodists; Editor, The Podiatrist._
+
+                             REUBEN H. GROSS
+
+  _Professor of Didactic Podiatry and Registrar, The First Institute of
+                Podiatry; Associate Editor, Pedic Items._
+
+
+                                EDITED BY
+
+                          MAURICE J. LEWI, M.D.
+
+    _President, The First Institute of Podiatry; Ex-Secretary, N. Y.
+     State Board of Medical Examiners; formerly Professor of Medical
+   Jurisprudence, Albany Law School; Ex-President, Albany Co. Medical
+ Society; formerly Instructor, Albany Medical College; Member, American
+ Medical Association; Member, N. Y. State Medical Society; Member N. Y.
+                       Co. Medical Society, etc._
+
+
+                              PUBLISHED BY
+                     THE FIRST INSTITUTE OF PODIATRY
+                      213-215-217 WEST 125TH STREET
+                                NEW YORK
+
+
+
+
+                    COPYRIGHT, MAURICE J. LEWI, 1918
+
+
+                       THE WILLIAM G. HEWITT PRESS
+                             BROOKLYN, N. Y.
+
+
+
+
+                            TO THE MEMORY OF
+
+                               GEORGE ERFF
+                                   AND
+                           ELLIOTT W. JOHNSON,
+
+                  builders of the foundation upon which
+                    the edifice of modern podiatry is
+                   reared, this book is reverently and
+                        appreciatively dedicated.
+
+
+The beauties of contour of the human foot, coupled with its strength
+to perform the functions for which it was created, caused the ancient
+Greeks to glorify it in song and in art. Medically and surgically
+it has always been a negligible factor in the world of science,
+notwithstanding the burdens which it is made to bear and in spite
+of the interference with locomotion and with general health which
+this non-care has occasioned for all centuries since creation. Our
+propaganda recognizes the importance of this part of the anatomy and is
+causing the race to realize the need for foot care in health and for
+scientific foot treatment in disease.
+
+
+
+
+CONTENTS
+
+
+         FOREWORD                                      ix
+
+      I  THE RECENT HISTORY OF PODIATRY                 1
+
+     II  THE SKIN                                      11
+
+    III  ASEPSIS AND ANTISEPSIS                        19
+
+     IV  STERILIZATION                                 39
+
+      V  THE CARE OF THE FOOT                          46
+
+     VI  DRESSINGS AND BANDAGING                       60
+
+    VII  INSTRUMENTS                                   78
+
+   VIII  SHIELDS AND SHIELDING                         96
+
+     IX  LOCAL ANESTHESIA                             143
+
+      X  HELOMA                                       149
+
+     XI  CALLOSITAS                                   182
+
+    XII  VERRUCA                                      185
+
+   XIII  CALLOUSED NAIL GROOVE                        205
+
+    XIV  ONYCHOCRYPTOSIS OR INGROWN TOE NAIL          210
+
+     XV  DISEASES OF THE NAILS                        237
+
+    XVI  FISSURES, BLISTERS, AND BURNS                248
+
+   XVII  BURSITIS                                     263
+
+  XVIII  CHIMATLON                                    283
+
+    XIX  DISEASES OF THE SWEAT GLANDS                 297
+
+     XX  ULCERS                                       306
+
+    XXI  CUTANEOUS MANIFESTATIONS OF SUPER-ACIDITY    329
+
+   XXII  VOCATIONAL FOOT DISORDERS                    339
+
+  XXIII  LOCOMOTION AS AN AID IN DIAGNOSIS            343
+
+   XXIV  MISCELLANEOUS FOOT LESIONS                   357
+
+    XXV  X-RAYS IN PODIATRY                           385
+
+   XXVI  THE PODIATRIST’S OFFICE                      405
+
+         GLOSSARY                                     411
+
+         INDEX                                        433
+
+
+
+
+FOREWORD
+
+
+This volume has been compiled by men who started out in life as
+chiropodists. They have lived to see the genesis of podiatry from the
+trade which was theirs, and each of them has taken active part in the
+efforts which marked the transition from the old to the new order
+of things. The period of evolution has been extremely brief. Five
+short years have sufficed to transform the corn-cutters’ trade to the
+podiatrists’ profession.
+
+One of the programmed features of the educational development of
+podiatry was the creation of a scientific literature bearing upon
+the practice of this branch of medicine. The earliest manifestation
+along the lines of this progress was the production of “The Text Book
+of Chiropody.” This ponderous tome (1183 pages) contained matter
+pertaining to the teaching of medical and other scientific subjects
+that led up to the study of chiropody and to practical chiropody
+itself. The chapters on this latter topic were the first attempts of a
+scientific nature to collect material relating to podiatry practice.
+In consequence, the articles were few and their contents were meagre.
+Nevertheless this pioneer attempt to array chiropodical facts and
+methods of treating foot lesions proved efficacious in stimulating
+members of the chiropody profession to the higher educational needs,
+and all over the english speaking globe this literature was hungrily
+masticated and digested by individual practitioners and by chiropody
+societies.
+
+Bright and intelligent members of the profession utilized the material
+thus furnished them by practically applying suggested treatments and
+methods. Aspiring to augment their own knowledge and to add to this
+literature, they wrote up their experiences and, from time to time,
+their matured deductions were given publicity through the columns
+of “The Pedic Items” and “The Podiatrist.” The instructors on the
+faculties of the various chiropody teaching institutions, utilized
+these chapters in their pedagogic work, and medical practitioners
+turned to them to gain their first concrete knowledge of the subjects
+which they treated. These initial chapters thus filled an acute want
+and so proved their worth.
+
+In this volume, a more serious task has been undertaken. Each article
+will be found to have been prepared with a view to presenting the
+subject matter in its entirety, in scientific order and with accuracy.
+There has been no guessing as to cause and effect. Empiricism finds
+no place in these pages. The medical and surgical viewpoint is
+continuously in evidence and “Practical Podiatry” thus becomes the
+first medical work of its kind ever published, a sad commentary on the
+negligence of medical teachers and medical practitioners who have thus
+permitted non-medical graduates to compile the first facts relating to
+an important branch of medicine. The erstwhile tabooed “corn-cutter”
+thus becomes a leader in a collateral branch of medicine, and medical
+practitioners are compelled to glean their knowledge of this subject
+from laymen, who, without their material, moral or monied support--yes,
+often in spite of obstacles which medical practitioners have placed
+in their way--have succeeded in clearly and scientifically portraying
+features of essential medical practice which are to aid materially in
+creating a better species of the genus homo, and in relieving the woes
+of our race. Podiatrists may well feel a pride in this achievement
+and medical practitioners would do well to take home the lesson of
+indifference which this incident discloses.
+
+Podiatry has not alone enriched the scholastic literature of medicine,
+but has also augmented the language of science. New terms have had to
+be coined to properly designate conditions, diseases and instruments.
+In order that these may be understood by the readers of this volume,
+their purport is given in the general glossary which will be found
+in the book. The etymologic construction of these new words is not
+explained because their origin will be readily apparent from their
+definitions.
+
+“Surgery with special reference to Podiatry” was the first volume of
+this series to be published. In presenting “Practical Podiatry” to the
+profession and to the public, the second rung in the ladder of podiatry
+literature has been created and within two years it is hoped that the
+“System of Podiatry,” of which both of the above volumes are a part,
+will have been completed.
+
+Thus will be constituted a library for practitioners and students of
+podiatry which it is hoped will ever prove creditable to its sponsors,
+profitable to the profession and helpful to humankind.
+
+  M. J. L.
+
+
+
+
+CHAPTER I
+
+THE RECENT HISTORY OF PODIATRY
+
+
+The first steps in the movement for the enactment of a law governing
+the practice of chiropody in the United States were made in the state
+of New York, when, in 1895 C. S. Levy, H. Levy, L. B. Rosenberg, H.
+Mayer, E. Werther and M. M. Marks met at the residence of C. S. Levy
+to discuss this matter. As a result of this meeting, a bill drafted by
+Maurice Marks, a well known New York lawyer, was subsequently presented
+to the New York State legislature. John B. Stanchfield, leader of the
+assembly, spoke at length on the question of “feet” and amid mirth and
+laughter (the question was considered somewhat of a joke), the bill was
+passed by the lower house. Shortly thereafter, the senate took similar
+action on the bill, whereupon Governor Morton promptly signed it.
+
+In accordance with the provisions of the law, the Pedic Society of the
+State of New York was organized on the 3rd of June, 1895, and R. H.
+Westervelt was elected president, George Erff, treasurer and Louise
+Hartogensis, secretary. Wm. D. Gaige, Jonas M. Heimerdinger and L. B.
+Rosenberg were selected as the first board of examiners.
+
+R. H. Westervelt served as president of the society for a period of two
+years, when he was succeeded by Elliott W. Johnson, who acted as chief
+executive officer for fifteen years. George Erff was the next president
+and he in turn was succeeded by Alfred Joseph, J. P. Solomon and Ernest
+Graff.
+
+The affairs of the society improved with each succeeding year, and
+much of the credit of its success should go to Maurice M. Marks, who
+acted as attorney for the society, and in addition, assisted wherever
+he could.
+
+
+BIRTH OF “THE PEDIC ITEMS”
+
+“The Pedic Items,” which has done so much to advance the calling of
+podiatry, is the child of Alfred Joseph. In 1906 he outlined a plan
+to the members of the Pedic Society of the State of New York, whereby
+a journal could be created and conducted profitably. On January 1st,
+1907, a leaflet called the “Pedic Society Items” was sent to the
+members. On April 1st, 1907, a four page paper was published, and after
+that Alfred Joseph was offered the position of editor. The “Items”
+appeared every four months for the first few years of its existence,
+and finally became a monthly paper which has grown to a sixty-four
+page book, and even this is inadequate to convey all that is new and
+of interest to the members of the profession. This book is now current
+podiatry literature in every english speaking country in the world. A
+number of chiropody publications have appeared from time to time, most
+of them, of no scientific value, and they died an early death. The
+newest paper, “The Podiatrist,” is a thoroughly scientific journal,
+that has already found a place in the profession; it is edited and
+published by E. K. Burnett, one of the progressive members of the
+podiatry profession, and appears once each month.
+
+
+FIRST SCHOOL OF CHIROPODY
+
+At the March, 1911 meeting of the Pedic Society of the State of New
+York, Alfred Joseph, as chairman of a committee appointed to take the
+matter under advisement, read a report on the question of organizing
+a school, and asked that moneys be subscribed for the purposes of
+incorporating such an institution. In a short time, over $1,200.00 was
+subscribed and the corporation known as “The Chiropodists of America”
+came into existence, with George Erff, president and Alfred Joseph,
+secretary.
+
+This school was conducted along commercial lines, and although its
+purposes were good, it did not meet the standards which its promoters
+were hopeful of establishing for it and which it later secured through
+the action of the Regents of the University of the State of New York.
+
+
+THE NATIONAL ASSOCIATION OF CHIROPODISTS
+
+The October, 1911, issue of “The Pedic Items” contained the first
+announcement of a proposed plan to organize a national association
+of chiropodists. All chiropodists were invited to become members,
+and after a mail vote, Chicago was selected as the first convention
+city. On July 1st, 2nd, and 3rd, after the usual preliminaries, the
+organization was completed, and Alfred Joseph, who was the organizer
+of the association, was elected president. Ernest Graff was elected
+secretary-treasurer. This organization has grown from 225 members at
+its first meeting, to the present large society of over 1,000 members.
+The influence of the N. A. C. is and has been decidedly salutory, and
+its organizers can well be proud of the work they have accomplished.
+
+
+CHANGE IN THE CHIROPODY LAW OF NEW YORK
+
+The members of the Pedic Society of the State of New York, after a
+brief experience, realized the shortcomings of the original law which
+governed the practice of chiropody. They sought to advance their
+calling and to provide so that those entering the profession should be
+properly equipped.
+
+A committee of the Pedic Society of the State of New York composed of
+George Erff, Maurice Marks and Alfred Joseph, called upon Edward Milton
+Foote, M. D., a prominent surgeon, for advice as to procedure. Dr.
+Foote, in turn, advised that the secretary of the N. Y. State Board
+of Medical Examiners be consulted. Thus it came to pass that these
+gentlemen met Maurice J. Lewi, M. D.
+
+Dr. Lewi listened attentively to the request of the committee that he
+devise ways and means for improving the then inefficient chiropody
+law, fell in heartily with their objects and after outlining a plan
+of procedure, drafted a bill which, after receiving the sanction of
+the State education authorities, was introduced in the legislature.
+The bill was unanimously passed and became a law September 1st, 1912.
+Thereupon the State Education Department delegated Dr. Lewi to outline
+a standard for chiropody schools which they promptly adopted. Much to
+the surprise of the officials of the New York School of Chiropody,
+these standards were so high that they feared it would be impossible
+for them to carry them into effect.
+
+Conducting a school along the lines set by the State made it necessary
+to engage as its head one who was a medical practitioner, an educator,
+an executive and a man of character. Where was such a man to be found?
+After much deliberation and numerous consultations, the committee of
+the Pedic Society decided that there was but one man known to them
+who combined all of these attributes and he was the very individual
+who had guided them in seeking to advance their profession, Dr. Lewi.
+When the proposition was put to Dr. Lewi, he declined with thanks
+on the ground that his position as Secretary of the State Board of
+Medical Examiners was to his liking. The committee was insistent and
+pleaded with him to reconsider his determination. For three months
+the committee and their friends labored with Dr. Lewi and finally,
+after making certain stipulations which placed the management of the
+school in his sole charge, he capitulated, and on January 1st, 1913, he
+assumed the presidency of the reorganized School of Chiropody of New
+York. With meagre funds, but with earnest zeal he commenced his task
+and soon surrounded himself with a splendid faculty and with a modest
+but sufficient equipment. The school has flourished. It behooves every
+member of the profession of podiatry to remember that had it not been
+for the broad-mindedness and the foresight of Dr. Lewi, this calling
+which is gradually taking its place as a legitimate branch of medicine,
+would still be the trade it was, and the podiatrists of today would
+still be the “corn-cutters” of yesterday.
+
+On September 27th, 1917, the Regents of the University of the State
+of New York granted a provisional charter to The First Institute of
+Podiatry and henceforth the School of Chiropody of New York will be
+known by that title.
+
+
+THE DEVELOPMENT OF OTHER SCHOOLS
+
+After the organization of the new regime in podiatry education, the old
+system of conducting schools for gain only, was gradually eliminated
+and the need for schools to teach foot ills in a scientific manner,
+became apparent. Since the organization of The First Institute of
+Podiatry, several other institutions have come into existence whose
+purpose is to equip their students to be true podiatrists. The
+California College of Chiropody, situated in San Francisco, is the only
+institution west of Chicago, imparting knowledge of this character. In
+the middle west, the City of Chicago boasts of two schools, viz.: the
+Illinois College of Chiropody and the Chicago School of Chiropody. The
+State of Ohio is well represented by the Ohio College of Chiropody in
+the City of Cleveland. Temple University of Philadelphia, Pa., has a
+Department of Chiropody and is educating specialists in conjunction
+with its medical course. The latest addition to chiropody teaching
+institutions is the University of Massachusetts in East Cambridge, Mass.
+
+All of these institutions are endeavoring to educate their students
+along ethical and scientific lines, and it is but a question of time
+when they will have attained the status and educational influence of
+The First Institute of Podiatry.
+
+
+ORGANIZATION OF PEDIC SOCIETIES
+
+After the Pedic Society of the State of New York had been conducting
+its affairs for several years, podiatrists throughout the country,
+recognizing the advantages to be derived from a conjunction of
+individual interests into groups, created organizations in thirty-seven
+States of the Union. It is safe to predict that within the next five
+years, there will be a podiatry organization in each of the remaining
+States not now so organized.
+
+Activities along these lines have not been limited to the United
+States alone. In England, the Incorporated Society of Chiropodists
+is a flourishing body, boasting a large membership. Ernest G. V.
+Runting is president of that organization and he and many others in
+the British Isles are helping to make podiatry a real profession. The
+other European countries are not progressive in podiatry work (possibly
+due to the war situation), but as the United States and Great Britain
+advance, so will the other nations follow. It is unfortunate that the
+people of many of these European countries do not fully appreciate
+the value of scientific foot treatment, but, as in other educational
+branches, it is only a question of time when every government in the
+civilized world will recognize the necessity for a full study of this
+important branch of medical science, and will also pass laws regulating
+podiatry practice.
+
+In the United States, one of the first states to follow the example of
+New York, was California. In July, 1901, George Koenigstein called a
+meeting of the chiropodists in San Francisco, and an organization known
+as the San Francisco Chiropodists Association was formed. This society
+had for its prime purpose, the passing of a law governing the practice
+of chiropody in the State of California; the organization elected no
+regular set of officers but held desultory meetings once or twice a
+month at the office of Charles L. Scharff.
+
+The bill that this society formulated was presented to the legislature
+at Sacramento and Drs. Scharff and Koenigstein were delegated to press
+it to passage. They worked like Trojans but to no avail. The bill was
+pigeon-holed and nothing more was heard of it. Subsequently the Society
+died a peaceful death.
+
+In 1907, following the great fire in San Francisco, a few chiropodists
+again attempted to pass legislation in California, but this endeavor
+was also fruitless. In the latter part of 1911 and in the early part
+of 1912, stimulated by an article relating to the subject which
+appeared in “The Pedic Items,” and fully realizing the benefits of
+chiropody organization, if properly conducted, several California
+practitioners were elected to membership in the National Association.
+Among these were Oscar L. Gruggel, S. Rutherford Levy, and Charles
+L. Scharff. These men became N. A. C. propagandists, and secured the
+applications of others in California for membership in the National
+Association. On January 12th, 1912, The Pedic Society of the State
+of California was permanently organized and chartered. Its first
+officers were, S. Rutherford Levy, President; William F. Leck, First
+Vice-President, Oscar L. Gruggel, Second Vice-President; H. H. Katz,
+Third Vice-President; Charles L. Scharff, Secretary-Treasurer; Z. L.
+Comet, Sergeant-at-arms, and F. Schilling, Counsel for the Society.
+
+This society attempted to pass a State law regulating the practice
+of chiropody (in 1913) and a bill drafted for the purpose by Mr.
+Schilling, was presented to the legislature. By almost superhuman
+effort on the part of every member of the society, the bill passed both
+houses of the legislature, but the Governor vetoed it on the ground
+that he was opposed to the creation of new State Commissions.
+
+Dismayed, but not disheartened, the legislative committee immediately
+made arrangements to carry on the fight at the next session of the
+legislature. The new bill introduced, instead of creating a separate
+commission, placed the supervision of chiropody practice in the hands
+of the existing State Board of Medical Examiners. Changes agreeable to
+all concerned were made, and in the 1915 session of the legislature,
+the Benson Medical Act, 443, to regulate the practice of podiatry in
+California, was passed by both houses. On June 8th, the bill was signed
+by the Governor and the law became effective August 8th, 1915.
+
+In the State of Illinois, the first organization was effected in
+September, 1904. A charter was applied for and granted to Charles
+Kenison, Nicholas Von Schill, Frank Johnson and Ignace J. Reis. The
+officers elected were, Charles Kenison, President; Leonard Lower,
+Vice-President; C. G. Sims, Treasurer and Ignace J. Reis, Secretary.
+
+On September 18th, 1912, the temporary organization of The Illinois
+Pedic Association was effected. The organization was made permanent on
+October 2nd, 1912, and the following were elected as the first officers:
+
+President, Ignace J. Reis; Vice-President, Maximilian Pincus, M. D.;
+Secretary, Henry Schmidt; Treasurer, John Kenison; Trustees, Leonard
+A. Lower; Henry J. Riegelhaupt; Charles Kenison; Counsellors, Frank S.
+Lower, M.D., H. P. Kenison, M. Pincus, M.D.
+
+In the year 1906, S. L. Lawton of Fall River, Mass., consulted with
+F. J. Coughlin of Boston as to the advisability of forming a state
+chiropody association. Harry P. Kenison of Boston was advised with
+and readily fell in with the plans. As a result, a meeting was called
+at the office of the latter and the Massachusetts Association was
+created. The first officers were J. P. Buntin, Boston, President;
+S. D. Lawton, Fall River, Vice-President; F. J. Coughlin, Boston,
+Secretary-Treasurer, and the following Directors: H. P. Kenison, F. E.
+Davis, C. R. Watkins, A. M. Brackett, W. E. Lee and G. M. Pettingill.
+This society has flourished and, due to the efforts of several of
+its members, including the present president of the N. A. C., H.
+P. Kenison, the present law governing the practice of chiropody in
+Massachusetts was passed. This was accomplished in spite of strenuous
+opposition on the part of medical practitioners and a few disgruntled
+chiropodists within and out of the organization.
+
+In the West, there is gradually springing up a progressive spirit in
+all that pertains to podiatry. Much of this spirit has been created
+through the efforts of a few practitioners in the State of Colorado who
+have been extremely active in the past few years. In 1914, Bertha De
+Wolfe, having taken a course at the School of Chiropody of New York,
+located in the City of Denver. Realizing the necessity of organization,
+she immediately set to the task, and in December of that year, the
+Colorado Pedic Society held its first meeting. It was incorporated,
+January, 1915. Its first officers were, C. S. Rees, President; A. M.
+Parker, first Vice-President; Lucy Ballou, second Vice-President;
+Bertha De Wolfe, Secretary-Treasurer.
+
+The late Benjamin Oelsner of Bridgeport, Conn., was always an active
+member of the profession, and through his efforts, the Connecticut
+Pedic Society was organized, in the city of New Haven, March 23rd,
+1910. This organization has grown rapidly, and because of its
+activities, Connecticut now has a chiropody law on its statute books.
+
+The Rhode Island Chiropodists Society was organized November 8th, 1914,
+largely through the efforts of Alfred C. Moran, who represented the
+National Association of Chiropodists in that section of the country.
+This organization is gradually growing, and since the convention of the
+N. A. C. which was held in Providence, R. I., many practitioners who
+previously showed no interest in the union of podiatry forces, have
+become active workers in the interests of the profession. The officers
+of The Rhode Island Chiropodists Society are Charles T. Heilborn,
+President; Henry S. Batchelder, first Vice-President; F. S. Sargent,
+second Vice-President; Alfred C. Moran, Secretary-Treasurer.
+
+
+LAWS GOVERNING PODIATRY PRACTICE
+
+Since the first law governing the practice of podiatry passed in the
+State of New York, eighteen other states have taken similar action.
+The National Association of Chiropodists has been largely responsible
+for most of the success along these lines. The committee in charge
+of legislation has been a most active one, and its usefulness may be
+realized, when it is recorded that during the period from August,
+1916, to July, 1917, six states in the union passed laws regulating
+the practice of podiatry. As the profession advances, and the academic
+requirements are increased, the laws are so changed as to create a
+greater scope of endeavor for our practitioners. Thus in some states
+the law permits the podiatrist to perform operations of a major nature,
+while in others the practice is limited to structures involving the
+true skin only. It is safe to predict that in a few years, every state
+in the union will have enacted legislation regulating the practice of
+podiatry. The states now governed by such laws (New Jersey was the
+first) are Colorado, California, Connecticut, Illinois, Louisiana,
+Maryland, Massachusetts, Michigan, Minnesota, New Jersey, New York,
+Ohio, Pennsylvania, Rhode Island, Vermont, Virginia, Washington, West
+Virginia and Wisconsin.[1]
+
+Educators and the public generally throughout the entire country are
+beginning to realize the value of scientific foot care, and where the
+chiropodist was derided and scoffed at years ago, the podiatrist of
+today is gradually taking the place he so rightly deserves, at the
+side of the members of the other professions, honored and respected as
+a well trained, educated man who is proving a benefactor to the human
+race. So it is, that the schools of chiropody are being developed, and
+in a few years when the academic requirements will have become the same
+as for the other professions, the courses of study at these schools
+will run on all fours with the schedules of study maintained at medical
+schools.
+
+
+
+
+CHAPTER II
+
+THE SKIN
+
+
+Podiatry deals largely with ailments involving the skin or its
+appendages and it is deemed advisable to describe briefly the anatomy
+and physiology of that organ, so as to refresh the memories of those
+who study this work.
+
+It is not the intention of the authors to enter deeply into this
+subject and the reader is referred to the works in this series
+which deal exclusively with anatomy and physiology, for a more
+intimate knowledge of the skin. It is an accepted fact that no one
+can intelligently comprehend pathology without knowing the normal
+structure and functions of the tissues of the body to be considered,
+and it is for that reason that the pages to follow have been written.
+
+[Illustration: 1. Stratum Corneum; 2. Stratum Lucidum; 3. Stratum
+Granulosum; 4. Stratum Mucosum; 5. Papillary Layer; 6. Reticular Layer;
+7. Subcutaneous Tissue; 8. Hairs; 9. Fat Cells; 10. Sudoriferous
+Glands; 11. Sebaceous Glands; 12. Pacinian Body or Touch Corpuscle; 13.
+Connective Tissue Cells; 14. Nerve Endings 15. Vascular Papillæ and
+Capillary Loops]
+
+
+ANATOMY OF THE SKIN
+
+The skin as a whole is composed of two distinct layers resting upon a
+third structure, the subcutaneous tissue. The outer portion is called
+the epidermis, cuticle or scarf skin, and is without blood and nerve
+supply, while the inner portion is called the corium, derma or cutis
+vera, and contains the capillary loops and nerve endings.
+
+
+THE EPIDERMIS
+
+=The Epidermis= is divided into four layers, named from without inward,
+the stratum corneum, the stratum lucidum, the stratum granulosum and
+the stratum mucosum or rete Malpighii.
+
+=The Stratum Corneum=, or horny layer of the skin, is composed of many
+layers of horny, non-nucleated scales which are being continuously
+displaced by exposure to weather, water, etc., and are being as
+continuously renewed by the deeper layers. This layer of the skin is
+involved in the simpler foot lesions such as heloma and callositas.
+
+=The Stratum Lucidum=, or clear layer of the skin, is composed of a few
+rows of transparent cells, without distinct boundary, and, except on
+the palms and soles, is considered a part of the stratum corneum. It is
+composed of from two to four layers of cells, which are like the cells
+of the horny layer except that they are brighter and more homogeneous.
+This layer is not often clearly defined and is of no importance.
+
+=The Stratum Granulosum=, or granular layer of the skin is composed
+of several rows of polygonal shaped cells which are well marked on
+the soles of the feet. The nuclei of the cells are not well defined
+and the cell itself refracts light. The granules found in this layer
+are varied in shape and contain a fluid called eleidin and a peculiar
+solid substance called keratohyalin. This substance is derived from
+the cytoplasm of the cells and represents the first process in the
+cornification of the cells in the outer layers of the epidermis.
+
+=The Stratum Mucosum=, or mucous layer of the skin, usually called the
+rete, or rete Malpighii, is the deepest and most important layer of the
+epidermis. The basal layers of cells are separated from the corium by a
+basement membrane or membrana propria, and these layers, which are made
+up of columnar cells, contain the pigment of the skin. The next few
+layers show elongated, oval or rounded shaped cells, the form varying
+with the locality, the tendency being to a rounded shape, owing to the
+more even pressure on the cells from above and below. The cells are
+irregularly formed and are made up of a soft substance with large oval
+or rounded nuclei. In the intercellular spaces is found a fluid which
+is nutrient in character. In the stratum mucosum are found the prickle
+cells. These cells have hairlike processes on them which serve to hold
+the cells together.
+
+
+THE DERMA
+
+=The Derma, or Corium=, is divided into two layers, the outer, called
+the papillary layer, or pars papillaris, and the inner, called the
+reticular layer, or pars reticularis. It is composed of bundles of
+fibrous tissue, yellow elastic tissue and connective tissue cells, the
+reticular layer being more compact than the papillary layer. The derma
+contains blood vessels, nerves, lymphatics, touch corpuscles, hairs,
+sweat glands and sebaceous glands.
+
+=The Papillary Layer= of the skin is composed of small conical
+elevations called papillæ, which blend with the prolongations of the
+rete above. The best developed papillæ are found on the under or flexor
+surfaces of the fingers and toes and attain their greatest length at
+this point. They are placed in double rows that underlie the cutaneous
+ridges on the fingers and toes. These cutaneous ridges remain unchanged
+throughout life and are so characteristic of each individual, that they
+are used as a means of detecting and identifying criminals and others.
+Papillæ of two kinds are noticed, the one being very well supplied with
+blood vessels, and are called vascular, the others being only scantily
+supplied with blood, containing medullated nerves, and are called
+sensory papillæ.
+
+=The Reticular Layer= of the derma is composed of loosely arranged
+bundles of connective tissue which merge with the papillary layer
+without a distinct line of demarcation. In these bundles of connective
+tissue are found the sweat glands, the sebaceous glands, the hair
+follicles and the deeper lymphatics. This layer of the derma is made up
+of fasciculi of connective tissue which blend into each other obliquely
+and give it a plexiform appearance. As the bundles ascend towards
+the surface they divide into smaller and finer bundles, and when the
+papillary layer is reached, they have a close, felt-like appearance.
+
+=The Subcutaneous Areolar Tissue=, or tela subcutanea, connects the
+skin with the deeper structures and should be considered a part of the
+true skin. It is made up of loosely arranged bundles of connective
+tissue which cross each other repeatedly and form well defined spaces.
+These spaces contain fat, and where there are large quantities of this
+fat, as on the soles of the feet, the tissue is designated as adipose.
+The subcutaneous areolar tissue also contains the deeper hair follicles
+and the deeper sweat glands.
+
+=Blood Supply.= The layers of the epidermis are without vascular
+supply, but the derma and the subcutaneous tissue are well supplied
+with blood vessels. There are two plexuses, one superficial in the
+upper layer of the derma, and the other deep, in the subcutaneous
+tissue. The vessels of the upper layer arise from the deeper plexus and
+give off branches in all directions supplying the hair follicles, sweat
+and sebaceous glands. The papillary layer is richly supplied with
+delicate capillaries, which terminate in the papillæ, and are called
+capillary loops.
+
+=Lymphatics.= The lymphatics follow the vessels in a general way, there
+being two plexuses, viz.: deep and superficial. Lymph spaces are found
+in the rete Malpighii, which connect with the channels of those in the
+derma. The papillæ and the glands also have lymph channels.
+
+=Nerve Supply.= The skin contains both medullated and non-medullated
+nerve fibres; these fibres are especially abundant in the soles of the
+feet and at the ends of the toes. They enter the skin with the more
+important ascending blood vessels. The non-medullated nerves terminate
+in the rete as fine filaments, and the medullated nerves end in the
+corium and subcutaneous tissue in special terminals called corpuscles.
+Examples of these are Pacinian corpuscles, tactile corpuscles and the
+end bulbs of Krause.
+
+In addition to the sensory nerves, the skin also contains vasomotor
+nerves. These nerves are found on the smooth muscles of the skin and
+on all glands having such muscles, and have a direct action on these
+glands.
+
+=Muscles.= Both striated and non-striated or smooth muscles are found
+in the skin. Those of the latter variety are most common, while the
+former are sparingly found. The smooth muscle fibres are found in
+connection with the hair follicles, the sebaceous and the sudoriferous
+glands, and they act upon these organisms.
+
+=Sudoriferous Glands.= The sudoriferous glands, or sweat glands, are
+found in the reticular layer of the corium and in the subcutaneous
+tissue. They are simple tubular glands which are coiled into globular
+shape. The tubule of the gland empties into a gland duct which passes
+through the corium and the epidermis and opens on the surface of the
+skin in a funnel-shaped sweat pore. The sweat glands are very numerous,
+particularly on the soles of the feet. It is estimated that there are
+2,000,000 sweat glands in the adult human body.
+
+=Sebaceous Glands.= The sebaceous glands, or oil glands, are found in
+the reticular layer of the derma, usually associated with or in close
+proximity to a hair follicle. They may occur independent of the hairs
+however, as is the case in the lips. They vary in size from a simple
+pouch to a many pouched or multilobular gland. These pouches empty into
+a common duct, which in turn empties between the hair and the inner
+sheath. The ducts secrete sebum, which consists of fatty degenerated
+cells, in which is found epithelial waste matter. The sebum keeps the
+skin and the hair soft and oily.
+
+
+NAILS
+
+=The Nails= are a specialized form of epidermis, and are considered
+by many to correspond to the stratum lucidum of that structure. They
+are horny, elastic, transparent, quadrilateral plates, and are found
+at the distal ends of the fingers and toes, on their dorsal surfaces.
+The nails are convex on the outer surface and concave within. The
+nail itself is called the body and rests upon the nail bed. It has a
+free edge distally and two lateral and a proximal or short edge which
+latter lie in a groove called the nail or ungual fold. The ungual wall
+overlies the lateral and proximal portions. The nail is embedded into
+the derma at its proximal end by a root. This part of the nail is found
+beneath the ungual wall and is composed of cells which have not yet
+become horny.
+
+The thin layer of skin, which extends forward from the nail groove at
+the beginning of the body of the nail, is called the eponychium or nail
+skin. The lunula is the little whitish, crescentic spot, a portion of
+the nail bed, which is found in front of the nail fold, and extends to
+the lateral edges of the nail.
+
+The matrix of the nail is situated beneath the root of the nail,
+and is so-called because it is from this structure that the nail is
+produced. The matrix is thick, and raised in a series of longitudinal
+ridges, which are readily seen through the transparent nail tissue. It
+corresponds to the mucous layer of the epidermis, and is essentially
+of the same structure. The matrix is highly vascular, which accounts
+for the pink color seen through the nail, except at the lunula.
+
+
+PHYSIOLOGY OF THE SKIN
+
+The functions of the skin may be subdivided as follows:
+
+  Touch Organ
+  Protective Covering
+  Excretory and Secretory Organ
+  Temperature Regulator
+  Organ of Respiration
+
+The skin acts as a touch organ or as an organ of tactile sensibility;
+this power is supplied by special bodies found in the papillæ. The
+degrees of consistency, of size, of form and of other qualities are
+recognized by this function. Other sensations are conveyed by these
+special nerve endings, such as heat and cold, burning, itching,
+tingling, etc. The sense of touch is well developed, particularly in
+the skin at the ends of the fingers, and this sense may be farther
+increased, as is the case with blind persons.
+
+The skin acts as a protective organ to the body within, by excluding
+harmful agents such as bacteria, chemicals, heat, cold, etc. It is
+elastic and thick and is without sensation and thus protects the
+delicate structures beneath it from injury from various causes.
+
+The functions of excretion and of secretion are performed by the
+glands. The sudoriferous, or sweat glands, excrete the perspiration,
+and in this way also act as elimination organs, accessory to the
+kidneys. The body is continuously sweating. When there is no indication
+of this function, when the skin seems dry, the name “insensible
+perspiration” is applied; when the function is apparent, by the
+formation of drops of moisture on the surface, it is called “sensible
+perspiration.”
+
+The sebaceous glands are organs of secretion. They give off an oily
+substance called sebum, which lubricates the hairs, and gives an oily,
+soft appearance to the skin. This tends to keep the outer layers
+elastic and pliable; where this function is absent, the skin becomes
+dry and is likely to form cracks or fissures.
+
+The skin acts as a regulator of the body heat, by controlling the
+radiation of the heat as brought to the surface from within, and
+by regulating evaporation. The normal tension of the skin on the
+various parts of the body has an influence in the regulation of body
+temperature.
+
+The function of respiration is, to some extent, duplicated by the skin,
+the process being analogous to the respiration that takes place in the
+lungs. The amount of oxygen absorbed is small, but water and carbon
+dioxide are freely given off.
+
+
+
+
+CHAPTER III
+
+ASEPSIS AND ANTISEPSIS
+
+
+To understand thoroughly and rationally to practise asepsis and
+antisepsis, it is necessary for the operator to realize the difference
+between the two terms. There is a general belief among the laity--and,
+unfortunately, among some chiropodists--that these two words are
+synonymous, and that asepsis and antisepsis comprehend the same system
+of treatment. This is a fallacy.
+
+=Asepsis= is a condition in which living pyogenic organisms are absent.
+Aseptic surgery comprehends the performance of an operation in a field
+free from pyogenic or septic germs, with sterilized hands, instruments,
+etc., preventing the introduction of germs from without.
+
+=Antisepsis= is the process whereby germs causing disease,
+fermentation, or putrefaction are destroyed. Antiseptic treatment
+comprehends the use of certain drugs or a group of drugs which prevent
+the action of germs, which inhibit their growth, or which destroy them.
+
+In the comparison of these two foregoing definitions the distinction
+between the two words is clearly brought out. We speak of a
+drug--mercuric chloride, for instance, as having an antiseptic action.
+We speak of a piece of sterile gauze--sterilized, we will say, by
+heat--as being aseptic. The mercuric chloride is an active substance
+which, applied to a septic area, will proceed energetically to its
+work of germ inhibition or destruction. The sterile gauze, placed over
+a similar area, has no power to prevent or even retard the action of
+the invading bacteria, let alone destroy them, but once having been
+rendered free from such germ life by an antiseptic, the aseptic gauze
+will keep the area in a germ free condition for a greater or lesser
+length of time.
+
+To sum up, then, the term “antiseptic” is applied to a drug or group
+of drugs from whose actions bacteria are rendered innocuous or are
+destroyed; and “aseptic” is applied to a condition in which no germ
+life exists, having previously been freed from such contamination by
+the use of an antiseptic agent.
+
+Some years ago the term “germicide” was used in contradistinction
+to that of “antiseptic.” This usage was brought about through the
+belief that some antiseptics would not destroy all forms of germ life.
+Germicide, at that time, was used to distinguish a drug which would
+energetically attack and destroy all bacteria. Inasmuch as, on close
+survey, it was found that the antiseptics which would not destroy all
+germs were, in a great measure, weaker solutions, and that, if used in
+greater strength, they would be efficient as purifying agents, this
+distinction, today, has been done away with, and the terms germicide
+and antiseptic are used synonymously and will be similarly employed in
+this chapter.
+
+
+ANTISEPSIS
+
+Antiseptics to be actually efficient must be brought in direct
+contact with the septic area. There is an erroneous belief that all
+of the official germicidal agents and a majority of the proprietary
+preparations, the advertising matter of which latter claims for them
+great antiseptic proprieties, are efficient in deep-seated, septic
+processes by mere surface application. This is wrong, and it is for
+this reason that in all septic inflammations, free drainage must
+be obtained and maintained, and the actual surface upon which the
+bacterial action is in evidence must be exposed before the beneficial
+action of antiseptic agents can be exerted or prove beneficial.
+
+The skin unquestionably does, at times, absorb a drug applied to its
+surfaces; but where an active infective process is present, the
+antiseptic action of a germicidal agent is practically nil unless the
+drug is brought into direct contact with the septic surface.
+
+The present success of Dakin’s solution, for instance, is not so much
+on account of the great efficacy of the solution itself--although
+it has potent germicidal properties--as it is due to the Carrel
+method of irrigation whereby this solution is carried to the most
+obscure recesses in which the infective process is present. Applied
+superficially, as must needs be done in chiropodial practice, we find
+that Dakin’s solution is of no greater value than many other antiseptic
+agents, except perhaps that, on account of its being non-toxic, it can
+be used in cases where germicides with strong toxic properties are
+contra-indicated.
+
+
+HISTORY OF ANTISEPTICS
+
+The story of antiseptics is one of the most interesting in all the
+pages of medicine and surgery.
+
+Antiseptics were employed as remedial agents long before the exact
+causes of putrefaction or fermentation were known. The Egyptians
+preserved the human body against the attacks of putrefactive organisms,
+without any knowledge of the character of the organisms causing decay.
+The wonderful state of preservation in which we, today, find the bodies
+of their kings, was brought about by means of balsams containing,
+probably, such antiseptics as benzoic and cinnamic acids.
+
+In the sixteenth century the surgeons treated gunshot wounds with
+boiling oil. They knew that if these wounds were left untreated,
+putrefaction would ensue accompanied by great suffering, and the
+ultimate death of the patient. They also knew, empirically, to be sure,
+that boiling oil applied to the wound prevented the development of this
+putrefactive process, but they did not know why such was the case, nor
+did they realize that, by this use of superheated oil they were merely
+cauterizing the wound.
+
+Ambrose Pare (1510-1590), who started life as an apprentice
+barber-surgeon in Paris, became a military surgeon in the army of
+Francis I, in Piedmont; and he, more from a humane feeling, as his
+writings tell us, than from any particular scientific knowledge, had
+the temerity to dispense with this oil boiling technic and to trust to
+a simple bandage saturated with a concoction of herbs. Pare, however,
+has no particular place in the development of antisepsis, his principal
+contribution to surgery being in the development of the use of the
+ligature for large arteries, which made amputation on a large scale
+possible for the first time.
+
+Antiseptic surgery dates from the last few years of the nineteenth
+century, and among the names of its sponsors which will ever remain
+foremost, are Pasteur and Lister.
+
+Lister’s use of local antiseptics in surgery, however, should not,
+perhaps, be spoken of as a discovery. Without detracting in any way
+from the credit due him, it should be referred to, more correctly, as a
+practical application, in particular of the theories of Pasteur, and of
+several previous investigators.
+
+Prior to Lister’s use of phenol, the substance had already been
+described by Reichenbach in 1832, and by Runge in 1834, as one which
+would prevent putrefaction. Long before these, tar and a number of
+similar products were advocated and used for foul ulcers, but the fact
+remains that Joseph Lister placed the use of antisepsis in connection
+with surgical procedures on a sound and practical basis.
+
+Taking as a working basis the experimental researches of Louis Pasteur
+(Communications on the Theory of Fermentation 1853, 1858; The Germ
+Theory, read before the French Academy of Sciences on April 29th, 1878,
+and The Extension of the Germ Theory, which appeared in 1880), Joseph
+Lister, an English surgeon, developed his theory of antiseptic wound
+treatment. His first experiments were made public in 1860. At that
+time he stated that the evils observed in open wounds were due to the
+admission into them of organisms which “exist in the air, in water,
+on instruments, on sponges, and on the hands of the surgeon or the
+skin of the patient.” Having accepted the germ theory of putrefaction,
+Lister applied himself to discover the best way of preventing harmful
+organisms from reaching the wound from the moment it was made until
+it was healed, or, if this could not be done, of using some agent to
+destroy the organism, either before it reached the wound or after it
+had lodged there.
+
+Acting on the advice of Lemaire, who had already experimented with
+several substances which were known to be antagonistic to putrefaction,
+Lister chose carbolic acid, which he used first in the crude form.
+
+His experiments extended over a number of years during which period
+he surmounted many obstacles, until in the early 80’s he finally
+perfected his antiseptic treatment of wounds by means of carbolized
+sprays for the air of the room, carbolized solutions for irrigation,
+for instruments and for surgeons’ hands, and carbolized dressings with
+mackintosh protection, as post-operative procedures. Today we smile
+at the idea of a dressing of phenol in any strength, covered with
+mackintosh protection; but in advocating this procedure, Lister had in
+mind, as nearly as possible, to cover the wound so that no external
+agencies might come in contact with it.
+
+From this beginning, our present day antiseptic surgical technic has
+been gradually developed. Mercuric chloride gradually replaced phenol,
+and the use of the carbolic spray was discontinued on account of its
+chilling influences on exposed surfaces, which tended to lower their
+vitality.
+
+Aseptic surgery owes its origin primarily to antiseptic surgery. Not
+long after Lister’s rules for antiseptic procedure were generally
+observed, the realization came to many that the success of Listerian
+surgery did not depend so much upon the spray or the carbolized gauge,
+as it did upon cleanliness; the surgeon’s hands, the instruments, the
+area to be operated upon, and the dressings must be clean--surgically
+clean.
+
+Today we have the rule of “the soap and nail brush,” the sterilized
+instruments, the aseptic rubber gloves for the operator’s hands, and
+the sterile dressing. The modern surgeon uses no antiseptics during
+operations; he uses instruments which are positively germless and the
+dressings of aseptic gauze are not impregnated with medications.
+
+
+ANTISEPTICS
+
+The important subject of antisepsis embraces such a variety of agents
+which may be employed in the numberless conditions arising, that it
+is usually divided into three groups. (1) general antiseptics; (2)
+local antiseptics; (3) internal antiseptics. For the purposes of
+the podiatrist, some knowledge of the first group is desirable, but
+his principal thought on this subject should be given to a thorough
+knowledge and understanding of the second group, those for local
+application. Inasmuch as the podiatrist is not allowed to prescribe
+internal medicines, no discussion of the third group, comprising
+internal antiseptics, will be included in this chapter.
+
+=General Antiseptics=, or disinfectants, play so great a part today in
+preventive medicine that the podiatrist should at least inform himself
+on the general principles involved.
+
+Under this group we find a number of agents which are employed for
+purposes of general disinfection. First on the list comes:
+
+=Sunlight.= The bright, direct rays of the sun, coming into direct or
+immediate contact with germ life, are the best of all disinfectants.
+This does not mean their merely shining on one side of a carpet, or
+on small masses of blood, pus or sputum, but their penetrating each
+individual microorganism. When this can be accomplished, all germ life
+is destroyed in a few hours. But this cannot be accomplished in all
+conditions, and, unless the penetration of sunlight is thorough it is
+not dependable. For this reason we are forced to rely on other agents
+(thermal and chemical) to accomplish our purpose.
+
+=Heat.= A direct flame will, of course, instantly destroy all forms of
+microscopic life; dry air heated to 160° C. (320°F.) will destroy all
+disease germs--but not all spores--in one hour. Moist heat, water or
+air saturated with aqueous vapor, heated to 75°C. (167°F.) will destroy
+most germs.
+
+Boiling water will even kill spores in ten minutes, if they are not in
+small masses. To break up such masses the addition of a small amount
+of baking soda will serve, not alone to dissolve these albuminous
+collections, but will also keep instruments from rusting (see
+Sterilization). Steam, or air which is supersaturated with steam, is
+fatal to pathogenic organisms, and at a much lower temperature than dry
+hot air.
+
+Chemicals which may be included under this group of general
+disinfectants are: formaldehyde, lime, sublimed sulphur and chlorinated
+lime.
+
+=Formaldehyde=, formalin or formic aldehyde, is widely used as a
+general disinfectant. It is exceedingly powerful, one part of the gas
+rendering fifty thousand parts of air irrespirable. The action of
+formaldehyde is increased by moist heat, it does not actively corrode
+metallic instruments nor does it injure fabrics. The formaldehyde
+cabinet is used generally by podiatrists. (See Sterilization).
+
+The official preparation of formaldehyde is a 37% solution known as
+liquor formaldehydi, U. S. P. For the disinfection of rooms, the
+solution may be applied directly by washing or spraying, or it may be
+used in vapor form. When the latter is employed, the windows and doors
+are tightly closed and all the crevices are plugged with paper.
+
+=Lime=, calx, or calcium oxide, is extensively used but must be freshly
+prepared to be effective. Unslacked lime is a cheap, and an efficient
+means of destroying animal matter, but the milk of lime, freshly
+slaked, is by far the most desirable form.
+
+=Sublimed Sulphur=, or flowers of sulphur, is not so generally used
+today as is formaldehyde. It should be used only in places where
+nothing can be injured by the corrosive action of the resulting
+sulphurous acid. As with formaldehyde disinfection, the vapor must come
+into actual contact with the microorganisms and the atmosphere should
+be moist.
+
+=Chlorinated Lime=, improperly called chloride of lime, is a ready
+source of chlorine, and is a convenient and inexpensive agent for
+general disinfection purposes. It has a corrosive action, however, and
+therefore should not be used in places where this action will do damage.
+
+There are a number of drugs which may be more or less successfully
+employed as general antiseptics and disinfectants. Phenol, cresol,
+potassium permanganate, mercuric chloride and copper sulphate are
+on this list, but as the podiatrist is principally concerned with
+the second group, local antiseptics, these drugs, which are included
+usually under that group, will now be discussed.
+
+It is deemed wise before passing on to the subject of local
+antiseptics, to bring one important point to the attention of the
+student. Under no circumstances must the term deodorant be confused
+with disinfectant. A deodorant is an agent which merely destroys or
+conceals an offensive odor and has no power whatsoever to actually
+destroy or inhibit the growth or action of bacteria. Many disinfectants
+are also deodorants, but a deodorant may not always have germicidal
+properties.
+
+=Local Antiseptics= are agents which are applied locally and externally
+for the purpose of arresting putrefaction. In podiatry there are a
+number of drugs belonging to this class which may be safely employed
+and whose beneficent action may be depended upon.
+
+There has been a marked tendency in podiatry in the past toward the use
+of a number of proprietary drugs for germicidal purposes. Happily this
+practice is dying out, and a few years will find the therapeutics of
+podiatry established on a sound, rational basis.
+
+The following local antiseptics can be safely employed in podiatry
+operations:
+
+=Alcohol= is used generally in practice to render fields of operation
+surgically clean. The pure grain alcohol is used for the immersion
+of instruments prior to operation, but a 60% solution is found more
+efficient for antiseptic action upon the body surfaces. A pledget of
+sterile cotton, saturated with alcohol and placed over a part, insures
+absolute asepsis in a short time. Alcohol alone cannot be practically
+used as a wet dressing. In this connection it is combined with boric
+acid, equal parts, and is efficient as an antiseptic.
+
+=Liquor Alumini Acetatis=, an 8% aqueous solution of acetate of
+aluminum, is used almost entirely as a wet dressing in infective
+inflammations. It is non-toxic and, while it is irritant to extensive
+denuded surfaces, it is usually employed for its astringent action.
+
+=Balsam of Peru= is used chiefly in podiatry as a stimulating agent;
+its antiseptic properties, however, are well known and are probably due
+to the benzoic and cinnamic acid which it contains. It is used either
+alone, in ointment form, 3% to 10%, or in combination with collodion,
+10%.
+
+=Boric Acid= is employed principally as a wet dressing in cases of
+inflammations. It is quite free from toxicity and is but slowly
+absorbed. It is also used in powder form as an antiseptic.
+
+=Boroglycerine=, U. S. P., contains 30% of boric acid. It is found
+particularly effective in the treatment of indolent ulcers where a mild
+antiseptic lotion is desired.
+
+=Borate of Sodium= (Sodii boras, U. S. P.), borax, has an alkaline
+reaction and for this reason is sometimes substituted for boric acid.
+It is soluble in 16 parts of water.
+
+=Dakin’s Solution= is a solution of hypochlorite of soda, ¹⁄₂%. The
+preparation of the original solution is so difficult that large
+quantities of the drug are not easily obtainable. Chlorazene, an
+American product which is recommended by both Dakin and Carrel, is
+obtainable in tablet and in ointment form. One tablet dissolved in 8
+ounces of water makes a solution, ¹⁄₂ of 1%. The solution is unstable,
+necessitating its being constantly made fresh, and for this reason the
+use of the drug is not practical in podiatry practice today. When used,
+the solution must be changed within twenty-four hours; if this is not
+done it becomes irritant, setting up an acute dermatitis. The drug is
+used as a wet dressing, but never with rubber or oiled silk covering.
+
+=Di-Chloramin-T=, the newer form in which Dakin’s solution is used, is
+a 5% or 10% hypochlorite of soda solution in oil of eucalyptus. This
+combination is found to be less irritating than the original solution.
+It is used as an antiseptic dressing.
+
+=Glycerinum=, U. S. P., is not alone useful as a mild antiseptic but
+is also extensively used as a vehicle for many other substances in the
+treatment of skin lesions.
+
+=Hydrogen Dioxide=, peroxide of hydrogen, is used principally in
+podiatry to decompose pus in which bacteria are protected from the
+action of other antiseptics. As the antiseptic action of hydrogen
+dioxide is dependent solely upon the liberation of its component
+oxygen, it is easily seen that once the ebullition occurring on its
+contact with albuminous surfaces ceases, it becomes inert. “Peroxide”
+is used as a pus germ destroying agent, and to loosen dressings which
+have become adherent from copious discharge.
+
+=Iodine=, Tinct. Iodii, U. S. P., is 7% of iodine in alcohol, and
+presents the best agent known at the present time by which surface
+sterilization can be obtained. It is highly germicidal, but continued
+applications are decidedly corrosive and not alone inhibit the
+development of new granules, but also cause severe dermatitis, and at
+times symptoms of iodine poisoning. The one feature which prevents its
+use in some chiropodial procedures is the discoloration of the tissues
+produced by its application. It may be used full strength or diluted
+with water, as weak as a 1% solution.
+
+=Iodoform=, despite its unpleasant and suggestive odor, is an efficient
+antiseptic and is used in powder form. Its antiseptic action is
+principally derived by the slow liberation of its component iodine.
+
+Several forms of mercury are used in podiatry.
+
+=Bichloride of Mercury=, or mercuric chloride, is used, ¹⁄₂₀₀₀, to
+prepare fields for operation, and from ¹⁄₅₀₀₀ to ¹⁄₁₀₀₀₀ as a wet
+dressing in infective inflammations. It is highly toxic and should
+never be used for any great length of time, or on a denuded surface
+of any size, as it is rapidly absorbed into the general system, and
+its corrosive action tends to inhibit the development of new granules.
+There are also systemic effects to be feared from its absorption.
+
+=Mercurous Chloride=, calomel, can be used as an antiseptic dusting
+powder on many chiropodical lesions. It is combined generally with
+bismuth, equal parts, as an antiseptic and astringent application for
+blisters and burns.
+
+=Unguentum Hydrargyri=, U. S. P., is a 50% ointment, used principally
+in chiropody in the treatment of parasitic diseases of the nails.
+
+=Unguentum Hydrargyri Ammoniatum=, 10%, is an antiseptic ointment used
+safely in any case where such action is desired.
+
+=Phenol Liquefactum=, U. S. P., carbolic acid, is used as an antiseptic
+in solution, 2¹⁄₂%. It is highly toxic and is never used as a wet
+dressing under any circumstances. Phenol, besides its toxic properties,
+has an anesthetic action on the peripheral nerves, and due to this
+action, many cases of carbolic gangrene have been reported.
+
+=Liquor Cresolis Compositas=, U. S. P., also a coal tar product, can be
+advantageously used in a general spray for the foot, or for the special
+field of operation. It is antiseptic, and its saponaceous properties
+(it is a solution of cresol and soap) aid in softening the tissues as
+well as in cleansing them. It is used in 2% strength.
+
+=Lysol=, an unofficial phenol derivative, is also used as a general
+spray, 2%, in water. Its odor is very strong and it is therefore
+objectionable to many persons.
+
+=Thymol= is a phenol occurring in a volatile oil. It possesses strong
+antiseptic properties, but its comparative insolubility in water has
+prevented its more general use. The only official combination of thymol
+is
+
+=Thermolis Iodidum=, U. S. P. Thymol iodide, or more correctly
+dithymoldiiodid, has been better known for years under its trade name
+“aristol.” It is used as a dusting powder, is actively antiseptic
+by the liberation of iodine, and has become popular as an iodoform
+substitute.
+
+=Potassium Permanganate=, U. S. P., has its greatest usefulness as a
+local antiseptic application where deodorant action is also desired. In
+the treatment of indolent, foul ulcerations it is very efficacious.
+
+=Sulphur= is used principally in podiatry in the form of =Unguentum
+Sulphuris=, U. S. P. It is composed of 15% of washed sulphur, usually
+in a lanolin base, and has a mildly stimulating and antiseptic action.
+
+There are any number of additional drugs, both official and
+unofficial, which can be and are used in podiatry practice, but it is
+deemed sufficient to name the foregoing which constitute a complete
+armamentarium for all antiseptic procedures.
+
+
+THE FIELD OF OPERATION
+
+For rendering the field of operation aseptic the following technic will
+be found efficient:
+
+In addition to preparing the immediate field it is found advantageous
+to treat the surrounding areas to prevent the washing in of bacteria.
+To accomplish this the use of an antiseptic spray is to be advocated.
+
+Equipped as the podiatrist is with modern air compressing devices,
+this is a simple matter, the principal question being the selection of
+a proper spray.
+
+An aqueous solution of alcohol is exceptionably suited for purposes of
+this kind and where a lesion is already present this drug should be
+used to the exclusion of all others.
+
+Most cases the podiatrist is called upon to treat, however, present no
+lesion, yet asepsis must be procured in the event of a lesion being
+made during his operative procedures. In cases of this nature a spray
+of liq. cresolis compositus, U. S. P., 2¹⁄₂%, will be found to be an
+agreeable and efficient application. This solution has but a slightly
+disagreeable odor and has marked softening as well as antiseptic
+properties.
+
+After the whole foot has been thoroughly sprayed and dried with a
+sterile towel, the immediate field of operation may be coated with tr.
+iodine, 3¹⁄₂%. This is one-half the strength of the official tincture
+and is advocated to obviate the deep stain occasioned by the use of
+the 7% tincture. In many cases, however, no stain whatsoever can be
+countenanced for fear of obliterating some diagnostic point, and it
+may be found advisable to dispense entirely with iodine, substituting
+alcohol, 60%, in its stead.
+
+A pledget of sterile cotton saturated in this solution of alcohol
+and placed over the area under treatment, will produce asepsis in a
+short time. The penetrating qualities of alcohol are, however, found
+to be increased, if application is made by means of a cotton wound
+applicator, the mixture being rubbed vigorously into the parts.
+
+The use of either of these two methods will procure a sterile field
+upon which any chiropodial operation may be commenced and completed in
+safety.
+
+Should hemorrhage be caused during operation, it may be arrested in a
+number of ways: (1) Bichloride of mercury, ¹⁄₁₀₀₀, may be applied on a
+pledget of sterile cotton. This will serve to check the blood flow by
+hastening coagulation, and at the same time will procure asepsis. (2)
+Tr. iodine may be painted over the lesion and digital or tourniquet
+pressure applied until coagulation is complete. (3) Astringent and
+antiseptic dusting powders may be applied. (4) Styptics (Monsel’s
+solution is efficient and the least irritating) may be used, but it
+must be remembered that these drugs combine no antiseptic qualities and
+therefore it is good surgery to apply tr. iodine before their use.
+
+A hemorrhage arrested by any of the foregoing methods should be
+dressed antiseptically, as well. For this form of dressing, antiseptic
+ointments or dusting powders are found to be most effective.
+
+
+ASEPSIS
+
+The topic of asepsis will be found more thoroughly, discussed under the
+chapter “Sterilization.”
+
+Aseptic procedure comprehends the employment of all instruments and
+materials which have by some means been previously rendered free from
+germ life. Instruments are to be thoroughly sterilized by boiling in
+water for at least fifteen minutes, the hands of the operator are to be
+thoroughly cleansed, or are made as nearly germ free as is possible;
+the dressings used are to be surgically cleansed (usually by moist or
+dry heat) before application; and no antiseptic solutions are included
+in the treatment.
+
+It is doubtful if aseptic procedures can be practised in podiatry to
+the exclusion of antisepsis. It must be remembered that after most
+chiropodical surgical procedures, the foot surfaces (again encased in a
+shoe) teem with septic matter which present the mediums best suited for
+the propagation of bacterial life,--heat, moisture and darkness.
+
+An aseptic dressing having been employed, the length of time it
+will remain germ free is problematic; so it is found advisable in
+most instances where there is danger of infection, to resort to an
+antiseptic method of treatment rather than to rely solely upon the
+aseptic.
+
+Dr. Edward Adams, Professor of Surgery at The First Institute of
+Podiatry, lecturing to the students on “The Newer Antiseptics in the
+War,” spoke as follows:
+
+“The immense number and variety of wounds encountered in the present
+war, necessitating the care of many thousands of men at one time,
+and the entirely new situations created by modern warfare, have led
+to an amount of research heretofore unknown. True to its traditions,
+the medical profession has endeavored to discover the best methods in
+treatment and to render the best service in its power to bestow. Never
+has the surgeon had to face greater difficulties and never has he
+recorded more brilliant success.
+
+“Where practically every wound is infected, antisepsis has necessarily
+received unusual attention, and the merits of different substances
+having antiseptic properties have been thoroughly discussed and have
+narrowed down to a very few. The fact is emphasized that those which
+are strong enough to be antiseptic must be used with great care,
+especially in cases where drainage is not free.
+
+“After many trials and many discussions the tendency of men of the
+greatest experience, however, is to reduce the problem to very simple
+terms which may be expressed thus: (1) How to secure a clean wound.
+(2) How to give nature a chance with a minimum of interference, since,
+after all, she must do the healing.
+
+“The early part of the war demonstrated the fact that both antisepsis
+and asepsis, as heretofore practised, have been vanquished by Mars. By
+some it was even considered that Lister’s work went for naught. Now,
+however, antisepsis and asepsis, each in its proper place, have come
+into their own again and Lister is still the apostle of good tidings.
+
+“The reasons are plain: first, at the beginning of the war we did not
+possess sufficiently effective antiseptics such as have now been given
+us; second, we were not masters of an efficient technic. We owe these
+innovations especially to two men, Dakin and Carrel, who have wrought a
+marvelous change. Lister taught us above all how to prevent infection;
+Dakin and Carrel, following his principles, have taught us how to
+conquer even the most virulent infections. For nearly half a century
+surgeons have been fighting strenuously against infection, but it
+required the stimulus of war to enable us to win a victory. Prevention
+and cure both are ours now.
+
+“The newer antiseptics that have been discovered and used since the war
+are chiefly: Dakin’s solution of hypochlorite of soda, di-chloramin-T,
+eusol and eupad, both preparations of hypochlorous acid, flavin,
+acriflavin, and proflavin, and a mercurial preparation known as
+mercurophen.
+
+“These newer antiseptics, especially the flavin group, have pronounced
+bactericidal qualities, but it is too recent as yet for them to have
+been tested on a sufficiently large scale to permit of positive
+conclusions as to their value. Flavin is described in detail as to its
+process of manufacture and its action in an article by C. H. Browning
+and his colleagues in the Bland-Sutton Institute of Pathology of
+Middlesex, London (_British Medical Journal_, January 20, 1917, page
+73). For technical reasons flavin as one of the acridin group is now
+called acriflavin, and a more potent preparation is called proflavin,
+which is described in the _British Medical Journal_, June 9, 1917.
+Dakin, in the same journal, June 23, 1917, endorses Browning’s method
+of treatment with acriflavin. Its antiseptic action, instead of being
+diminished by blood serum, is increased thereby, even up to five times
+its potency. Moreover, as used by Browning, it is harmless to the
+tissues and does not interfere with the activity of the leucocytes nor
+with phagocytosis.
+
+“The most important paper yet published on these newer antiseptics is
+by Browning Culbranson and L. H. D. Thornton in the _British Medical
+Journal_, July 21, 1917. The principal points brought out by their
+experiments with the use of acriflavin and proflavin are as follows:
+first, that the bactericidal power of acriflavin and proflavin, instead
+of being diminished and even destroyed by the contact of blood serum
+(as is the case with hypochlorite of soda, bichloride of mercury,
+etc.), is greatly increased from 10 to 40 fold. Second, as a result,
+these two antiseptics, though acting at first merely by inhibiting
+bacterial growth, later become increasingly powerful and actively
+destroy the bacteria. After two hours’ contact in the presence of
+serum, mercuric chloride is practically equal to acriflavin in its
+lethal effect on the streptococcus and bacillus coli, but by this time
+the effective action of the mercury salt on the bacteria has come to an
+end, and a concentration which has then failed to kill the organisms,
+exerts little or no inhibiting effect on the proliferation of the
+survivors. On the other hand, concentrations of the flavins, which
+at this period have merely inhibited multiplication, later on prove
+bactericidal, so that finally the flavin compound is ten to twenty
+times more lethal than corrosive sublimate. Therefore, instead of
+renewing the solution every two hours, only one or two daily dressings
+are required. Moreover, they are apparently harmless to the tissues.
+Experiments show that such concentrations of flavin as will effectively
+control the bacteria do not interfere with phagocytosis.
+
+“Brilliant green, like the hypochlorites, in the presence of serum,
+soon loses its value as a bactericide; hence, if used it must be
+renewed at frequent intervals. On the other hand, it possesses the
+advantage of being an extremely potent bactericide, far exceeding the
+flavins in watery solutions, while at the same time it is comparatively
+harmless to phagocytosis, as well as to the tissues locally, and when
+applied to a wound it is devoid of general toxic action on the body.
+Its use by two hourly flushings after the Carrel method, has proved
+most encouraging.
+
+“The Dakin Solution. The value of this antiseptic has been demonstrated
+by Drs. Carrel and Dakin. It is a carefully standardized solution of
+sodium hypochlorite and is usually prepared from chlorinated lime
+(bleaching powder), but may be prepared directly from chlorine gas. The
+formula has been varied from time to time. Some surgeons use an acid
+solution (anærobes do not live in an acid medium), others an alkaline
+solution, while Drs. Dakin and Carrel in their method, avoid an excess
+of either quality. In the solution now used by them which is made
+according to the formula of Dufresne, the chlorinated lime is combined
+accurately with both sodium carbonate and sodium bicarbonate, making
+a nearly neutral product which contains from 0.45 to 0.5 per cent. of
+sodium hypochlorite, because less is too weak and more is too strong.
+The advantages of this solution are as follows: (1) It is antiseptic
+and does not damage the tissues. (2) It is non-toxic and no danger is
+to be apprehended from its absorption. (3) It is hypertonic, that is,
+the concentration of the solution is greater than that of blood serum
+and tissue fluids, and therefore, it produces an outflow of lymph. (4)
+If used as an acid solution it is available against anærobic bacteria
+which require an alkaline medium.
+
+“The fact that nearly all wounds of the present war are infected, in
+connection with the serious and often fatal nature of the infection,
+has stimulated an unusual amount of research with the hope that a
+reliable and safe disinfectant may be discovered--especially one that
+will not injure the tissues of the body, since these are more easily
+affected by the disinfectant than the bacteria themselves. This object
+has been realized in large part by the Dakin-Carrel solution, which,
+however, to be effective, must be frequently renewed according to the
+Carrel technique. It is also frequently very irritating to the skin,
+although this may be avoided by the use of petrolatum.
+
+“According to the investigation of Dakin, a chemical action takes place
+between the hypochlorite in the solution and the proteins in the wound
+exudate with the formation of the new substances called chloramines.
+One of these chloramines has been prepared synthetically and introduced
+under the name of chlorazene, which is said to possess a germicidal
+power four times greater than the Carrel-Dakin solution itself and
+is unirritating to the skin but, like the latter, must be frequently
+renewed. By dissolving one of these chloramines in an oily medium,
+however, it is possible to keep it in contact with the wound surfaces
+for a much longer time than can be done with a watery solution. The
+advantage of this is evident.
+
+“The solution which is used at present has been named di-chloramin-T,
+the medium being chlorinated eucalyptus oil or paraffin oil. A ten
+per cent. solution of di-chloramin-T and eucalyptol may be kept in
+a colored bottle for at least one month with only slight change. It
+is applied to the wound surface in the form of a spray after the
+removal of infection foci and devitalized tissues. Deep cavities are
+filled with the liquid and drainage afterwards provided for. The high
+percentage of disinfectant contained in this preparation renders it
+active for a period of twenty-four hours because of the slow liberation
+of the germicide. It would appear that when applied with strict
+attention to detail it is not only less expensive than the Dakin-Carrel
+method, but will secure healing of a wound in a much shorter time. The
+gradual elaboration of the remedy makes it particularly applicable
+in cases that cannot be frequently dressed during transportation.
+Di-chloramin-T, hypochlorites and hypertonic salt solutions all have
+the power of dissolving dead tissue. A precaution to be remembered,
+however, is that if used near a blood vessel hemorrhage may occur.
+
+“For a detailed report of the use of di-chloramin-T in the treatment
+of infected wounds, read Dr. H. T. Dakin’s article in the _Journal of
+the American Medical Association_, July 7, 1917. For a still later
+description of the Dakin-Carrel treatment of wounds, see the report of
+the Surgical Commission to the Directors General of the British Army
+Medical Service reprinted from the _British Medical Journal_, November
+3, 1917.
+
+“To my mind the best preparations that can be easily used are: (1)
+Chlorazene (Abbott), in tablet form; (2) in form of a non-irritating
+surgical powder containing 1 per cent. chlorazene; (3) in form of a
+cream containing 1 per cent. of chlorazene in a sodium stearate base.
+These I can recommend.”
+
+
+
+
+CHAPTER IV
+
+STERILIZATION
+
+
+In the practice of medicine and its allied branches, it is recognized
+that no unsterilized object is clean; it is therefore necessary for
+every such object to be sterilized before being brought in contact
+with, or near to a wounded surface, or to a surface about to be wounded.
+
+Previous to the time of Lister, who was the first one to practise and
+to advocate asepsis and antisepsis, it was considered normal for a
+wound to suppurate and the consequent appalling results were accepted
+as being in order. Today, however, asepsis and antisepsis have been
+proven to be absolute essentials to intelligent treatment, and it is
+accordingly necessary that every practitioner treating the human body,
+should exercise the greatest care so as to prevent the invasion of
+hostile bacteria.
+
+Sterilization may be defined as the act of rendering an object sterile
+(clean), by the destruction of microorganisms, preferably by means of
+heat. To perform any operative work, so that there is perfect asepsis,
+or freedom from bacteria, depends entirely upon the care exercised in
+practising such asepsis. The instruments, the dressings, the field of
+operation and the hands of the operator are all media for contamination
+and the infection of wounds, and the sterilization of all these is
+necessary, as infection might come from lack of care in the preparation
+of any one of these details before an operation.
+
+=Instruments.= The most efficient way of rendering instruments sterile,
+is by immersing them in boiling water for fifteen minutes. To each
+quart of water used in the sterilizer, is added one-half an ounce of
+sodium carbonate (washing soda). This prevents rusting and also acts
+as a solvent for any fatty substance that may be on the instruments.
+
+Superheated steam is used for sterilizing instruments, but this
+requires especially large and expensive apparatus which is not at the
+command of most practitioners. Dry heat will destroy bacteria, but it
+is not as effective as moist heat (steam). To procure absolute results
+requires a high temperature, which effects the temper of the steel in
+the instruments.
+
+Instruments with sharp cutting edges, such as are used in the removal
+of helomata, are blunted by boiling. They are therefore best sterilized
+by immersing them in pure carbolic acid for a few minutes, followed by
+dipping in grain alcohol, the instruments being handled with a pair of
+forceps.
+
+=Dressings.= Dressings such as gauze, bandages, absorbent cotton and
+other cloth materials are best sterilized by steam which is allowed to
+circulate through the material for fifteen minutes, and they may then
+be placed in dry heat for a short time, thus allowing the moisture to
+evaporate. If a steam sterilizer is not available, the dressings may be
+boiled, or they may be baked for ten minutes in a temperature not lower
+than that of the boiling point of water. Care should be taken that the
+heat is not great enough to scorch or burn the materials.
+
+Sterilized dressings of all kinds may be purchased in convenient,
+hermetically sealed packages, and may be safely used without
+preparation. Once such a package has been opened and used, the contents
+do not remain sterile; the materials left over from an operation should
+not be used at another operation unless they have been again thoroughly
+sterilized.
+
+=Field of Operation.= The skin of the foot is much thicker than that
+on the other parts of the body and in addition it usually does not
+receive the same hygienic care as does the rest of the skin surface. It
+is therefore highly essential that additional precautions be taken in
+preparing the foot for operation.
+
+The entire foot should be scrubbed with soap and warm water so as to
+remove as much of the exfoliated skin and dirt as possible. It is then
+immersed in a solution of bichloride of mercury (¹⁄₂₀₀₀) and wrapped
+in a sterile towel until ready for operation. The foot may also be
+prepared by first scrubbing with soap and water, washing with alcohol,
+60%, and finally painting the part to be operated upon with tincture of
+iodine. Iodine has proven to be the best antiseptic in use today, but
+very often it interferes with chiropodical operations due to the stain
+it produces. This may be overcome to a certain extent by washing the
+part with alcohol after the iodine has been applied.
+
+Alcohol in a sixty per cent. solution is a very efficient antiseptic
+and wherever iodine cannot be used, it may be substituted. A piece of
+absorbent cotton, dipped into the alcohol, is placed in contact with
+the part to be treated and is allowed to remain for a few minutes. Like
+iodine, alcohol penetrates the layers of the epidermis and so destroys
+the bacteria that lurk between the outer layers.
+
+=Hands of the Operator.= There are several ways of cleaning the
+operator’s hands, but each such procedure is preceded by thoroughly
+scrubbing them with green soap and a nail brush for at least ten
+minutes, in warm water. Alcohol or ether should then be rubbed over the
+hands to dissolve fats, and they should then be dipped in a solution
+of bichloride of mercury (¹⁄₂₀₀₀) for a few minutes. A most efficient
+way of sterilizing the hands consists of the following: after scrubbing
+the hands as before described, take equal parts of chloride of lime and
+carbonate of soda (about one-half teaspoonful of each) and add enough
+water to make a paste. This is thoroughly rubbed into the hands and
+when the sensation of warmth has disappeared they are rinsed in sterile
+water.
+
+The use of rubber gloves to protect the hands is of some advantage in
+that they may be thoroughly boiled before they are used; but unless
+the hands are sore or the skin is tender, they should not be employed,
+as they decrease the sense of touch so necessary in chiropodial
+procedures.
+
+
+STERILIZING APPARATUS
+
+There are many kinds of apparatus for each form of sterilization, and
+the podiatrist, in selecting a sterilizer, must be guided by the size
+of his purse as well as the amount of space he can afford for such an
+apparatus.
+
+The steam sterilizer is unquestionably the best for general purposes,
+and the dual compartment arrangement is better than a single chamber
+outfit. Steam sterilizers for office purposes vary in size from the
+small single chamber, measuring four inches wide, eight inches long and
+four inches deep, to the larger double chamber which measures twelve
+inches wide, twenty-four inches long, the upper chamber twelve inches
+deep and the lower chamber six inches deep. The latter sterilizers are
+the best possible for the podiatrist’s work, in that they allow for the
+sterilization of towels, dressings and instruments at the same time,
+and there is no direct contact between the instruments and the boiling
+water. The apparatus may be heated by gas or by electricity, gas being
+the most desirable as it is more easily controlled and regulated. The
+cost of the instrument equipped for gas heating is very much cheaper,
+and the operating expense is less than when electricity is similarly
+used.
+
+As its name implies, the double compartment sterilizer is composed
+of two distinct sections which are easily separated, and when put
+together look as if they were one section. The lower compartment is
+more shallow than the upper and contains the water which is boiled for
+the manufacture of the steam to be utilized in the sterilization. The
+upper compartment has an inner jacket which is so arranged that the
+steam passing from below is collected in it, and is admitted into the
+compartment proper through a small opening at one end. This causes
+the steam to be forced in under a slight pressure, which increases the
+heat and adds to its power as a germ destroying agent. The opening is
+controlled by an inlet valve which may be adjusted so as to prevent the
+steam from entering the compartment. The steam then circulates around
+it in the jacket and in this way dry heat is generated in sufficient
+quantity to allow for dry heat sterilization. If space permits, it is
+advisable to have two such sterilizers, one for steam sterilization
+and the other for dry heat sterilization. The instruments, towels and
+dressings may thus be dried which prevents the rusting of the steel,
+and makes the linen more easy to handle. These sterilizers are as well,
+an ornament to any office.
+
+[Illustration: ELECTRIC STERILIZER]
+
+Where space is limited, the smaller electric sterilizers may be
+substituted for the larger outfits. There are many styles and shapes
+of this kind of instrument, but the principle is the same in all of
+them. There must be ample space for the reception of the instruments,
+and the cover must be closed when the water is boiling. The electric
+current is passed into a metallic disc, situated beneath the bottom
+of the water receptacle. As the current passes through this disc, it
+becomes hot, and the water in the compartment is gradually heated until
+the boiling point is reached. The current must never be left on when
+the machine is not in use, for when the water has evaporated, the heat
+will cause the solder holding the joints of the sterilizer to melt and
+cause a separation of the seams. This molten solder might even drip
+on something combustible and set it alight. There are some electric
+sterilizers which are equipped with safety devices which prevent this
+possible accident. The device provides so that when this heat is great
+enough, it melts a small piece of an alloy with a very low melting
+point. This metal is held in position by a clamp which is attached
+to the current flow and when this melts, the current is cut off and
+further heating is impossible. This is a very valuable attachment,
+particularly when one is inclined to be careless.
+
+Another form of smaller electric sterilizer consists of a glass
+compartment into which is placed the heating apparatus. This latter
+is composed of coils enclosed in a metal protector. The protector is
+attached to a handle, through which pass the electric wires. This coil
+and handle is placed into the glass bowl and is held fixed by a small
+clamp. A cover is then placed over the bowl, which is so arranged as to
+allow the wires to pass through it.
+
+For sterilization with pure phenol and alcohol, it is necessary to
+have two wide mouth, glass stoppered, two-ounce bottles. When the
+instruments are being sterilized they may be left standing in either
+bottle until ready for use. A piece of felt, cut to fit the inside
+bottom of each of the bottles, should be placed in situ, so that when
+sharp edged instruments are placed in the bottles, their points will
+not be broken, by coming in contact with the hard glass.
+
+[Illustration: FORMALDEHYDE STERILIZER]
+
+Formaldehyde gas is an agent which has germicidal properties, and is
+used to a great extent where steam sterilizers are not available.
+Formalin, a concentrated solution of the formaldehyde gas, readily
+gives up its gaseous constituent so that when the liquid is placed on
+a flat tray, the gas will penetrate objects around it. Cabinets have
+been constructed which are so arranged that the lower shelf contains
+the solution, and the upper shelves may be used for instruments,
+dressings, towels, etc. When the cabinets, which vary greatly in size,
+are tightly closed, the gas will penetrate every object contained
+therein, thus destroying any microorganisms which might be present.
+
+
+
+
+CHAPTER V
+
+THE CARE OF THE FOOT
+
+
+=The Naked Foot.= For many centuries the human foot was allowed to go
+naked, and our aboriginal ancestors never knew what foot clothing of
+any type meant. Much the same as with the rest of his body, unaided
+nature was allowed to minister to the needs of his pedal extremities.
+Research has shown that primitive man was very strong and able to
+withstand the abuses of the elements to a marked degree. The body
+adapted itself to nature and the elements, so that it could bear
+extreme heat or cold, wind or rain, or any condition of the weather,
+without giving way before these nature forces.
+
+So it was with the foot of man during this period. The skin of the
+soles became thickened so that even the roughest surfaces caused no
+discomfort when borne upon by his bare feet. Even to this day, savage
+tribes that still go barefoot have skin on the soles of the feet that
+is tough and hardened. The author has seen natives of Central America,
+who are of this class, step on objects such as glass, lighted cigars,
+etc., without experiencing any appreciable discomfort.
+
+In aboriginal man, muscular action of the entire foot was developed
+to its maximum. The muscles of the toes were under perfect control so
+that objects could be felt and lifted with them, much the same as with
+the fingers of man today. The leg muscles were well developed so that
+the position of the body in walking could be altered quickly and the
+body weight could be rapidly changed from one foot to another, so as to
+avoid contact with sharp pointed objects, such as burrs, sharp twigs,
+pointed stones, etc.
+
+Nature was primitive man’s physician. Being continuously exposed to
+the air, skin exfoliation, evaporation of moisture and other normal
+functions were never interfered with. The objects with which the body
+came in contact in wading through small streams, or in walking through
+the wet grass and dewy underbrush, acted much the same as the bath
+brush of modern times. Further, man of that period, living on nature’s
+foods, was never subject to the various conditions brought about by
+improper diet and which in turn manifest themselves in the feet as well
+as in other parts of the body.
+
+=Advent of Foot Clothing.= As time went on and man became more and
+more civilized, clothing for the foot was gradually adopted, and from
+that time to the present the foot has undergone changes that make it
+necessary for the human race to resort to treatment for lesions that
+could not have developed if nature had had her way, and man had never
+adopted covering for the foot.
+
+The first style of foot covering was the sandal. This caused no special
+trouble, but when man began to depend upon them for protection for the
+soles of the feet, nature consequently no longer required the tough,
+protecting, heavy skin, and gradually the integument of that region
+became thinner. The result has been, that today, slight trauma or
+irritation causes many disturbances on the soles, among which are the
+common helomata dura and verrucæ.
+
+An evolution of footgear followed the use of the sandal, and with
+civilization came vanity in foot dress and finally the modern shoe,
+completely at variance with nature’s demands and causing so many
+disturbances that specialists in treating foot lesions became requisite
+to care for them.
+
+=Modern Footgear.= The modern shoe, as compared to the normal foot, is
+worthy of special consideration. As a rule, the men who build shoes
+have from time immemorial been pure commercialists. Their purpose in
+engaging in the manufacture of footwear always has been and is to do
+business. They have attempted to create styles that would sell. They
+have produced wares that would be popular and therefore saleable.
+The question of the niceties of the anatomy and physiology of the
+foot and leg played no part in their calculations because they knew
+nothing about these features as factors in gaining results. The foot
+was treated as a whole, much as the hat manufacturer considers the
+human head when building a head covering. No consideration was given
+the natural beauties of the foot, so much appreciated by the ancient
+Greeks. The need for conserving the functions of the small bones of the
+foot so that their articulations would not be disturbed, caused them no
+pause. The necessity for allowing free play to all of the muscles which
+abduct, adduct, evert, invert, flex and extend the foot was and is a
+negligible quantity with the shoe-builder. There are few exceptions to
+this rule.
+
+Suppose the dentist were to make sets of teeth to be fitted to the
+jaws of those who had become toothless, basing their manufacture of
+these dental adjuvants on the prevailing needs of groups of these
+tooth-defectives, and tooth-shops were to be instituted to fit
+these sufferers from wares in stock! The public would deride such
+an innovation. And still it is almost as ridiculous to suppose that
+our shoe-shops can properly clothe the feet of the public as they
+should be clothed from a stock of shoes which are made without careful
+relevancy to the anatomy and physiology of the foot. Let us take one
+feature of the modern shoe as a sample of this pandering to style:
+the high heel, so common on women’s shoes, is a pure conceit. It is
+responsible for many of the foot lesions of today, and in addition
+causes systemic disturbances of a serious nature. When the body in
+standing is erect, the foot should be at right angles to the leg.
+When the heels are raised, however, it would be necessary to tilt
+the body forward to still maintain the right angular posture. It
+therefore becomes necessary in maintaining the erect position to allow
+for the malalignment of the body, due to the high heels, and this is
+accomplished in the knees, hips and spine. The knees are flexed, the
+hips rotated and the abdomen thrust forward. This latter interferes
+with the normal position of the abdominal organs, and thus arise many
+diseases common to women. The high heel is the etiologic factor.
+Locally, the calf muscles become contracted and an inward lateral
+displacement of some of the tarsal bones results. Gradually the other
+bones of the foot are displaced, and weak and flat foot result.
+Further, the high heel causes the foot to slip forward in the shoe and
+the toes are thus crowded. When the body weight is brought to bear upon
+the ball of the foot in walking, this crowding prevents the normal
+spreading of the metatarsal bones, and there is distortion of the
+bones, causing anterior displacement, or dropping of the anterior arch
+with resulting metatarsalgia.
+
+Another illustration: the function of the sudoriferous glands, namely,
+the elimination of liquid waste, in the form of sweat or perspiration,
+is going on continuously. As the fluids are brought to the surface
+by the gland ducts, evaporation takes place immediately, except
+under unusual circumstances, such as mental excitement, increased
+temperature, etc., in which instances the production may be very
+rapid or may be retarded. When the foot is encased in a shoe, or in a
+stocking that does not absorb moisture, such as silk or lisle, this
+evaporation is retarded to a greater or lesser degree, depending upon
+the leather of which the shoe is made. Such interference with normal
+functions is productive of many foot ills elsewhere noted in these
+pages. In this connection the podiatrist should be familiar with these
+facts: Vici kid is the most porous of all the leathers used in shoe
+manufacture, so that most if not all of the moisture excreted by the
+glands evaporates. Calf skin is not so efficient for foot covering, in
+that evaporation is limited; both of these leathers are far superior to
+either patent leather or colt skin, which latter are absolutely air and
+water tight, and should never be used as a foot covering. The stocking
+should be of a material that will absorb moisture, and cotton or woolen
+hose are best for this purpose and will assist in keeping the feet dry
+and normal.
+
+Again, the nails of the toes are often unfavorably affected by the
+modern shoe, especially the nails of the great toes. The toe box of
+the average shoe is made of stiff, unyielding material so that if
+the shoe is narrow or short, irritation or undue pressure is brought
+to bear upon the nail or the surrounding tissues, causing disease.
+It is especially necessary to obviate the possibility of pressure of
+the soft tissue of the nail groove against the hard nail substance,
+because if such a condition arises and is allowed to persist, calloused
+nail grooves, helomata and often ingrown toe nails result. In the
+same manner, pressure on the various parts of the nail may cause club
+nail, onychia or paronychia. Simple packing of the nail grooves with
+absorbent cotton, if properly done, is often the means of avoiding
+serious nail lesions, which, as a rule, are very painful.
+
+In this connection it would be well to remember that it is most
+important that the nails be cut properly. The corners of the nails
+should never be removed, unless there is some trouble beneath the
+part. Removal of the corners of the nails changes the position of the
+surrounding soft tissues, which depend upon the hard nail substance
+for support, and thereby causes them to collapse. This is one of the
+primary etiologic factors of ingrown toe nail.
+
+The bony structures of the foot have suffered extensively since the
+advent of modern footgear, and the treatment of the lesions in which
+the osseous tissue is involved is of importance to the podiatrist as
+well as to the surgeon or orthopedist. Many deformities of the foot are
+such that only the surgeon is qualified to successfully treat them, but
+the more common lesions properly come under the care of the podiatrist,
+and should be treated by him.
+
+Pointed shoes cause displacement of the metatarsal bones, with
+subsequent nerve compression; hallux valgus is a common deformity due
+to misfitting shoes. These latter conditions are the result of improper
+footgear, as also of incorrect posture and of faulty locomotion.
+
+The soft tissues of the foot have suffered to a great extent because of
+the modern shoe, especially the muscles that arise in the leg and are
+inserted in the foot. Upon these muscles principally depend the motions
+of the foot, especially those of flexion, extension, adduction and
+abduction. The calf muscles, as previously stated, become shortened,
+due to the high heels. Additionally the muscles on the outer side of
+the leg are shortened while those on the inner side are lengthened. The
+long extensors of the toe are also shortened.
+
+When it is remembered that there are twenty muscles in addition to the
+twelve muscles of the leg inserted into the foot, the limited motion
+of this area, as compared to other parts of the body, is apparent.
+Take for instance, the movements of the toes in the average adult. The
+action of the great toe is markedly limited and that of the lesser
+toes is almost lost. This loss of action is brought about by a lack
+of use of the digits of the feet. The hands and fingers being used
+continuously, the movements of these digits are active and numerous.
+The toes have a like muscular supply, but are far less efficient. The
+ability of the barefoot races to use their toes as accessory fingers,
+is proof that lack of development is due to lack of motion because of
+the toes being encased for most of the time in footgear.
+
+=Hygiene of the Foot.= The many perverted functions of the foot that
+have been brought about by the use of modern footgear have made it
+essential that this part of the body be given special attention
+both by the specialist and by the individual himself. There are
+several essentials for proper foot care with which everybody should
+be familiar, and it is the duty of the podiatrist to instruct his
+patients in these essentials. The general hygiene of the foot is little
+understood by the average layman, and the fact that a patient takes a
+daily bath is no indication that the feet are being properly cleansed.
+To accomplish this the foot should be washed with soap and water, care
+being taken that any excrementitious matter which may have accumulated
+between the toes is thoroughly removed. It is best to use warm water
+for this purpose, and when the feet have been thoroughly cleansed
+they should be rinsed in cold water. This closes the glands which
+have become dilated by the heat; if allowed to remain open, they will
+over-functionate. The foot must be dried well, especially between the
+toes, and after this has been done, alcohol may be applied to assist in
+this purpose. Alcohol is both astringent and dehydrating. In cases of
+a normally dry skin, alcohol may be dispensed with; instead, a small
+quantity of an animal oil should be rubbed into the skin; lanolin is
+very efficient for this purpose.
+
+Water, as a therapeutic agent, is used extensively and has many
+advantages that are lacking in other remedial measures. It is one of
+the most ancient of remedies, and its value has been recognized to such
+an extent that there are large institutes in this and other countries
+devoted exclusively to hydrotherapy.
+
+No other agent is capable of producing so great a variety of
+physiologic effects as water; it is easily obtained and is also readily
+adaptable for the various conditions in which it is of benefit. Pastor
+Kneipp obtained excellent results with his water cure in Europe, and
+although his methods are not original creations, and their application
+was largely empiric, they attracted international attention. The entire
+system of treatment as practised by him was based upon some hygienic
+principle, and most of the results achieved were due to the application
+of common sense.
+
+Water has three properties to which its value as a therapeutic agent
+are due; first, its power to absorb and communicate heat; second, its
+solvent properties; third, the ease with which it changes its physical
+state from the liquid to the solid or gaseous form. These three
+properties, either alone or combined, are to be considered when water
+is applied to the body as a therapeutic agent.
+
+A given quantity of water by weight can absorb more heat than any other
+substance. The readiness with which this heat is absorbed makes it
+possible to apply either heat or cold to the body. Thus, ice applied to
+the body will melt, and in doing so will extract a large amount of heat
+from the tissues. It is valuable therefore in conditions such as local
+infections, in which the heat of the body is above normal.
+
+Every substance is more or less soluble in water. Water is therefore
+called the universal solvent. Water is the medium by which foods are
+dissolved and absorbed in digestion; water also dissolves and carries
+off the waste products to the various organs of elimination.
+
+For therapeutic application, the temperature of water varies from 32
+degrees, F. to 120 degrees, F., depending upon the condition in which
+it is used and also the purpose of its use. Foot baths are of special
+interest to the podiatrist, so that it is necessary to be familiar with
+the particular type of foot bath that is valuable in the treatment of
+foot lesions.
+
+The _alternate foot bath_ is used for stimulating the cutaneous
+circulation, and acts as a general tonic for the nerves and other
+tissues. The bath is given as follows: the feet are placed in hot water
+for two minutes and then plunged into cold water and kept there for 30
+seconds. They are then returned to the hot water for two minutes and
+back into the cold water for 30 seconds. This is repeated a number of
+times, always starting with the hot water and finishing with immersion
+in cold water. This bath affords great relief to those suffering with
+tired feet after having worn shoes for a long period. As a general
+hygienic adjunct, the alternate foot bath is of great benefit, and
+should be employed at night before retiring.
+
+=Foot Care of Infants and Adolescents.= About eighty per cent. of the
+civilized, shoe wearing people, are foot afflicted to a greater or
+lesser degree, and most of this can be traced to neglect of the feet
+in infancy and youth. Many of the most common diseases found in adults
+might have been avoided if proper care had been taken and the causative
+factors removed in proper time.
+
+The foot of an infant, which has never worn a shoe, is really a perfect
+foot, and it is the only stage in life in which the perfect foot is
+commonly found. The toes are spread and the forefoot is slightly
+adducted. When the first footgear is selected for the infant (it must
+be borne in mind that the foot grows rapidly at this age) the shoe
+should be of sufficient length and width to allow for this growth. The
+softest materials should be used for the first shoes of the infant, for
+as the feet are not used in walking at this age, the necessary support
+to locomotion received from the material in the shoe, is a negative
+factor.
+
+When the child commences to walk, the shoes should be changed, and a
+sole should be provided. The upper should be of kid, and should extend
+slightly above the ankle. Laced shoes should be used, and continued
+throughout the entire period of infancy and youth. The normal adduction
+of the forefoot should be considered and the outer border should curve
+inward in a gradual line. The foot should be measured for shoes with
+the child bearing its weight on the foot. This allows for the spread
+of the foot in weight bearing, and measurements taken under these
+conditions give assurance of a proper fit.
+
+As the infant grows, the muscular strength of the legs is increased,
+and eventually the limbs are strong enough to support and carry the
+body weight. It is at this time that the child will commence to walk
+by natural impulse or instinct. From the short, jerky, uncertain
+step, there is a gradual improvement and, with time, the infant gains
+confidence and strength and the step soon becomes firm and steady.
+The question is often asked of physicians and podiatrists by anxious
+mothers: “why is it that my baby does not walk?” It seems to be a
+source of worry to them, for as these mothers watch other children
+walking, they become envious and attempt to teach their children to
+walk. Walking is a natural function and it is foolhardy to insist upon
+infants attempting this foray until the bones to which the muscles are
+attached are sufficiently unyielding and the muscles involved can
+coordinate for that purpose. The use of artificial means of assistance
+for the child, viz., the various contrivances on the market that
+support the child under the arms and allow the feet to drag on the
+ground, should be discouraged.
+
+Premature locomotion causes an unnatural strain upon the legs and feet
+and is often the cause of malformations which continue on in later
+life. Many foot and leg lesions can be attributed to an over-anxious
+mother who insisted upon her child walking before the time was ripe for
+it to do so. Therefore it behooves every mother to allow nature to have
+its way, and to wait until the legs are strong enough. In cases where
+walking is unsteady, it may be advisable to assist the strengthening of
+the muscles by massage and passive motion.
+
+The use of appliances to assist a child which already walks should be
+guarded, and only when there is something pathologically wrong should
+they be employed. Weak-ankle shoes, or weak-ankle braces or supports,
+although they apparently help the child’s gait, really retard the
+normal motions at the ankle joint, and there is little possibility of
+a compensatory increase in strength of the parts as a result of their
+use. When the ankle is continuously supported by some outside agent,
+the normal support, i.e., the muscles of the leg, become weaker.
+This is because they are not used, and atrophy is the result. When
+conditions are such that assistance must be sought, the part should
+be exercised by massage, exercises and passive motion. It is often a
+difficult matter to prescribe exercises for a child, but if given in
+a cheery way, so that the child thinks it is playing a new game or
+is having heaps of fun, the results are often remarkable. The First
+Institute of Podiatry is now planning an exercise room for children
+of the poor whose locomotion is impaired and the experiment will be
+watched with interest.
+
+As the child grows into adolescence, the shoes should be changed often
+enough to allow for the normal growth of the foot. It is better to buy
+shoes oftener, than to attempt economy at the expense of health. The
+parents should acquaint themselves with an orthopedist or a podiatrist
+to advise and a competent shoe man, under the direction of the advisor,
+should fit the shoes of the growing child. Thus, caring for the same
+foot over a protracted period, such a specialist is better able to
+judge the size and shape best adapted for the individual. Walking
+and other forms of exercise should be encouraged, especially those
+exercises that develop the muscles of the foot and leg. It must be
+borne in mind that the flat foot and weak foot of later life are caused
+by deficient muscular action of certain groups of muscles.
+
+=Foot Care of Adults.= After the foot has attained its full growth, and
+the bones have become calcified, correction of the lesions involving
+the bony tissue is difficult. Young persons who have been accustomed
+to wearing shoes with a straight inner line, and with broad toes, will
+pass into middle age without much, if any foot trouble. Slight friction
+or pressure may produce small helomata, but these are of little
+consequence and are easily relieved by intelligent care and treatment.
+
+As previously stated, pointed and narrow shoes with high heels are
+responsible for many of the local foot lesions, and corrective
+treatment should be begun at as early a period as possible. When a
+person reaches middle age, the bones of the foot have become set.
+Attempts at correction, such as the prescribing of shoes with a
+straight inner line for such persons, cause the foot to be put into an
+entirely new position, and because the bones have become firmly set,
+such a new departure is frequently fraught with discomfort, and at
+times causes other bone and muscle troubles which are painful.
+
+In younger adults, correction should be gradual. It is inadvisable to
+adopt radical measures for those who have been wearing incorrect shoes,
+or who have been walking and standing incorrectly for a long period of
+time. A woman who has been wearing high-heeled shoes for a few years,
+has a shortening of the calf muscles which should be corrected, but to
+change from a two-inch heel to one a half-inch high, without gradually
+reducing the height, will cause extreme discomfort. Appropriate
+exercises should be advised and the style of the footgear should be
+gradually and not abruptly changed as the foot responds to treatment.
+
+Walking is one form of exercise in which every able-bodied person
+can indulge, and is a means of maintaining body health as well as of
+keeping the muscles of the foot and legs strong. Like every other form
+of exercise, it should be practised with caution. The individual who
+walks long distances is placing an undue strain upon the muscles of the
+lower extremity, and instead of being benefited, he is being harmed.
+The position of the foot is important in walking. The foot should point
+forward, and the forefoot should swing slightly inward with each step.
+In this way all of the muscles of the leg receive their proper share of
+work. The pace should be brisk and steady, yet not fast enough to cause
+the person to suffer in breathing. Slow, leisurely strolls are useless
+as a medium for muscular improvement, and are simply a waste of time.
+
+=The Care of the Soldier’s Foot.= The foot of the soldier is subjected
+to unusual strain, both on the march and while in the trenches, and
+special care is necessary if the maximum of efficiency is to be
+maintained. Hygiene should be practised to a greater extent than under
+ordinary circumstances, and immediate attention should be given to
+minor troubles that might pass unnoticed in civil life.
+
+The feet should be washed daily, and if long marches are contemplated,
+they should receive this attention both before and after the march. The
+feet should be thoroughly dried after each washing, and dusted with
+some foot powder that will absorb moisture. Lycopodium is the best
+base to use in foot powders. Socks should be examined and if found
+torn or badly mended, should be discarded because the pressure of the
+spots that have been darned may result in painful troubles. Shoes
+should be large enough to accommodate the spreading of the anterior
+arch in walking, yet should be snug in the heel to prevent the foot
+from sliding and creating friction. When soldiers are to serve in the
+trenches their feet should be given special attention, to prevent the
+possibilities of trench foot and other foot lesions that are the result
+of trench life. It has been proven by those who have gone thoroughly
+into the matter that the water and mud which is found in the trenches
+is responsible for these lesions, therefore it is necessary to guard
+against it reaching the feet of the men. In addition to wearing rubber
+boots, the feet should be thoroughly rubbed with some greasy substance
+immediately before entering the trenches. Mineral oils are best, and
+although the process of rubbing the feet and legs with oil is repulsive
+to the men, it should be compulsory, as it is the means of preventing
+loss of limbs. Cloths dipped in melted paraffin and then wrapped around
+the feet will suffice to keep the water from the skin.
+
+Immediately after a siege in the trenches, the feet should be
+thoroughly washed with soap and warm water, carefully dried, and dusted
+with an antiseptic foot powder. One containing boracic acid and talcum
+will answer ordinary purposes. If abnormal lesions develop, these
+should be treated in keeping with the requirements.
+
+The men should receive instructions at regular intervals, and lectures
+on the care of the foot should be given by the officer in charge of
+that particular branch of the medical department. Foot inspections
+should be made at prescribed times, and during these inspections, the
+podiatrist can easily determine whether or not the men are in need of
+foot attention beyond that which comes with self-care. The feet should
+also be examined before a march of ten miles or more, and should be
+re-examined immediately after the march. This procedure will save
+the men from developing any serious trouble, as the beginning of any
+such trouble is thus detected, and proper preventive treatment can be
+applied, sufficiently timely.
+
+One or two podiatrists should be attached to each ambulance train
+while the troops are on the march, so that they are available at short
+notice. The immediate application of a shield or pad over some part of
+the foot that is being irritated will often save the individual from
+foot infection that may be serious. Too much care cannot be given the
+feet of the soldiery as their efficiency is based upon their powers
+of locomotion. It was the opinion of the first Napoleon that an army
+moved upon its stomach. By that he meant that plenty of proper food was
+essential to every fighting force. In these times, it is conceded that
+the foot-whole alone can be counted as competent soldiers, important
+as may be the food question. It behooves us, therefore, to give to the
+men who are willing to offer up their lives for their country’s weal,
+the very best possible care, and although the foot of the soldier has
+received no special attention in the past, the time is now ripe for the
+recognition of the podiatrist as an integral part of every officered
+unit in the Medical Corps of the Army and of the Navy. From a national
+economic standpoint alone, this recognition should be accorded because
+it must be clear that unless proper precautions are taken to note the
+condition of the soldier’s feet before he goes overseas, thousands
+will be found unavailable for first line work and will thus constitute
+themselves an incubus rather than an aid to the fighting force of our
+country.
+
+
+
+
+CHAPTER VI
+
+DRESSINGS AND BANDAGING
+
+
+DRESSINGS.
+
+=Definition.= A dressing is the material applied to a wound for the
+purpose of excluding the air, stimulating repair and protecting the
+affected areas from irritation and from other untoward conditions.
+
+Four classes of dressings are used in podiatry, viz.: the moist
+dressing, the dry dressing, the ointment dressing and the occlusive
+dressing.
+
+=The Moist Dressing.= The moist dressing is generally composed of
+several thicknesses of gauze applied to a part and moistened with some
+germicidal, antiseptic, astringent, antiphlogistic or sedative solution.
+
+There are two forms of moist dressing: the evaporating and the
+non-evaporating.
+
+=The Evaporating Moist Dressing=, generally known as the wet dressing,
+is an application of several thicknesses of gauze saturated with a
+solution and allowed to remain uncovered so that evaporation of the
+solution takes place. The gauze is remoistened from time to time so
+that it is kept continually wet. The action of this form of dressing,
+independent of the specific action of the solution employed, is heat
+reducing and causes localized anemia. It may be employed wherever
+infection or inflammation is present.
+
+=The Non-Evaporating Moist Dressing= is composed of several thicknesses
+of gauze saturated in a solution and covered with some impervious
+covering such as gutta percha tissue, oiled silk or fish skin. This
+form of dressing, independent of the action of the solution employed,
+is heat producing and locally hyperemic. It is contra-indicated in
+the presence of pus, as the warmth and moisture produced by its use is
+congenial to the growth of bacteria. It should only be used when the
+skin is unbroken, in such cases as sprains and bruises, or where the
+action of a poultice is not contra-indicated.
+
+=The Dry Dressing.= The dry dressing is composed of several thicknesses
+of sterile gauze applied to a part and allowed to remain dry. There are
+two forms of dry dressing, (1) that in which the gauze itself is alone
+applied, and, (2) one composed of dry sterile gauze or cotton used for
+the purpose of applying a dusting powder, having either antiseptic,
+astringent or stimulative qualities or in some instances, all three.
+The plain gauze dressing is used where asepsis and drainage alone are
+desired in a wound, all symptoms demanding the treatment by means of
+drugs having been eliminated. The gauze is used either as a “wick” and
+packed into a cavity as a drain, or in a series of thicknesses covering
+the whole affected area.
+
+The dusting powder dressing consists in applying a powder to the
+affected surfaces and covering the same with several thicknesses
+of sterile gauze, or with a pledget of sterile cotton. The dusting
+powder is used when astringency is desired, as from bismuth subgallate
+(dermatol); or where stimulative and antiseptic action is desired, as
+from thymol iodide (aristol).
+
+=The Ointment Dressing.= The ointment dressing is one in which an
+ointment, held in place either by lint, gauze or cotton, plays a
+conspicuous part in the repair of the lesion. The ointment is either
+spread upon the fabric used, or is applied directly to the affected
+areas by means of a spatula. This form of dressing can be used in the
+treatment of superficial inflammations, blisters, pernio, etc., but is
+contra-indicated in the presence of a discharge, as the fatty or oily
+base of the ointment interferes with the absorption of such a discharge
+and so prevents proper drainage of the part.
+
+=The Occlusive Dressing.= The occlusive dressing is one employed for
+the purpose of excluding the air and of completely sealing the parts.
+In podiatry this occlusion is obtained by the use of collodion, either
+plain or medicated, by a combination of collodion and cotton, or by the
+application of compound tincture of benzoin.
+
+
+FABRICS.
+
+There are a number of fabrics which may be used for dressing materials
+in podiatry. The three most important are gauze, cotton and lint.
+
+=Gauze= is a thin meshed, loosely woven cloth employed in the
+manufacture of bandages and used for wound dressings; such gauze should
+be sterilized or impregnated with antiseptics.
+
+The varieties of gauze which are of practical use in the practice of
+chiropody are:
+
+    (1) _Plain aseptic gauze_, either dry or moist; a gauze
+    sterilized either by dry heat, so that the fabric remains dry,
+    or subjected to moist heat (steam) sterilization from which
+    the gauze retains a certain amount of moisture. The dry gauze
+    is put up commercially in pasteboard boxes, and can be thus
+    obtained in quantities of one square yard and upwards. The
+    moist aseptic gauze is obtainable in as small a quantity as the
+    former, but comes in sealed glass jars which may be kept upon
+    the operating stand or cabinet.
+
+    (2) _Corrosive sublimate gauze_ is put up in glass jars in
+    quantities of one square yard and upwards. The gauze is
+    saturated in a solution of mercury bichloride and may be
+    obtained in strengths from ¹⁄₂₀₀₀ to ¹⁄₁₀₀₀₀.
+
+    (3) _Iodoform gauze_ is put up for surgical use in the same
+    manner and quantity as No. 2. The medication impregnates the
+    whole fabric and constitutes an excellent method of applying
+    the drug. On account of the suggestive odor of iodoform,
+    however, this gauze has lost favor with the podiatrist.
+
+    (4) _Borated gauze_, or gauze impregnated with boric acid in
+    10% strength, is used in podiatry where a mild antiseptic
+    dressing is desired. It comes in glass jars in quantities
+    similar to the two foregoing varieties.
+
+The forms in which gauze are used in podiatry practice are numerous.
+The following are the most important:
+
+    (1) _Bandage._ Gauze, in varying widths, makes a highly
+    practical bandaging material. Cotton bandages are used, but
+    cannot compare with even the poorer grades of linten gauze
+    for durability. The reader is referred to the sub-heading,
+    “Bandaging,” at the end of this article.
+
+    [Illustration: LARGE GAUZE SQUARE FOR DRESSING INGROWN NAIL]
+
+    (2) _Large gauze squares._ It is a common practice among
+    podiatrists to cut large quantities of gauze into pieces
+    about three inches square. These have two uses: (a), to dry
+    off instruments dripping with alcohol or whatever germicidal
+    solution has been used, before operation, and (b), as a
+    dressing applied over the affected area. In the latter instance
+    this size square is practical where the whole distal end of
+    the toe is to be covered, as in applying a moist dressing in
+    the treatment of ingrown nail, or where there is a large area
+    to be covered on the dorsum, plantar or lateral sides of the
+    foot or upon the lower leg. As a “wipe” for instruments, one
+    thickness, and as a dressing, three or four thicknesses are
+    used.
+
+    (3) _Small gauze squares._ These are about an inch-and-a-half
+    square and have their principal use as a dressing to cover
+    one side of a toe nail, or to cover a small area of the
+    integument, or as a “wick” in the drainage of a large sinus or
+    deep ulcerative condition. Both the large and small squares,
+    cut to size, are sterilized by heat and are then placed in a
+    formaldehyde sterilizer until used; this assures their absolute
+    asepsis.
+
+    (4) _Nail Groove and Sinus Pledgets._ For the more confined
+    areas of the nail groove or for a small sinus, gauze is cut
+    into small pieces measuring about one-half inch long and
+    one-eighth inch wide. Several thicknesses of the fabric are cut
+    together so that even from a small amount of gauze many small
+    pledgets or “wicks” are obtainable. These small gauze pieces
+    are very practical for packing a nail groove, and, as the fibre
+    is looser and the pledgets do not harden, they make a much
+    softer and more yielding pad for the nail than does cotton.
+
+    In the drainage of a small sinus, these small pieces of gauze
+    offer a very practical material for use as a “wick.” Three or
+    four strands of the fabric may be inserted at the mouth of the
+    sinus to prevent surface granulation, while the repair in the
+    deeper tissue is still incomplete.
+
+=Cotton.= Cotton is the white, fluffy, fibrous covering of the seeds
+of the cotton plant which, when ginned and refined to a uniform
+smoothness, furnishes a medium which is used extensively in surgical
+dressings.
+
+Aseptic absorbent cotton is manufactured by a number of firms and,
+except in the cheaper grades, no irregularities or foreign matter are
+found in the fabric.
+
+Cotton is used in podiatry practice by winding it on the end of a
+wooden or metal applicator. The fabric, thus fashioned about the
+applicator, is used either dry or dipped in some medication for
+applying solutions to the foot. It is also used to dry parts or to wipe
+instruments; as a dressing, it is used principally in combination with
+collodion to make the cocoon dressing. This name is derived from its
+resemblance to the cocoon of the silkworm or the butterfly.
+
+A cocoon dressing is a pledget of cotton, the fibre of which is
+smoothed and is placed in one direction, while the edges of the pledget
+are thinned out or “feathered.” The cotton is applied over the part and
+collodion (preferably flexible collodion) is painted over it by means
+of a brush or a glass rod in such a manner as to bind the edges of the
+cotton firmly to the skin. The collodion when applied is semi-liquid,
+and as its constituents, ether and alcohol, evaporate upon contact
+with the air, the pyroxylin remaining becomes an integral part of
+the cotton, joining intimately with its fibres and with the surface
+of the skin. After the edges are bound down in place, the collodion
+may be painted once along the length and once across the fibre at the
+centre of the dressing, so as to bind the dressing into one cohesive
+whole; it is not wise, generally, to saturate the whole pledget with
+collodion, as when dried, the dressing will be hard and unyielding.
+In the procedure first described the dressing is semi-occlusive; in
+the latter, occlusive. The cocoon dressing is used principally as a
+covering for a part when an ointment has been applied and, as in these
+cases the parts beneath are tender, it is wise to have the dressing as
+soft and pliable as possible.
+
+This form of dressing may be used alone or it may be applied as a
+covering and protection over the aperture of a shield after an ointment
+has been applied to the part. It is found very practical when applied
+over a nail fold and groove in which an ointment has been used. The
+dressing will confine the unguent to the proper areas and prevent it
+from running over that side of the digit. In dressing a blister or
+other irritated area, due to ill-fitting shoes or mended hosiery, the
+cocoon is also very practical. The cotton not alone serves to hold the
+medication in place, but acts as a padding so that the part may not be
+subjected to further irritation.
+
+Cotton is also used in the form of a small pledget for packing a nail
+groove. The pledget or roll should be small and thin and is used to
+hold a medication in place; at the same time it constitutes a soft pad
+upon which the edge of the nail rests.
+
+=Lint.= Lint is a flocculent material procured by ravelling or scraping
+linen.
+
+Surgeon’s absorbent lint as a dressing and shielding material, is
+continuously coming more into vogue. Otto Sjogren of New York is a
+great believer in its efficacy and in his demonstrations at The First
+Institute of Podiatry strongly advocates its use. The late W. A.
+Kennedy of Philadelphia was also strong in his advocacy of lint as
+a dressing and is on record as follows: “The essentially favorable
+feature in utilizing lint for shielding purposes is that, when properly
+adjusted, there is no pressure on the parts which it serves to protect.
+Most, if not all, of the material of which shields are ordinarily made,
+is of an unyielding character, and, in consequence, the capillary
+circulation of the compressed part is disturbed. If such a condition
+exists, absorption is prevented and the treatment is in most instances
+harmful rather than helpful. Because lint is a loosely woven cotton
+fibre, it does not pack in a hard mass, but always remains soft and
+yielding; nor is it necessary to apply it excepting in thin layers.
+
+“The method of use should be as follows:
+
+“Select a perfect sheet of lint and cut off a square or oblong piece
+slightly larger than the lesion and round off the corners so that they
+will not bulge when plaster strips or bandages are applied. Then cut a
+round opening in the lint, slightly larger than the lesion. Spread such
+medicament as is desired on the part requiring it, and then place the
+fluffy side of the lint next the skin, in situ, with the edges of the
+opening surrounding the part under treatment. Over this dressing, place
+a piece of lint so as to cover the existing dressing in its entirety
+and apply ordinary adhesive plaster to retain the whole in place. The
+thickness of the dressing represented in layers of lint will depend
+upon the necessities of each individual case, but in the experience
+of the writer, the most satisfactory results are obtainable where the
+dressing is least bulky. At times, when several layers of the lint are
+requisite to the patient’s comfort, it will be found advisable to cut
+out the sides of one of the under layers for the purpose of making a
+half-moon dressing; then apply the top covering.
+
+“In the accompanying illustrations most of the required dressings shown
+are of two thicknesses only, the under layer having the round opening
+and the upper layer acting as a protective as well as an absorbing
+medium. This method will be found useful, in that drainage may take
+place properly where there is a suppurating surface, and even though
+the patient does not return for treatment at the time suggested, there
+will be no danger of septic infection because of a damming in the flow
+of exudate, a menace which is so common in some forms of dressing.
+Patients will rarely complain that the plaster ‘draws’ offensively if
+the above dressing is properly applied.
+
+[Illustration: DORSAL LINT DRESSING]
+
+[Illustration: PLANTAR LINT DRESSING]
+
+“The plantar aspect of the foot exhibits four full dressings and half
+of another.
+
+“The dressing covering the great toe may be utilized for any lesion
+from a callous to a perforating ulcer; the one on the distal end of the
+middle toe, for heloma or for any other condition usually met with in
+this region.
+
+“The dressing covering the fifth metatarsophalangeal articulation can
+be applied for perforating ulcer, for callous or for vascular heloma
+and can be placed anywhere after treating this lesion. The dressing
+covering the os calcis region is of a single thickness and can be used
+in varying sizes for any lesion found on the plantar surface.
+
+“The partial dressing, covering the first metatarsophalangeal
+articulation is used from one to any required number of layers for
+covering bunions, enlarged joints, etc.; the other section of this
+dressing is shown on the dorsal aspect of the foot in the other
+illustration.
+
+“The dressing covering the dorsal aspect of the great toe is used after
+any ingrown nail treatment and the dressings on the third and fifth
+toes are applied after the removal of helomata.
+
+“The dressing covering the fifth tarsometatarsal articulation is very
+useful in combating the calloused and oft-times inflamed area produced
+by the side seam of shoes, especially of the low-cut type.
+
+“Lastly, the dressing covering the tarsal aspect is a comfortable
+arrangement to apply after removing the minute helomata produced by the
+eyelets of a shoe or for any other lesion found on the dorsal surface.
+
+“In case of extensive ulceration or of profuse discharge from a lesion,
+it is advisable to use several layers of sterile or medicated gauze
+before applying the absorbent lint to the surface.”
+
+=Collodion.= Plain flexible collodion is used extensively in podiatry
+as an agent to bind cotton into place upon a part or as a vehicle of
+application for a number of drugs, or whenever an occlusive dressing is
+applied. Flexible collodion is ordinary collodion to which is added
+castor oil and turpentine. These drugs serve to reduce the contraction
+of the film during evaporation. Plain collodion, as evaporation
+takes place, contracts in area and when applied is liable to draw or
+“pucker” the skin about the part. Flexible collodion has practically no
+contractile tendencies during evaporation.
+
+Flexible collodion, unmedicated, is used as an application over
+chilblains or in other conditions where occlusion is desired.
+
+=Medicated Collodions.= Flexible collodion, medicated with various
+drugs, is also used extensively in podiatry. The four named and
+described below are the most important, and are most generally used.
+
+=Iodized Collodion= (C. Iodatum, N. F.). Iodized collodion is a five
+per cent. solution of iodine in flexible collodion.
+
+It is used in podiatry as a covering for the exposed tender tissues
+after removal of a callositas or an heloma. The film formed by
+the collodion serves as a protection against friction to the part
+and the iodine contained in the mixture acts as an antiseptic and
+counter-irritant. This combination may also be used where any
+counter-irritant action is desired and wherever the tincture may be
+used.
+
+=Ichthyolated Collodion=, 5 to 15% of ichthyol in collodion, is used
+for the same purposes as the iodized collodion in the protection of a
+previously pared callous, and as an antiphlogistic and stimulant in
+erythematous chilblain, this form of medication is used extensively and
+with good results. It forms an occlusive film over the chilled parts,
+and by the action of its constituent, ichthyol, serves to stimulate the
+deranged functions and to promote absorption in the congested parts.
+
+=Benzoated Collodion=, 5 to 10% of tinctura benzoini composita in
+flexible collodion, may be applied in post-operative procedures in
+heloma, etc., as described in preceding paragraphs, and is also
+efficient as a stimulant in the treatment of pernio and as a covering
+for blisters and other superficial lesions where no discharge is
+present.
+
+=Salicylated Collodion= is a medicated collodion with the following
+formula:
+
+  Salicylic acid, 30 parts;
+  Ext. of cannabis Indica, 5 parts;
+  Collodion, 240 parts.
+
+It is extensively used in the medical treatment of heloma or
+callositas. This combination is disintegrative in its action and should
+not be applied on sound or normal integument.
+
+Collodion, either plain or medicated, is contra-indicated in the
+presence of a discharging surface. By sealing the lesion, no drainage
+is possible, and the waste materials thrown off are kept confined to
+the detriment of the healing process.
+
+=Paraffin Preparations.= Barth de Sandfort, a French naval surgeon, in
+experimenting for drugs to treat the cases of burns developing from
+the liquid fire and burning oil attacks of the Great War, discovered
+and perfected a substance known as “ambrine.” The exact composition of
+this paraffin is a secret, and for this reason it has been received
+coldly in this country, but a number of similar paraffin preparations
+have been developed and are in general use today. The four most popular
+of these are known commercially as paraffin No. 7, paraffin No. 7-11,
+parresine and redintol.
+
+Paraffin No. 7 (Dr. Hull) consists of paraffin (hard), 67%; paraffin
+(soft), 25%; olive oil, 5%; oil of eucalyptol, 2%, and resorcin, 1%. To
+prepare paraffin 7, first melt the hard paraffin, then add in the order
+named the soft paraffin, olive oil, oil of eucalyptol and resorcin.
+
+Paraffin No. 7-11 (Dr. Adams) consists of paraffin (hard), 69%;
+paraffin (soft), 25%; olive oil, 3%, and thymol iodide, 3%. The
+preparation of paraffin 7-11 is similar to that described for the
+preceding combination.
+
+Parresine (officially adopted by the United States Army and Navy) is a
+wax-like substance, containing about 95% of paraffin; this is treated
+by the addition of a vegetable wax and mineral and vegetable resins so
+as to modify its physical character, especially as regards plasticity,
+ductility, pliability and adhesiveness. It also contains eucalyptol,
+a valuable antiseptic, which is added to cover the characteristically
+disagreeable odor developing from burned surfaces and other large
+abrasions during the process of healing.
+
+Redintol is a mixture of paraffin and resins, having similar melting
+points. The firm manufacturing it have prepared a special form of sheet
+cotton for use in connection with the application of this product.
+
+_Technic._ The technic of the application of these paraffin
+preparations is similar and is described in detail in the chapter on
+“Burns.” The advantages of the wax treatment are numerous.
+
+(1) It is an inexpensive dressing (a pound of wax and a pint of liquid
+petrolatum, together costing about sixty cents, will dress many burns).
+
+(2) It is a comfortable dressing because it is smooth, and the
+granulating surface does not grow through it as with the gauze. The
+paraffin is hard enough to make the dressing somewhat rigid and to act
+as a splint.
+
+(3) It is a cleaner dressing, because the wound discharge is not
+permitted to soak through the impermeable wax covering, soiling all the
+linens that come in contact with the patient.
+
+(4) Superficial burns heal more readily under this treatment than with
+any other previously used method.
+
+(5) It is a most comfortable dressing, for the reason that the
+granulations do not grow through it, and the dressing is lifted off
+painlessly.
+
+(6) The resulting scars are not as pronounced.
+
+(7) It is a stimulant of granulations.
+
+_Disadvantages._ The disadvantages of the wax treatment are:
+
+(1) Some patients refuse to be treated with the wax (it is applied hot
+directly to the injured area) because of the pain.
+
+(2) So many extravagant claims have been made for it, that the one who
+uses it for the first time will probably be disappointed.
+
+(3) An infected wound is covered with a sealed dressing.
+
+(4) We have no way of controlling the temperature of the wax. Taken
+from the boiling water at 212 degrees Fahr., it is too hot. Cooling
+at 114 degrees Fahr., it is too cold. The degree of pain caused the
+patient is the only means one has of knowing if it is too hot, unless
+one tries it first on the back of the hand.
+
+(5) Around the skin edges it is painful.
+
+
+IMPERVIOUS COVERINGS.
+
+In connection with moist dressings, several varieties of impervious
+covering may be used.
+
+=Oiled Silk= is a rubberized material of great strength, usually yellow
+in color and soft and smooth to the touch. The use of this material is
+quite general in podiatry for all moist, non-evaporating dressings.
+The technic of application consists in cutting a square of the fabric
+of sufficient size to cover the whole of the gauze dressing, also all
+sides of the toe (if this be the location of use) and a considerable
+amount of the surrounding healthy tissue. It is held in place either
+by a roller bandage, or by means of adhesive strips fastening down its
+edges to the adjacent surfaces. Dressings covered by oiled silk are apt
+to be bulky and for this reason, when the shoe is to be worn, it is not
+generally used.
+
+=Gutta Percha Tissue= is a thin perishable material placed on the
+market by several firms. It is not to be compared with oiled silk for
+durability, but the dressing covered by gutta percha is not nearly so
+bulky, and for this reason it is popular and practical for use in
+podiatry. It is generally applied over the gauze by vulcanizing its
+edges to the surrounding integument. This is accomplished by means of
+heat, and, when completed, presents a neat dressing which is absolutely
+occlusive, and from which none of the solution used on the gauze
+underneath can escape. A square of the rubber tissue of sufficient
+size to more than cover the dressing is cut and held in place with the
+hand. A match is then applied to the edges of the square and while
+they are still melted they are lightly adhered to the surrounding
+skin. The tissue will adhere to the skin and will remain intact for
+a considerable period of time. The gutta percha is then covered by
+several turns of a roller bandage to protect the thin tissue from the
+rubbing of the shoe. Gutta percha tissue may also be held in place
+by means of adhesive strips as with oiled silk, but the vulcanizing
+process is by far the most popular and, insofar as confining the
+solution is concerned, it is also far more practical.
+
+=Fish Skin= is a manufactured material of tissue paper thinness and has
+proven very popular for use as an impervious covering. The technic of
+application is similar to that described for oiled silk and it is held
+in place by the same means. It does not make a bulky dressing and for
+this reason its popularity has probably exceeded that of oiled silk.
+
+
+BANDAGING.
+
+A bandage is a strip of gauze, muslin, flannel or other material of
+varying widths and lengths, used in the various branches of medicine
+for retaining dressings, applications and splints and to produce
+compression. Occasionally they are applied to retain heat. Bandages
+also help keep a wound clean by preventing the ingress of foreign
+matter.
+
+Bandages are made of different materials, chief among which is gauze.
+This is made of lint, woven into a soft material, which is easily
+applied to all parts of the body. Muslin is a heavier cotton material
+and is made of cotton or silk or of a mixture of both (lisle) with
+rubber. Flannel is wool woven into a soft, firm, semi-elastic material.
+Rubber bandages are used to induce excretion and for compression.
+
+Bandages vary in width and length, depending on the size of the parts
+for which they are intended. For convenience, bandages are usually
+manufactured in widths varying from one-half inch to six inches, and in
+length from one to ten yards or more. Those which are used in podiatry
+vary in width from one-half inch to three inches. The standard length
+of bandages is five yards and ten yards. These may be cut and the
+unused piece preserved. A table of the widths of the various materials
+used in podiatry practice, showing the parts for which they are best
+adapted, follows:
+
+           LESSER  GREAT TOE  ANKLE   ANKLE WRIST  LEG      LEG
+           TOES    FINGERS    WRIST   LEG FOREARM  FOREARM
+  Gauze     ¹⁄₂″      1″         1¹⁄₂″     2″         2¹⁄₂″    3″
+  Muslin              1″         1¹⁄₂″     2″         2¹⁄₂″    3″
+  Flannel                                  2″         2¹⁄₂″    3″
+  Elastic                                  2″         2¹⁄₂″    3″
+  Rubber                                   2″         2¹⁄₂″    3″
+
+_A roller bandage_ consists of one piece of material rolled in the
+shape of a cylinder, having a core and a free end, and is the kind used
+in podiatry.
+
+_A double roller bandage_ consists of one piece of material, rolled
+from both ends, so that when it is completed there are two cylinders
+and no free end.
+
+_A plaster of Paris bandage_ is composed of a piece of gauze or
+crinoline into which is rubbed powdered plaster of Paris. This bandage
+is placed in water and then applied to a part; after a few moments the
+entire bandage becomes hard and solid. This form of bandage prevents
+mobility and is used for fractures and dislocations. In podiatry it
+is used for taking impressions of the foot for fitting mechanical
+appliances. Bandages are classified as follows:
+
+_Circular_--being circular turns around a part.
+
+_Figure of eight_--the turns crossing each other like the strokes of
+the figure 8.
+
+_Oblique_--covering the part by oblique turns.
+
+_Recurrent_--the turns returning to the point from which they
+originated.
+
+_Spica_--the turns crossing and recrossing, resembling in arrangement
+the husks of an ear of corn.
+
+_Spiral_--the turns ascending or descending, each turn covering about
+two-thirds to three-fourths of the preceding turn.
+
+_Spiral reverse_--when the bandage is turned in reverse position so
+that the inner side becomes the outer and the outer side rests against
+the skin, in order to better adapt itself to the part.
+
+Bandages are designated by various names, according to the shape they
+assume when completed, and they are sometimes named after the men who
+first used them; for example, “Barton’s bandage” of the head.
+
+The bandages used in podiatry are designated by the shape they assume.
+The names of the various bandages of the foot follow in the order of
+their importance:
+
+  Spiral bandage of the toes.
+  Spica bandage of the foot.
+  Figure of eight bandage of the ankle.
+  Spiral reverse bandage of the leg.
+
+_The Spiral Bandage of the Toes._ This bandage is applied to the great
+toe more often than to the lesser toes. Gauze, one inch wide for the
+great toe and one-half inch wide for the lesser toes, is used.
+
+This bandage may be started by a few circular turns around the ankle,
+then diagonally across the dorsum of the foot to the base of the great
+toe; but this may be simplified by making a simple circular turn around
+the proximal end of the toe, with the free end towards the heel, which
+will firmly lock the bandage. If the distal end of the toes is to be
+covered, the bandage is now applied from the proximal end of the toe
+on its plantar surface, over the distal end to the proximal end on the
+dorsal surface. This is repeated back and forth as often as necessary
+to cover the parts by what are known as recurrent turns. The spiral
+turns are now started and as the bandage moves toward the distal end
+of the toe, each turn must cover about two-thirds or three-fourths of
+the preceding one. When the toe is covered, the spirals are continued
+back to its base, where the bandage is tied off. Many toes are not
+cylindrical but taper to a point; so that when the spirals reach the
+distal end of the toe, the bandage bulges on the inner side. This
+bulging may be avoided by making a reverse turn over the part instead
+of a simple spiral.
+
+_The Spica Bandage of the Foot._ Bandage 1¹⁄₂ to 2 inches wide is
+used, depending on the size of the foot. The free end of the bandage
+is placed on the dorsum of the foot at the ankle joint, and is locked
+by several circular turns around the ankle. The bandage is passed
+diagonally forward across the dorsum of the foot to a point opposite
+the head of the metatarsal bone, then across the plantar surface of the
+foot to the opposite metatarsal bone, and diagonally backward across
+the dorsum of the foot, crossing the first half of the turn, producing
+an X. The turn is finished by passing the roller back over the tendo
+Achillis. This is repeated, the second turn covering about two-thirds
+of the first and so on backward until the desired area is covered. The
+bandage is finished by a few circular turns around the ankle and is
+tied off in the usual manner.
+
+_Figure of Eight Bandage of the Ankle._ This bandage resembles the
+spica bandage of the foot in every way except that the first turn
+extends to the base of the metatarsal bone instead of to the head and,
+instead of tying it off at the ankle, a few spiral reverse turns are
+made up the leg. It is tied off as are the other bandages.
+
+_The Spiral Reverse Bandage of the Leg._ This bandage is considered by
+many to be the most difficult of all the bandages of the extremities to
+apply. A few figure of eight turns are made around the ankle and then
+the spiral turn is made; the bandage is reversed so that the inner side
+becomes the outer and the outer side rests against the skin. Each turn
+should cover about three-quarters of the preceding one, and care should
+be taken that at the point of reversing the bandage, no wrinkles or
+uneven folds are produced. The reverse turns should not be made over a
+wound or a part that may be irritated by additional pressure.
+
+
+
+
+CHAPTER VII
+
+INSTRUMENTS
+
+
+TYPES, VARIETIES, USES, THEIR SELECTION AND CARE
+
+No comprehensive monograph has yet been written discussing at any
+length the instruments of the podiatrist, and in compiling the
+following data there must necessarily be omissions. Up to the present
+moment no great amount of standardization has been accomplished along
+this line, either in the general use of a given instrument or in its
+name. It is the object of the author of this chapter to at least build
+a foundation upon which a complete and standardized line of instruments
+may be developed.
+
+Many special instruments developed by practitioners who have refrained,
+for reasons best known to themselves, from giving their ideas and
+discoveries to the profession at large, must necessarily be omitted,
+and it is to be greatly desired that the next few years will be rich in
+the development and standardization of our instruments and appliances.
+
+The instruments in general use today and manufactured by several
+companies, are all made practically of the same material and in the
+same manner, the differences between them, being due principally,
+to the finish. All such instruments as chisels, scalpels, spatulas,
+curettes, etc., are made from Sheffield steel, and are hand forged.
+The handles of these instruments are made of a silver or aluminum
+composite. Scissors, nail clips, thumb forceps, etc., are made also of
+Sheffield steel, but are drop forged.
+
+Most instrument makers today have discarded the older method of
+finishing, known generally as the “crocus” polish. This has come about
+principally for the reason that the application of the crocus polish
+or finish demands that the instrument be subjected to extreme heat. In
+accomplishing this, many instruments are rendered useless owing to the
+fact that the temper of the blade is ruined by the added heat.
+
+What is commonly known as a “satin” finish, accomplished by buffing,
+is now generally employed and does not tend in any way to injure the
+already highly tempered steel.
+
+
+HISTORY OF INSTRUMENTS
+
+With the exception of possibly two or three, it is doubtful, if
+chiropody has developed any really individual instruments. Our scalpels
+are similar to or are modifications of those of the surgeon; the nail
+chisels and excavators in general use have been borrowed from the
+realms of the dentist, as has the rotary drill; the nail clips, of
+course, are instruments which are purely for the purposes coming within
+the jurisdiction of the podiatrist; so, also are the various forms of
+the nail file.
+
+The chisel used by a great number of practitioners for the surgical
+removal of helomata, is one of the oldest of chiropody instruments and
+is one which was unquestionably developed by the chiropodist for his
+own needs. There is no instrument in use by the surgeon which bears
+any resemblance to the chisel, and for this reason we can safely say
+that it is a true chiropody instrument and may therefore safely be
+called the helotomon--the podiatry surgical instrument. This also, in
+a measure, can be said of the soft corn spoon. This is, to be sure,
+nothing but a very shallow curette, but nevertheless no instrument
+in use in general surgery can be rated as being similar to it; it is
+therefore properly styled the podiatrist’s curette.
+
+Prior to 1909, the chiropodist found it necessary to select his own
+manufacturer and have his instruments made according to his own ideas,
+or to select them from the catalog of the surgical supply house. This
+condition of affairs resulted in a wide diversity of styles. No two
+practitioners had similar instruments, and it seemed to furnish keen
+delight to one chiropodist to outdo his neighbor as to the size, finish
+and appearance of his instruments. Pearl handled scalpels were much
+in evidence and, when so, served to prove, without question, that the
+owner did no sterilization by boiling. Gold-plated blades and inlaid
+handles were frequently to be seen, proving nothing, unhappily, but the
+eccentricities of their owners.
+
+In the year 1909, however, the manufacture of instruments as individual
+appliances for the chiropodist was started at the instigation of the
+late George Erff, by an instrument maker in Jersey City, N. J. His
+wares found such instant approval and the sales of his product so
+increased that it was not long before several other firms embarked in
+the business of manufacturing instruments solely for chiropodical work.
+
+This has done much to standardize instruments and today men and women
+in all parts of the world are beginning to use similar instruments made
+from standard patterns.
+
+[Illustration: Fig. 1. SCALPELS]
+
+=The Scalpel.= Several varieties of scalpel are used in podiatry
+today. Some of them have been developed from an absolute need and some
+from the personal desire of the practitioner. The scalpel should be
+about five-and-one-half inches long, having a blade length of from
+one-and-one-half inches to one-and-three-quarters inches. Made from
+these dimensions, the instrument is practical as to size and has a
+working surface sufficient for any purpose.
+
+Fig. 1 shows several varieties of scalpel. No. 2 in this group is a
+practically shaped blade to be used for work on callositas or heloma.
+This instrument will maintain a good shape with honing and is used by a
+great number of practitioners.
+
+This No. 2 is used for the removal of heavy callous and general work.
+Nos. 3 and 5 may be successfully used for the dissection and removal of
+helomata. These pointed scalpels are indicated whenever delicate work
+on small surfaces is demanded.
+
+[Illustration: Fig. 2. CHISELS]
+
+=The Chisel.= The heloma and callosity chisels, Nos. 1, 2 of Fig.
+2, are about five-and-one-half inches long with a blade length of
+one-and-one-quarter inches. Nos. 5 and 6 are nail chisels and will be
+discussed under that heading.
+
+A series of chisels which are advocated by Harry P. Kenison, of
+Boston, differ from those shown in Fig. 2 only in that the handles are
+one-quarter of an inch in diameter and are round, being corrugated to
+prevent slipping. These instruments are five-and-one-quarter inches
+long.
+
+[Illustration: Fig. 3. HELOMA AND CALLOSITY CHISELS]
+
+Fig. 3 shows heloma and callous chisels (helotoma) recommended by E.
+C. Rice, M.D., of Washington, D. C. This variety of instrument is
+used principally for dissection work, but is also useful for shaving
+or paring methods. No. 1 of this group is used principally for large
+calloused areas on the plantar surfaces of the foot. The handles of
+these instruments are hexagonal and are five-and-one-quarter inches
+long.
+
+=The Nail Chisel.= Varieties of straight chisels for the removal of
+ingrown portions of nail are shown in Fig. 2, Nos. 5 and 6.
+
+Curved nail chisels are shown by Nos. 1 and 2 in Fig. 4. Their use is
+described in the chapter on Ingrown Nails. Nos. 3, 5, 6, in this group,
+are nail packers used for packing gauze or cotton in the nail groove.
+No. 4 in this figure is a curette excavator used for the removal of
+nail splinters or callous from the nail groove.
+
+There is a newer type of nail chisel with a guard along one edge. This
+is to prevent the instrument from penetrating the soft tissues of the
+nail bed while removing an imbedded portion of nail. This flange also
+aids in lifting the nail from its bed and in breaking up adhesions
+which may have formed in advanced cases.
+
+No. 2, Fig. 5, is a nail groove gouge used for the removal of callous
+in that location.
+
+[Illustration: Fig. 4. NAIL CHISELS]
+
+[Illustration: Fig. 5. MISCELLANEOUS INSTRUMENTS]
+
+[Illustration: Fig. 6. SOFT CORN SPOON]
+
+=Soft Corn Spoon.= (_Podiatrist Curette._) The soft corn spoon, Fig. 6,
+is in reality a shallow curette used for the purpose of dissecting an
+epithelial growth between the toes. The working edge of the instrument
+is sharp.
+
+A modification of this spoon is shown in Fig. 5, No. 1. This instrument
+is commonly known as a “golf stick.” It is used for the same purpose
+as the soft corn spoon. These instruments are of the same length, in
+fact, are uniform in every way to the scalpel and nail chisel.
+
+=The Spatula.= This is an instrument used almost entirely for the
+mixing of ointments and their application to a part. It is not sharp.
+(Fig. 7, No. 1.)
+
+=The Nail Scraper.= The scraper is used for cleaning around the nail,
+and for the removal of any callous which may be adherent to the nail
+body in or about the grooves. Two varieties are shown in Fig. 7, Nos. 2
+and 3.
+
+[Illustration: Fig. 7. MISCELLANEOUS INSTRUMENTS]
+
+[Illustration: Fig. 8. EXCAVATORS WITH DETACHABLE HANDLE]
+
+=The Excavator.= Excavators for use in the nail grooves are of great
+service to the podiatrist. Probably the most practical variety of this
+instrument is that borrowed from the dentist. This form of excavator
+is composed of two parts, a handle, called commercially a cone socket
+handle, and an excavator point which screws into the hand piece. These
+points may be obtained in a great number of styles but the two shown in
+Fig. 8 are practical in all cases. No. 2 has a small semi-sharp point,
+while No. 1 has a larger point and is dull. These instruments can also
+be used as packers for placing gauze or cotton under the nail and in
+the grooves.
+
+Other forms of excavators are shown in Fig. 9. No. 1 is a combination
+excavator and packer; No. 2, a packer; No. 3 an excavator; No. 4 a
+combination spatula and packer.
+
+[Illustration: Fig. 9. EXCAVATORS]
+
+[Illustration: Fig. 10. INGROWING NAIL INSTRUMENTS]
+
+=Special Ingrown Nail Instruments.= A set of special instruments for
+use in surgical procedures in ingrown nail cases is shown in Fig. 10.
+Nos. 1, 2, and 3 are used for the removal of ragged edges of nail. No.
+4 is a nail elevator, used for pre-operative examination, and No. 5 is
+a special oil stone used for sharpening Nos. 1, 2, and 3.
+
+=Ingrown Nail Forceps.= Two types of forceps for the removal of the
+imbedded portion of the nail after it has been loosened from the
+nail body, are in general use. One is of a curved variety and is
+particularly practical; the other has a straight point and a locking
+device and is in reality a small artery forceps. Fig. 11 shows the
+straight point forceps.
+
+[Illustration: Fig. 11.
+
+STRAIGHT NAIL FORCEPS]
+
+[Illustration: Fig. 12.
+
+NAIL SPLITTER]
+
+=Ingrown Nail Clippers.= The clipper shown in Fig. 12 is used almost
+entirely in ingrown nail operations. It is extremely light and if used
+in the general cutting of nails will surely be sprung. The clipper
+illustrated is more correctly a nail “splitter.” These clippers may be
+obtained in two sizes, four and one-half and five inches.
+
+=Nail Clippers.= The nail clipper should be of heavy stock so that all
+nails may be easily cut without injury to the instrument or pain to the
+patient. A heavy nail clip, even though it be dull, will do much more
+efficient work in general, than will a sharp light clipper.
+
+Two styles of nail clippers are shown here. Fig. 13 is a clip for
+general work while Fig. 14 finds its particular efficacy in club nail
+cases. Notice the angle of the blade in this type of instrument.
+
+[Illustration: Fig. 13. NAIL CLIPPERS]
+
+[Illustration: Fig. 14. CLUB NAIL CLIPPERS]
+
+=Thumb Forceps.= Thumb forceps are used extensively in podiatry
+practice. All sterile dressings are handled with these instruments to
+insure immunity from the contamination of the hands.
+
+Three varieties of thumb forceps are shown in Fig. 15. No. 1 has needle
+point corrugated jaws; No. 2 has curved, corrugated needle jaws; and
+No. 3 is a heavy pointed corrugated jawed instrument. These three
+styles are all four inches in length.
+
+=Iris Tooth Forceps.= This instrument is used where the dissection
+method of treatment is employed. The sharp teeth at the end of the
+jaws, grasp the thickened mass as it is loosened from its bed. (Fig.
+3-A.) The ordinary thumb forceps may also be used in this connection
+but they are much more liable to slip than are those of the iris tooth
+variety.
+
+[Illustration: Fig. 15. THUMB FORCEPS]
+
+[Illustration: Fig. 16. HEAVY STRAIGHT SCISSORS]
+
+[Illustration: Fig. 17. HEAVY CURVED SCISSORS]
+
+=Scissors.= The podiatrist needs at least four styles of scissors in
+his general practice.
+
+For buckskin, felt and adhesive plaster a heavy scissors with straight
+blades is necessary. This scissors should be six or six and one-half
+inches in length and should preferably have round ends (Fig. 16).
+
+A pair of heavy, curved scissors is also useful for shaping shields,
+cutting apertures and for other similar work. It is suggested that
+these be not too large for they are apt to be unwieldy. Four and
+one-half or five inches is ample size, and one point should be rounded,
+and one pointed (Fig. 17).
+
+[Illustration: Fig. 18. CUTICLE SCISSORS (Curved Blades)]
+
+[Illustration: Fig. 19. CUTICLE SCISSORS (Straight Blades)]
+
+[Illustration: Fig. 20. BANDAGE SCISSORS]
+
+Cuticle scissors are useful in many chiropodical procedures. Fig. 18
+shows a four-inch, lance point curved scissors. Fig. 19 shows a four
+and three-quarters inches straight pointed cuticle scissors.
+
+A small bandage scissors, (Fig. 20) should be included among the
+podiatrists’ instruments. It is not necessary to have a large pair, but
+one about four and one-half or five inches in size is very useful.
+
+=The Hypodermic Syringe.= The choice of the hypodermic syringe is
+purely a matter of preference, but certainly an all-glass syringe (both
+barrel and piston) appears to be more practical from the standpoint of
+use and of sterilization. The metal barrel syringe is fast going out of
+use excepting of the type in which no washers are employed. A syringe
+having a capacity of 2 c.c. is ample for the use of the podiatrist
+(Fig. 21).
+
+[Illustration: Fig. 21. HYPODERMIC SYRINGE]
+
+[Illustration: Fig. 22. ROUGH CUTTING BURS]
+
+=The Rotary Drill.= One of the greatest boons to modern podiatry is the
+development of the rotary file or drill for their use. This instrument
+has become so all important in the treatment of many nail diseases,
+and, in fact, in the prophylactic treatment of the normal nail, that we
+may well wonder how any results were obtained before its advent.
+
+It is not the purpose of this chapter to go into the mechanism of
+the drill, but the selection of burrs is a subject which is of such
+importance as to merit mention.
+
+Fig. 22 shows several varieties of rough or “cutting” burs for use
+in grinding down club nails. In this group “B,” “D” and “E” are
+particularly practical.
+
+Finishing burs are those used to smooth off the nail after the use of a
+cutting bur, for filing the edges of a normal nail, or for thinning the
+nail in prophylactic treatments (Fig. 23).
+
+=The Nail File.= The hand file, for smoothing the edge of a nail after
+clipping (Fig. 24), should have a smooth and a rough side. The rough
+side is used in cases where the use of a drill is impossible.
+
+=Toe Separators.= These are appliances used for the purpose of holding
+the toes apart while operating between them. The implement shown in
+Fig. 25, depends upon the tension of the heavy wire for its efficacy.
+There is also an appliance used for similar purposes which is dependent
+upon a screw adjustment.
+
+[Illustration: Fig. 23. FINISHING BURS]
+
+[Illustration: Fig. 25. TOE SPREADER]
+
+[Illustration: Fig. 24. HAND FILE (SHOWING ROUGH SURFACE)]
+
+=Applicators.= Applicators, used for solutions, may be obtained in
+metal and in wood. Those of metal have a short hexagonal handle and are
+corrugated at the distal end so that cotton may be wound about them.
+
+The wooden applicator is a small round stick about six inches long.
+Such applicators are more practical than those of metal, for they may
+be thrown away after use. The metal applicators corrode after several
+applications of a corrosive drug and soon become useless.
+
+=The Skiving Knife.= The choice of a knife for the manufacture of
+shields of felt or buckskin depends principally upon the fancy of the
+user. Some prefer an all-metal, flat-handled knife similar to those
+used by leather workers (Fig. 26); others find it more practical
+to employ a blade set in a larger wooden handle, claiming that
+more purchase can be brought to bear upon the material to be cut,
+and consequently more accuracy is obtained. An instrument, known
+commercially as the “Murphy” knife, is a practical example of this
+latter variety. It has a wooden handle about four inches long, and a
+blade of similar length. The cutting edge is narrow toward the point
+and gives the operator a bias edge with which to do his cutting. The
+all-metal knife blade is similarly slanted. Skiving knives need not be
+made of the finest, highly tempered steel, and the edge placed upon
+them, when honed, need by no means be a “razor” edge.
+
+[Illustration: Fig. 26. SKIVING KNIVES]
+
+
+CARE OF INSTRUMENTS
+
+Instruments need care just as do any fine machine. Knives and other
+pieces of fine metal will rapidly lose their usefulness unless proper
+and unceasing care is taken of them.
+
+=Honing.= Nearly every chiropodist at the present time hones his
+own knives or chisels. This is an art which comes naturally to some
+but usually is only developed through constant practice. The first
+important point that needs to be considered in this connection is the
+selection of a hone. A hone is a plane true block of fine compact stone
+for sharpening edged tools, and there are a number of these which may
+be used for podiatry instruments.
+
+=The Belgian Hone= is in all probability the most popular of the
+sharpening stones and when genuine and of fine quality, they are
+superior to all other forms of stone. One of the principal drawbacks
+in the purchase of a hone of this variety is the fact that many are
+manufactured of a composite substance which is extremely hard and upon
+whose surface no impression can be made with the instrument. All hones
+should be fairly soft, so that the knife blade, as it is drawn across
+the surface, will take hold, and not “rough” or “gritty.” Any stone
+which has a tendency to roughness or coarseness will never put a real
+fine “razor” edge on a delicate instrument.
+
+=The Swatty Hone= has been popular for years among barbers and others
+who are called upon to use razor-like blades. The one disadvantage
+in the use of this variety of stone is that they are hard, and
+considerable honing is needed to place a proper edge upon the
+instrument.
+
+=The Oil Stone= is used more particularly for heavy instruments not
+demanding a fine surface for finishing. Skiving knives and the like may
+be successfully sharpened on stones of this kind. Some practitioners
+prefer to “rub down” an instrument on an oil stone or a “carborundum”
+stone and then smooth the edge or “finish” it on a genuine old rock
+Belgian hone. Carborundum hones cannot be obtained, as a rule, fine or
+smooth enough for real delicate work on podiatry instruments, but they
+are efficient for heavier instruments.
+
+=Technic of Honing.= Having selected a stone the block is placed before
+you on a table. The knife is grasped firmly by the handle with the
+thumb and the third, fourth and fifth fingers. The second or index
+finger is placed at the junction of the blade with the handle on the
+upper surface. The blade of the knife is now laid upon the hone in such
+a manner that it is flat upon the stone’s surface, and, using the whole
+forearm, the fingers and wrist remaining stationary so that the angle
+of the blade remains unchanged, the blade is drawn in an oblique (right
+to left) direction toward the operator’s body. It must be remembered
+that the blade be drawn _obliquely_ for if it be drawn straight no edge
+will be placed upon the instrument.
+
+Having completed this oblique stroke, the whole instrument is turned in
+the hand and laid upon the stone so that the other side of the blade is
+now upon its surface. An oblique (left to right) stroke is then made
+toward the operator using, as before, the whole forearm. This stroke
+having been completed the whole procedure is recommenced.
+
+The marks appearing on the blade of the knife caused by contact with
+the hone, plainly tell the operator whether or not he has the proper
+angle or whether he is holding the blade at the proper level through
+its long axis. Testing the sharpness of the blade on the finger-nail or
+skin, or judging from the appearance of the contact marks, tells the
+operator whether or not the instrument be sufficiently sharp.
+
+Do not overhone! This is a bad fault and will develop a “wire” edge on
+the instrument which may take hours to remove. An edge may be “wired”
+also by continued heavy pressure during the honing process. This should
+also be avoided. Usually several heavy strokes on either side of the
+blade, followed by a series of lighter ones, is sufficient to place an
+instrument in serviceable condition for a considerable period of time.
+
+=Polishing.= Instruments which are subjected to boiling sterilization
+are bound to become discolored (not rusted) no matter what chemical may
+be put in the water to prevent this condition. For this reason it is
+found necessary, if the brightness of an instrument is to be retained,
+to clean or polish it from time to time.
+
+Scrubbing with sapolio or some similar substance, not too gritty,
+will serve to remove most of the stains but the labor occasioned by
+a procedure of this kind is considerable and is greatly lessened by
+the use of a motor buffer or polisher. In cases where rust stains
+are present, this machine is indispensable, for no amount of manual
+rubbing will remove these marks. The buffer wheel should be of some
+soft material, usually chamois, bound firmly. Machine buffing can never
+be used on delicate, sharp blades, as it will ruin whatever edge may
+be present. Handles may be cleaned efficiently as can scissors, thumb
+forceps, and similar instruments by this method.
+
+=Wiping.= After an instrument is removed from boiling water it must
+be thoroughly dried if it is to be kept in good condition. The
+ideal sterilizer is one combining a superheated steam chamber, or a
+water boiling receptacle, and a dry hot air chamber for drying the
+instruments after sterilization. If such an apparatus is not included
+in the podiatrist’s equipment, the instruments must be thoroughly wiped
+until dry. This must be done with a sterile wipe to maintain surgical
+cleanliness and the process must be thorough.
+
+Care must be exercised in using superheated steam as a sterilizing
+agent that the instrument does not remain for too great a length
+of time in the vapor. Boiling water can only reach 212° F., and
+an instrument will stand subjection to this degree of heat for a
+considerable time, but steam is often heated to twice this degree and
+this terrific temperature is bound to untemper an instrument which is
+allowed to remain in the vapor over 30 or 40 seconds.
+
+
+
+
+CHAPTER VIII
+
+SHIELDS AND SHIELDING
+
+
+Shielding is one of the most important branches of practical podiatry.
+A great amount of study must be given to this work, and to afford his
+patient relief and comfort through the application of shields and
+strappings, the operator is continuously called upon to exercise his
+mechanical ingenuity or to develop this trait if it be not already
+existent.
+
+The surgical treatment of a condition may be faultless, and yet upon
+the application of an ill-fashioned or poorly-fitted shield, the
+patient will experience even a greater amount of discomfort or pain
+than before the treatment was commenced, and the operator’s previous
+good work is thus undone.
+
+=Definition.= A shield is an appliance fashioned from some skin or
+fabric and used for the purpose of relieving pressure or friction,
+or to protect a tender part upon the foot. The nomenclature which
+is adhered to under this heading is comparatively a simple one. The
+various forms and varieties of shields mentioned and discussed are
+named either for their shape or for the particular parts of the foot to
+which they are applied. In some instances the two are combined. Thus a
+“lateral plantar half-moon or crescent shield” has a crescent shaped
+body and is used for the protection of an area on the lateral part of
+the plantar surface.
+
+
+MATERIALS
+
+Various materials are in general use today in the practice of podiatry
+for padding or shielding. The object is to give here a brief yet
+comprehensive description of each in its turn, together with a general
+survey of when, where and how they may be used.
+
+=Chamois.= This skin presents a material which may be used in shielding
+parts where a pad of great thickness is not required. Chamois skin
+is quite thin and has not a great deal of stability or “body” in
+its make-up, and skins of a uniform thickness throughout are seldom
+obtainable. The hide thins out considerably toward the belly of the
+animal and for this reason there is a great amount of waste. However,
+in many cases chamois may be used with success in connection with
+helomata on the dorsal or outer lateral surfaces of the fifth toe, the
+dorsal surfaces of the intermediate, and the ends of all the toes. For
+heloma molle, shields of chamois may also be used to good advantage,
+as they are soft and pliable and when placed between the digits they
+readily take the shape of the toes without causing the irritation
+following the use of shields of a coarser or stiffer “body” in like
+positions.
+
+=Buckskin.= Buckskin is probably the most generally used material for
+shielding in practice today. This hide has good “body” and even when
+skived to paper thinness retains a great amount of its stability.
+Buckskin can be obtained in thicknesses ranging from one-sixteenth
+to one-quarter or even three-eighths of an inch, but care should be
+exercised in its selection that no pieces of coarse-grained skin be
+chosen. This is noted because the coarse or “pebbled” skin does not
+skive readily, and when bevelled off, the edges remain ragged and
+uneven. There are several firms manufacturing excellent grades of
+buckskin. Shields of buckskin may be generally used in all conditions
+and locations, the thinner skins on the toes and dorsal surfaces and
+the thicker on the plantar surfaces and on the metatarsophalangeal
+joints of the great and fifth toes.
+
+=Adhesive Moleskin.= A so-called moleskin having a prepared medicated
+adhesive substance on one side is becoming very popular with the
+profession. It may be obtained in rolls of from one to ten yards
+long, and from seven to twelve inches wide. It is very thin but has
+good “body,” and under the pressure to which it would be ordinarily
+subjected as a shielding material, does not stretch nor pull out of
+shape. Because of this thinness and its pliability and softness,
+no skiving of its edges is necessary, and it makes a neat, clean,
+practical material from which thin shields may be fashioned. Adhesive
+moleskin may be employed wherever chamois or the thinner grades of felt
+or buckskin are used.
+
+=Sheep Skin.= Sheep skin is one of the lesser used but, nevertheless,
+practical shielding agents. Its one disadvantage is that the finished
+surface is smooth and shiny and an adhesive substance does not remain
+intact unless applied at the time the shield is to be used. This,
+however, does not present any serious objection to the use of the skin,
+as it is easily skived, has good “body” and presents a neat, clean
+appearance on the foot. It is employed wherever chamois may be used.
+
+=Felt.= Plain white piano felting, of the softer and more pliable
+grades, is largely used at the present time. This felt can be obtained
+in thicknesses of from one-sixth to three-eighths or even one-half
+inch. The last mentioned thickness is very seldom used, and then
+only in cases where a slight support is needed for the longitudinal
+arch or as a pad in cases of painful heel. In both these instances
+the felt is pasted in the shoe rather than adhered to the foot. The
+one-sixteenth inch grade is used (1) between the toes (applied usually
+without adhesive); (2) as a substitute for chamois, kid or buckskin
+in all places where these latter may be used. The thicknesses ranging
+from one-eighth to three-eighth inch are used generally on the lateral
+surfaces of the first and fifth metatarsophalangeal articulations,
+on the plantar surface under the prominences of the same joints, and
+for protecting painful areas on the dorsum of the foot (its lateral
+borders), or in the region of the heel and the tendo Achillis. Felt
+shields may be applied with or without adhesive, and strapping should
+be done dependent upon the length of time the shields are required to
+remain.
+
+For badly inflamed or tender helomata, felt presents an ideal material
+for shielding. Shields of this material are softer and more yielding,
+and while they cannot be expected to stand the same amount of usage as
+those of buckskin they are, nevertheless, strongly recommended in the
+above named condition. After the aperture is cut to fit the part to
+be protected, its (the aperture’s) edges are nicked with scissors so
+that when applied they will expand and readily take the shape of the
+indurated areas. While they naturally pack down and become of denser
+consistency than at the time of application, felt shields never become
+as hard as those made of buckskin.
+
+=Adhesive Felt.= This is the ordinary prepared felt manufactured by
+several firms, one side of which is covered with a preparation of dry
+gum arabic. Upon moistening this adhesive, the shield may be adhered
+to any part. Shields of adhesive felt are very handy to use when
+protection is desired for a short time and are very seldom strapped
+unless they are to be applied to the plantar surfaces. They have no
+specific use and may be applied wherever shields of other materials are
+used.
+
+=Lamb’s Wool.= This material is used principally for insoles in shoes
+in cases of painful heel or severe callosities on the plantar surfaces,
+and in conditions where the integument of the foot is thin and the
+patient experiences pain or burning sensations when walking. The wool
+is left on the hide, so that there is ample body for the application
+of adhesive substances. This material, in the uses mentioned above, is
+seldom adhered to the foot itself, but is, rather, placed in the shoe.
+
+
+PREPARATION OR MANUFACTURE OF SHIELDS.
+
+The definite points to be considered in the making of a proper fitting
+are not many; these are important:
+
+1. Location of the part to be protected so that the size and shape of
+the shield may be determined.
+
+2. Thickness of the shield.
+
+3. Skiving.
+
+4. Aperture.
+
+=Location of the Parts to Be Protected.= Extreme care should be
+exercised in deciding upon the size and shape of the shield. The
+location and size of the area to be protected should be taken into
+consideration and the shield should be so fashioned that no part of it
+extends on the tissue upon which its presence might cause irritation.
+For instance, a shield is to be applied on the dorsal surface of one of
+the intermediate toes; it should be wide enough to cover the surface of
+that toe, but should not be allowed to curl downward upon the digit’s
+lateral surfaces or to lap over or extend upon the adjoining toes.
+Again, a shield applied on the plantar surface should never be allowed
+to extend forward to a point where it might crowd under the toes and
+come in contact with their webs.
+
+No shield applied for the protection of one area should be allowed to
+extend over and press upon another area which is not normal integument.
+The reason for this is obvious, for in covering an heloma, for
+instance, a greater amount of pressure is brought to bear upon that
+excrescence, with the result that it is subjected to a greater amount
+of irritation and pressure than would be caused by the shoe itself.
+
+=Thickness of the Shield.= Just as great harm is brought about by
+using a shield that is too thick or too thin as follows the absence of
+the protection which a shield provides. If it be too thick, the great
+amount of pressure put upon the surrounding area will depress those
+tissues to such an extent that severe congestion, with its accompanying
+pain and discomfort, is liable to ensue. In making a shield too thin,
+no protection is afforded to the area where it is desired and at the
+same time the toe is bundled up with a lot of padding and plaster
+which is entirely unnecessary, in that it does no good. The use of a
+shield should be avoided in all cases, when possible, but there are
+many situations in which a shield is indicated and which, when applied,
+proves highly effective. Shields naturally pack down more quickly when
+the weight of the whole body is constantly being applied, and so,
+naturally, the thicker varieties of shielding are used on the plantar
+surfaces. This applies to all shielding materials and in particular to
+felt.
+
+=Skiving.= Skiving is a process by which the edges of a shield are
+thinned or bevelled to a “feather” edge. This is done for three
+principal reasons:
+
+(1) When a shield’s outer edges are skived to a “feather” edge, it no
+doubt adheres to the integument in a much more satisfactory and lasting
+manner than if those edges were allowed to retain a uniform thickness
+with the main body of the shield.
+
+(2) By thinning the shield down at the edges any danger of unneeded
+and detrimental pressure upon the underlying and surrounding areas
+is removed. The object is merely to protect a certain part, and,
+therefore, if a pad is used which is of sufficient thickness around the
+painful area to protect the diseased tissue, the aim is accomplished,
+and to have any considerable thickness to the shield, except as it is
+immediately adjacent to the area to be treated, is entirely unnecessary.
+
+(3) Skiving a shield at its outer extremities does away with, or at
+least minimizes, the danger of the shield being loosened or shifted,
+and consequently it will remain longer in place and with better results.
+
+The inner edges of the aperture made in the shield for the protection
+of the diseased part should also be skived. This is done with the idea
+of conforming the shield, as nearly as possible, to the shape of the
+indurated integument and does away with any irritation to the part
+which might be caused were these edges left perpendicular.
+
+[Illustration: Fig. 1.
+
+A. Oval; B. Half-moon or Crescent; C. Interdigital; D. Dorsal
+(Intermediate Toes); E. Fifth Toe (Right and Left); F. Boot Shield;
+G. Dorso-digital Half-moon (Built Up); H. Modified Half-moon I.
+Medio-plantar Crescent (With Cut-out for 1st or 5th Joint)]
+
+=Aperture.= For the purpose of protecting a diseased part from the
+pressure of footgear, an aperture or opening is made in the body
+of the shield. The size of this aperture is so fashioned as to be
+slightly larger than the part to be protected. Many mistakes are made
+in shielding, due to the aperture not being cut in the proper place,
+and care should be taken in this connection. This opening is not
+always made in the centre of the shield; in many instances it must be
+placed either to one or to the other side of the median line, running
+anterio-posteriorly, and in other cases it should be nearer the front
+rather than the back of the shield, and vice versa.
+
+For example: we are to shield an heloma on the fifth toe. Upon
+examination of the part we find that the growth occurs on the dorsal
+ridge of the digit and that while there is a considerable area of the
+normal integument on the toe’s outer lateral side, the space between
+the inner edge of the growth and the fourth toe is very narrow. The
+aperture must then be so made in the shield that a very narrow portion
+of the skin or fabric rests upon the strip of normal tissue toward the
+fourth toe and that the wider edge extends down the side of the fifth
+digit. Again: in some instances we find that the spot to be protected
+is much nearer the distal end of the toe and the nail than the proximal
+part. The opening should then be made much nearer the anterior part of
+the shield than the posterior, so that when applied, the anterior part
+of the shield will not cover the nail or overlap the distal end of the
+toe. Too much stress cannot be laid upon this particular feature of
+shield-making and their application, and the student and practitioner
+alike will do well to give these points great consideration.
+
+=Method of Skiving.= The most generally used and in all probability the
+most efficient method of skiving a shield is as follows: the material
+used, after being cut to the shape and size desired, is placed with the
+left hand. The skiving knife is then taken firmly in the right hand and
+with an oblique stroke away from the operator, the edges of the shield
+are cut away and thinned to a “feather” edge. This is continued around
+the whole outer circumference of the shield until a uniform thickness
+is obtained. After this procedure, should the centre of the shield
+present any inequalities or uneven ridges, these are pared away in a
+like manner until the whole surface is uniformly smooth.
+
+One side of all pieces of buckskin will be found to be firmer and
+have a better body than the other. This is the surface to be allowed
+to remain intact, the bevelling being done on the reverse side. This
+insures a firm surface for the application of an adhesive substance.
+
+=The Skiving Knife.= The knife which seems to be most practical for
+our purpose in this procedure should have a blade from three and
+one-half to five inches long, about three-quarters of an inch wide at
+its base and tapering gradually until, at the end, the width of the
+blade is about three-eighths of an inch. This insures a large cutting
+surface and the blade, being tapered instead of an even width from
+point to base, allows the operator to employ an oblique movement in
+skiving the shield.
+
+The handle of this instrument should be fairly large and round, so that
+it will admit of a firm hold. A so-called “Murphy knife” is found to be
+a very practical and inexpensive instrument for skiving.
+
+
+APPLICATION AND STRAPPING OF SHIELDS
+
+In applying a shield, care should always be taken that the aperture
+is of sufficient size to protect all of the affected area. If this is
+not done, great inconvenience and perhaps severe pain is caused to the
+patient, in that the shield rests upon tender tissue which should be
+protected. It is also good policy to allow for any shifting which may
+take place. As for example, in the instance of an heloma: the shield
+should be applied so as to leave some space between the anterior edge
+of the indurated integument and the anterior edge of the shield’s
+aperture. The foot in the process of walking (and particularly if the
+patient wears high-heeled shoes) is being constantly pushed towards
+the forward part of the shoe, and, therefore, a shield protecting an
+heloma on the dorsum of any of the toes will be pushed back rather
+than forward. By taking this into consideration the shield, if it does
+shift, will still have a sufficient amount of sound integument to rest
+upon before it pushes back on the growth itself.
+
+=Adhesive Substances.= Adhesive substances for adhering the shield to
+the integument should have no irritating properties whatsoever. The
+late George Erff perfected a small, neat alcohol lamp with a “sauce
+pan” attachment in which these adhesive substances, usually sold in
+stick form, are easily and quickly melted to a fluid consistency when
+they may be easily applied to a shield by means of a fine camel’s hair
+brush. This enables the operator to spread the adhesive substance in a
+thin and even coat over the whole surface and is a much superior method
+to the older way of applying it directly from the heated stick.
+
+=Strapping.= In adhesive plasters, by means of which shields may be
+securely held in place, we have a great assortment from which to
+choose. Plain rubber adhesive plasters are manufactured by many firms,
+as is the zinc oxide (medicated) adhesive plaster. Special plasters,
+medicated in various ways, are also on the market in abundance and no
+doubt find their use in special cases. It is found, however, that the
+zinc oxide plaster is perhaps the most practical in all instances,
+although by no means the cheapest. This plaster retains its adhesive
+properties much longer than the numerous other plasters which have
+been experimented with from time to time, and, being at the same time
+medicated with zinc oxide, an antiseptic, it makes a practical, cleanly
+and non-irritating adhesive plaster.
+
+There are several important points to take into consideration in
+applying adhesive plasters for fastening shields more firmly on the
+surfaces of the foot.
+
+(1) =No Strapping Should be Applied Too Tightly.= Too much cannot be
+said or written relative to allowance being made in strapping a shield
+for the natural movements of the foot. It must always be remembered,
+in the first place, that a patient’s foot, elevated on the support
+of the operating chair, is at rest. There is no weight upon it, and
+consequently the tissues of the foot are not expanded to their fullest
+extent. For this reason circular strapping placed around a toe to hold
+a shield in place may seem sufficiently loose to allow perfect comfort;
+but when the patient steps down and walks for a few minutes, this same
+toe is expanded to a considerable extent, with the consequence that the
+plaster either cuts into the tender integument between or under the
+digit, or if not that, at least causes a severe enough irritation to
+occasion great annoyance every time a step is taken. Therefore, one of
+the first important points to be taken into consideration in applying a
+shield is the tightness with which the adhesive strips may be drawn.
+
+This is equally important in applying shields to the plantar surfaces,
+because, here also, allowance must be made for a great amount of
+expansion. In applying shields to these surfaces the toes should be
+extended as far as possible (drawn back toward the dorsum of the foot),
+the strapping to be applied while the toes are held in this position.
+Were the adhesive strapping applied whilst the toes are in a flexed
+position, the integument on the plantar surfaces would be found in a
+series of folds or wrinkles. This integument is not always in that
+condition, however, and, consequently, when the patient allows the
+weight of his body to come upon the foot, in taking a step, and the
+toes are extended to their fullest, the tissues covering the plantar
+surfaces would be drawn and the strapping will pull on the skin, making
+the patient decidedly uncomfortable, or it will tear away altogether
+and so become useless.
+
+(2) =Allowance Made for a Swollen Toe.= In this connection particular
+attention must be paid to the strappings of a shield. In many cases of
+helomata, or more particularly in acute conditions of interphalangeal
+bursitis, the integument immediately adjacent to the induration is not
+alone inflamed, but the whole toe is ordinarily swollen. In cases of
+this nature it will be found advantageous not to carry the strappings
+completely around the digit, but rather to place them so that, while
+they will hold the shield in place, they do not cover or come in
+contact with more of the swollen areas than is absolutely necessary
+to secure adhesion. This applies, of course, more particularly to the
+dorsal and lateral surfaces of the four lesser digits. To accomplish
+this two strips of half-inch plaster, each about one inch in length,
+are placed parallel to each other, one over the anterior and one over
+the posterior end, and adhered to the integument on each side of the
+shield. In many instances it will be found advisable to do away with
+adhesive straps entirely and merely allow the shield to remain on for
+a day or two, when, the inflammation and swelling having subsided, a
+shield may be applied and strapped if necessary.
+
+(3) =Edges of the Shield to Be Covered as Much as Possible.= It should
+always be the endeavor of the operator to cover the anterior and
+posterior edges of the shield and as much of the lateral surfaces as
+is possible. This minimizes the danger of those edges being raised
+from the integument during the normal movements of the foot. With this
+in view, it is perhaps wise to use as wide plaster as possible on the
+plantar, and, in many instances, on the dorsal surfaces as well.
+
+There are five widths of plaster generally used in chiropody for the
+purpose of adhering shields. The narrow strip, manufactured by Johnson
+& Johnson expressly for chiropodists, the one-half-inch strip, the
+one inch strip, the inch-and-a-half strip and the two-inch strip.
+The two-inch width is seldom used, and then never in connection with
+shielding, but rather for strapping weak ankles and arches.
+
+(4) =End of the Plaster to Be Rounded.= This is for the purpose of
+preventing the tendency of the plaster to loosen up at the ends. By
+doing away with as many “corners” as possible and instead making
+rounded ends, the plaster is found to adhere much more firmly and the
+tendency to curl is reduced to a minimum.
+
+
+SPECIFIC SHIELDING
+
+=Great Toe.= The shields necessary in connection with affections of the
+hallux are four in number:
+
+1. Those used in connection with bunions or metatarsophalangeal joint
+affections.
+
+2. Those used in connection with corneous developments over the
+extensor tendon on the dorsum.
+
+3. Those used in connection with corneous developments along the inner
+border or on the plantar surface.
+
+4. Those used in connection with corneous developments on the adjacent
+sides of the great and second toes.
+
+_Location 1._ Affections of the first metatarsophalangeal articulation
+or of the superadjacent tissues, usually require shields of
+considerable size, thickness and “body.” Buckskin or felt are the
+materials to be used in this situation, as they can be skived to
+considerable thinness at the edge where pressure is unnecessary and
+often detrimental.
+
+There are two forms of shields which may be used in this connection,
+viz.: the metatarsophalangeal oval or the metatarsophalangeal
+half-moon. In a majority of cases the half-moon shield is the most
+practical, but the full oval may be used at times with equal or even
+better results.
+
+The metatarsophalangeal oval (Fig. 1-A), is an oval shield about three
+inches long and two inches wide, which is used principally where the
+pressure causing the painful affection comes from the under lateral
+side of the joint. The aperture is so placed that it is much nearer
+the edge of the shield which goes under the joint, for it must be
+remembered that this shield should not extend down and to the plantar
+surface of the foot, where it might cause an inequality and undue
+pressure. The greatest amount of protection should come from the
+position of the shield, and for this purpose that portion of the skin
+or fabric is left thick, so that its elevation will equal at least, if
+not exceed, that of the affected part.
+
+In strapping a shield in this location the half-inch, one inch, or
+inch-and-a-half strips may be used. The inch plaster is probably the
+most practical, as it is of sufficient width to bind down the anterior
+and posterior edges of the shield and still will not extend over on the
+affected part in the aperture. These strips should each be about four
+inches in length and should be so arranged as to cross each other on
+the dorsum, one binding down the other. Thus the anterior and posterior
+edges of the shield, as well as the lateral surface on the dorsum of
+the foot, are covered. Some practitioners even advocate the use of
+strips of sufficient length to “criss-cross” both on the dorsum and
+on the plantar surfaces. It will sometimes be found that the anterior
+strips of adhesive plaster will extend too far up on the dorsal surface
+of the great toe and thus may interfere with its proper movement. In
+these instances it is advisable to cut out a curved portion of the
+strip so as to allow normal extension of the toe, without irritation
+from the plaster. The same holds good if the plaster should for any
+reason extend over the affected part in the aperture. The plaster
+should be cut away with curved scissors so that it remains only on
+the body of the shield. The half-inch plaster is sometimes used in
+strapping the metatarsophalangeal oval shield and is most generally
+adhered in the form of a triangle, the strips to be of sufficient
+length to cover each other on the sound integument, and so applied as
+to bind down all edges of the shield. The inch-and-a-half plaster is
+generally used in this manner in cases where it is desirable to cover
+the affected part of the joint as well as the shield, making the whole
+dressing practically waterproof. Then two strips of the inch-and-a-half
+plaster are used; each strip is split on both ends and lapped over so
+that it may be drawn down tightly on all sides of the shield. Three
+strips of the inch width would answer the same purpose but would make a
+larger and more bulky dressing.
+
+The metatarsophalangeal half-moon (Fig. 1-B) is used in all cases where
+the pressure or friction comes upon the dorsum or the dorso-lateral
+part of the affected joint. The reason for its use in these instances
+is obvious. If the pressure comes only upon one or both of these
+locations, there is surely no need of protecting the joint from
+plantar-lateral pressure, and the use of the full oval shield is
+contra-indicated in that its one lateral surface, resting on tissue
+upon which there is already much pressure, might become uncomfortable
+and detrimental to the general condition of the joint.
+
+The shield is adhered to the dorsal surface in such a manner that its
+two points are anterior and posterior to the affected part, with the
+broad lateral portion resting alongside on the dorsal surface. It will
+generally be found advisable and necessary to fashion the “anterior
+point” of the shield somewhat narrower and thinner than the posterior,
+as the former usually extends over upon the dorsum of the great toe
+and interferes with its movement if allowed to remain thick and bulky.
+In any event the greatest amount of protection is derived from the
+“posterior point” and the broad lateral surface of the shield, and
+this anterior point may be safely thinned or entirely eliminated (see
+_Modified Half-moon Shield_). In strapping the metatarsophalangeal
+“half-moon” shield, three strips of the inch width plaster, each four
+inches long, are adhered, one over the anterior tip of the crescent and
+extending well upon the dorsal and plantar surfaces, and the remaining
+two strips across the posterior part of the shield, overlapping each
+other and the two ends of the first applied strip (Fig. 2).
+
+[Illustration: Fig. 2.
+
+STRAPPING FOR METATARSOPHALANGEAL HALF-MOON SHIELD]
+
+_Location 2._ Shields are often required on the dorsum over the tendon
+of the extensor muscle for the protection of corneous formations or
+denuded spots due to rubbing of a new shoe on this prominence. Felt
+shields of considerable thickness are most generally used in these
+instances, as they are more pliable than those of buckskin and, in
+consequence, are not so harsh. They are usually cut in oval shape
+(though not so large as those described under _Location 1_), and are
+strapped in triangular arrangement with half-inch strips. In some
+instances, where pressure upon those portions of the tendon anterior
+and posterior to the affected area is undesirable, two straight pieces
+of felt of considerable thickness (so as to be of higher elevation than
+the prominence of the tendon) may be substituted with good results.
+They are placed on each side of the tendon and parallel with it. The
+strapping in this case consists of two half-inch strips placed across
+the felt shield at right angles to the long axis of the toe. A very
+practical protection of tender areas in this location is a half-moon
+shield whose opening is only of sufficient width to protect the
+affected spot. This shield is made from adhesive felt, and after it is
+fashioned and skived, a strip of the glazed adhesive, slightly wider
+than the tender prominence, is removed without disturbing the balance
+of the felt constituting the body of the shield. The shield is then
+applied and the adhesive substance thus comes only in contact with
+integument on each side of the tendon, allowing that cord to move at
+will without interference; at the same time ample protection is given
+the affected part.
+
+This shield is usually strapped by using two strips of one inch
+width plaster, each about three inches long. They are adhered, each
+overlapping the other, on the body of the shield, thus binding down
+its posterior and two lateral edges to the sound integument. Where a
+strapping of this nature would interfere with the normal movements of
+the tissues of the toes or of the great toe, one strip, three inches
+long and an inch-and-a-half wide, may be substituted and placed across
+the body of the shield (at right angles to the toes), thus binding down
+its posterior and a portion of its lateral edges.
+
+_Location 3._ In cases of tyloma or heloma on the plantar or inner
+lateral border of the great toe, oval shields of buckskin are almost
+entirely used (same as Fig. 1-B, only smaller, to accommodate the
+smaller surfaces). There are two impractical points to be considered
+and avoided in this connection: (_a_) on shielding a part on the
+inner border of the great toe, the shield should never be allowed to
+extend up on the dorsum of the toe and lap over or cover the lateral
+and posterior nail folds. The tissues about the nail are sensitive to
+a degree, and any untoward pressure will in most instances start new
+troubles in this region. The adhesive strappings will, of course, cover
+a greater portion of the nail; but as the plaster is unusually thin, a
+great amount of trouble from the strips is seldom experienced. (_b_) In
+shielding the plantar surface of the hallux, the pad should never be
+fashioned to such length as to interfere with the natural bending of
+the toe at the web. If this be allowed the patient will experience a
+feeling of “fullness” at that point which may seriously interfere with
+his natural gait and comfort, besides which, irritation may be caused
+in these parts.
+
+The strapping of shields applied to the plantar or to the inner border
+of the great toe is of necessity similar, as the pad is merely in a
+different position and the strips must practically cover the same
+territory. One-half-inch plaster answers most purposes and two strips
+are cut of sufficient length to encircle the toe and overlap each other
+on the side of the digit opposite the shield. Too many thicknesses of
+plaster between the toes should always be avoided, and to make this
+effective many practitioners prefer the narrow chiropodist strip, using
+one strip to encircle the toe twice, once on the posterior and once on
+the anterior edge of the shield. This is a matter of preference, but
+the writer favors the half-inch strip, as it has more adhesive surface
+and will consequently fasten the shield more firmly to the integument.
+
+_Location 4._ Corneous excrescences, whether hard or soft, are not
+commonly found between the great and second toe but, when so located,
+a shield is generally needed as an aid to treatment. A shield for this
+condition may be of buckskin or chamois, if intended to last for any
+time, and should be strapped in place. Felt shields are often used,
+minus adhesive and strapping, where temporary protection is needed.
+Using a shield without adhesive in any interdigital disturbance enables
+the patient to remove it and set it back at will, in this way avoiding
+the hardening or shifting when the shield is allowed to remain in place
+during and after a bath.
+
+In fashioning any shield to be used in an interdigital location, the
+lower edge (that applied next to the web of the toe) should be cut on
+a slant (Fig. 1-C), to conform with the angle of the toe web. This
+procedure not alone makes the wearing of the shield more comfortable,
+but also gives it a steady base to rest upon, whether adhesive be used
+or not. In shielding an heloma between the great and the second toes,
+and particularly if the heloma be of any size or on either toe, it will
+usually be found advantageous to adhere the shield to the great toe.
+The second toe is uncommonly long and slender, and in most instances
+presents a very small surface around the heloma, to which a shield may
+be made to adhere.
+
+The strapping of a shield in this location is similar to that applied
+on the opposite side (inner border) of the great toe; in most cases the
+half-inch plaster is employed and the ends are fashioned to overlap
+each other on the plantar or inner lateral surfaces of the digit.
+
+=Intermediate Toes (2d, 3d, 4th): Dorsal Surfaces.= In shielding the
+dorsal surfaces of the intermediate digits, pads of buckskin, adhesive
+moleskin or chamois are exclusively used. On most feet the dorsal
+surfaces of these toes are quite narrow and care should be taken that
+the shield is not so wide as to interfere or rub against the toes
+adjoining or to lap around the toes on their interdigital surfaces. The
+shield should be wide in the centre (in which location the aperture is
+cut) and should taper slightly toward each end. “Tapering slightly”
+does not in any sense mean to a point, but merely sufficient to conform
+to the general shape of the toe. Proper skiving is essential to a well
+fitting shield in this location, as it must adhere firmly on all sides
+and must not act as an irritant to the underlying and surrounding areas
+nor to the adjacent toes. For a sample of this shield see Fig. 1-D.
+
+In strapping a shield to the dorsal surfaces of the three intermediate
+toes, the narrow chiropodist strip is generally found to be the most
+practical and probably the most generally used. It is best made to
+adhere in the following manner: strip to be six inches in length; with
+one end of the strip start on the side of the toe carrying the plaster
+downward on a tangent to a point opposite the rear portion of the
+shield, then crossing this posterior part of the shield, so bringing
+it (the strip) completely around the toe to the place of beginning.
+Cover the beginning “end” with the strip and carry it over the anterior
+portion of the shield; complete the dressing by adhering the remaining
+end of the plaster to the side of the toe opposite the beginning. We
+thus have two strips of plaster over the anterior of the shield lying
+next to each other and making approximately a quarter-of-an-inch of
+adhesive surface and only one strip over the posterior portion. In
+this way the anterior portion, which is most liable to loosen up from
+the constant rubbing of the stocking and shoe in walking, is doubly
+bound to the toe (Fig. 3).
+
+In many instances where a shield is to remain for a day or so only,
+glazed felt will admirably answer all purposes. It is cut similar
+in size and design to the buckskin or chamois shield, but is most
+generally applied without strapping.
+
+[Illustration: Fig. 3.
+
+SHIELD APPLIED TO DORSUM OF FOURTH TOE]
+
+=The Dorso-Digital Oval Shield.= One more practical method of
+shielding an heloma on the dorsum of any of the intermediate toes
+may be described. In many instances, whether distinct hammer toe be
+present or not, the first interphalangeal articulation will be found
+decidedly prominent, and enlarged to such an extent as to make the
+application of an individual shield impractical. A large oval shield
+of buckskin or eighth-inch felt (Fig. 4) should then be used. The
+aperture is fashioned to fit the part to be protected and the long
+axis of the shield is allowed to rest across and upon the adjacent
+toes. A shield of this nature is seldom if ever strapped, and is
+removable by the patient while at rest or during the bath, to be
+replaced when the shoe is worn. The writer has observed many cases
+where the proximal phalanges of the intermediate toes were in a state
+of constant extension due to the contraction of the extensor tendons,
+and leaving a decided hollow in the dorsum of the foot directly over
+their metatarsophalangeal joints. In a condition of this nature a thick
+shield of this pattern is particularly practical and may be used not
+alone to protect a tender part, but also to fill up this hollow and
+allow the shoe to fit more firmly.
+
+Where helomata are present on the dorsum of all of the phalangeal
+joints, this variety of shield is, of course, contra-indicated, as
+undue pressure would be brought to bear upon the already troublesome
+excrescences and a great amount of trouble would in this way be
+invited. In some instances a full oval shield is not used, but a
+dorso-digital half-moon, as shown in Fig. 1-G, is substituted. No
+definite ruling can be made as to which form of shield should be used,
+as each case presents a different aspect and the mechanical work must
+be applied accordingly.
+
+[Illustration: Fig. 4.
+
+DORSO-DIGITAL OVAL SHIELD APPLIED TO THIRD TOE]
+
+=End of the Intermediate Toes.= Shielding is often necessary on the
+ends of the toes, and in such instances the padding should, as a
+rule, be made very thin and the subsequent dressing not bulky. This
+is advisable for several reasons: first, helomata in this locality
+are usually under or immediately adjacent to the nails and too great
+an amount of pressure cannot be put upon these structures; second,
+that there is trouble on the end of the digit is proof positive of
+the shoe being too short and, therefore, if too thick a shield be
+used, the pressure on the surrounding tissues will be too great to be
+comfortable; third, helomata in these locations are seldom found to
+be elevated to any extent above the normal surface of the integument
+and when removed, the tissues are usually at their normal elevation,
+so that shields of material as heavy as those used in connection with
+helomata in other localities are unnecessary.
+
+A shield of thin buckskin, adhesive moleskin or chamois is best in
+these cases. It is applied, generally, so that the long axis is
+across the end of the toe and seldom so that the ends of the padding
+overlap the free edge of the nail or compress the plantar surface of
+the digit. Where the heloma to be protected is situated close to the
+nail, and it is advisable that the padding extend over that structure,
+by clipping the nail closely and filing it down and at the same
+time using an exceedingly thin shield, successful protection can be
+secured without unfavorable results. Such shortening of the nail is,
+however, not advisable in all cases. This article deals entirely with
+shielding, but attention must be here drawn to the fact that there are
+many instances of an heloma occurring on the end of one of the lesser
+toes, when a shield is contra-indicated. There are many cases where
+the toe nail, if allowed to grow long, will protect the tender part
+far more successfully than will a shield. Therefore, it is always well
+to consider if protection can be obtained from the nail itself before
+applying a shield in this location.
+
+=Strappings.= The application of adhesive strips to a shield in this
+locality demands considerable ingenuity on the part of the operator,
+but there is no stereotyped method to be employed. One general method
+may, however, be explained: cut two pieces of chiropodist strip, each
+about two-and-one-half or three inches long. Apply the centre of one
+strip over one end of the shield, lateral to the aperture, and carry
+one end of the strip on a line running toward the proximal end of the
+toe and in a manner so as to cover as much of the edges of the shield
+on that side as possible.
+
+Overlap these plaster ends on the interdigital surface of the toe
+opposite to the place of beginning. Adhere the second in like manner to
+the other surface of the shield on the side of the aperture, and carry
+the plaster ends in such a way as to cause them to overlap each other
+on the interdigital surface of the toe opposite the place of beginning.
+In this way both lateral and nearly all of the plantar edges of the
+shield will be covered and bound down with adhesive plaster. It will
+be found generally that the edge of the shield coming under the free
+edge of the nail needs no reenforcement by adhesive strips, as the
+length of the nail will prevent any tendency to loosen up the plaster
+in that location. Cut a third strip about two inches long and with it
+circle the toe, binding down all four ends of the two strips already
+applied. Trim off the ends of the plaster, which extend from under this
+last applied strip, and the whole makes a neat practical shielding for
+trouble in this situation. (Fig. 5).
+
+[Illustration: Fig. 5.
+
+SHOWING SHIELD APPLIED TO END OF FOURTH TOE]
+
+There are many ways in which a shield in this location may be strapped,
+but as always, and particularly in this instance, there are so many
+circumstances which go to alter the mode of strapping that it would be
+well-nigh impossible to explain them all or to outline a set method of
+procedure.
+
+=Interdigital Surfaces.= Helomata, both hard and soft, often occur
+between the toes and, in these cases, to insure complete relief to the
+patient, a shield is usually an absolute necessity.
+
+Buckskin, sheepskin, adhesive moleskin, and chamois are the materials
+most generally used for interdigital shields although the thinner
+varieties of white felting, with or without adhesive, may be
+substituted in some instances. The shield should be fashioned of equal
+length to the surface of the toe, from the web to the distal end, and
+should be only wide enough to correspond to the thickness of the toe.
+If the shield be allowed to lap over on the dorsum of the toe or under
+on its plantar surface, new pressure is brought to bear on these parts,
+to the discomfort of the patient. It must always be remembered that
+the toes bend during the various movements in walking, and that if a
+shield be allowed to curl under the toe, the thickness of the material
+used will interfere, to a great extent, with the normal flexing and
+extending of the toe, even to such a degree in some instances as to
+cause lesions of more or less severe character on the skin.
+
+To allow any shield to cover or to press upon the tissues directly
+adjacent to the nail is always to the discomfort of those parts, and in
+this, as in all other instances, should be avoided.
+
+The bottom of the shield (Fig. 1-C) should be cut on a tangent, so as
+to conform to the corresponding slant of the toe web. This insures not
+only the minimum danger of irritation on those tender parts, but also
+allows the shield a firm base upon which to rest, and prevents any
+possible tilting or shifting.
+
+Shields for application to the interdigital surfaces seldom need to be
+of great thickness, and the thinner the shield used the more flexible
+it is, and the less pressure is brought to bear on the outer surfaces
+of the toes. It must be remembered that everything placed between the
+toes, of necessity, spreads those members further apart, and naturally
+this causes a greater amount of pressure from the boot on the outer
+surfaces. Skiving is an essential requirement in interdigital shields,
+although in some instances where they are to be used between the great
+and second toes, this (skiving) may be omitted.
+
+Thin felt shields, minus adhesive, are often employed between the toes
+for transient protection, a fresh one being usually placed in position
+daily.
+
+=Strapping.= The most practical method of strapping an interdigital
+shield is by means of the narrow chiropodist strip. The method used is
+similar in every particular to that employed in the use of the same
+width strip in applying a shield to the dorsum of the intermediate toes.
+
+Another less used method is as follows: take a six-inch chiropodist
+strip; at its centre adhere it to the upper end of the shield (that
+nearer the distal extremity of the toe), and carry both ends around
+the toe, crossing them on the side opposite to the starting point.
+Then bring the loose ends around the toe again to the side upon which
+the shield is adhered and overlap them over the bottom of the shield,
+allowing the ends to run for attachment on the sound integument.
+
+=Fifth Toe: Dorsal Surface.= There are more corneous developments on
+this digit than on any of the others, and as this toe presents a free
+surface on its outer side, which is not the case with any of the other
+lesser digits, many varieties of shielding and of strapping are used.
+
+As with the dorsal surfaces of the intermediate toes, buckskin and
+adhesive moleskin are the most generally used shielding materials, and
+pads of the thinner varieties are in most cases sufficient for the
+needs. But, as this toe is probably the most abused of any and is often
+found distorted into positions of extreme flexion or extension and is
+sometimes lapped over the fourth toe, shields of a greater thickness,
+or “built up” pads, are very often indicated. The ordinary buckskin or
+adhesive moleskin shield is fashioned oval in shape, but the anterior
+end is cut either straight across or slanted toward the outer lateral
+edge, so that we have a shield, round at its posterior extremity and
+tapering toward the anterior end, having a straight edge (Fig. 1-E).
+Shields for the fifth toe must be carefully skived, especially at
+the anterior end which goes toward the nail. The writer has often
+seen cases in which new helomata, sometimes as many as three or four,
+have developed on the dorsum of this toe anterior to the original
+callosity, exclusively caused by the habitual wearing of thick shields.
+
+The size of the shield depends wholly upon the size of the toe
+and the area to be protected, but the length of the shield should
+never be allowed to interfere with the bending of the toe at its
+metatarsophalangeal articulation. If this precaution is not observed,
+in walking the shield rubs against the dorsum of the foot and is not
+alone loosened at its posterior edge, but causes irritation to the skin
+in that region. As with those used on the dorsum of the intermediate
+toes, the aperture of a shield for the fifth toe should be cut of
+sufficient size to allow a space between its (the aperture) anterior
+edge, and that of the calloused area; this is to allow for backward
+shifting.
+
+Another form of shield used in cases where the small toe is flexed
+to a degree and an heloma has developed on its apex, is what may be
+called the fifth digital half-moon (Fig. 1-B). It is usually necessary
+to build up a shield of this variety. By “built up” is meant that two
+thicknesses of material are used, one pasted upon the other, to give
+the shield greater thickness and stability. The upper thickness is
+formed so as to protect the rear and lateral sides of the corneous
+area, but not the front. The second, or under thickness, is fashioned
+round at its posterior edge and straight at its anterior surface.
+This, being placed under the upper layer, gives the shield sufficient
+thickness to be of equal height to the elevation of the heloma or even
+higher, thereby avoiding all undesirable pressure upon the painful
+area, and at the same time filling out whatever hollow there may be in
+the foot at this point.
+
+=Strapping.= There are five general methods of strapping to adhere a
+shield to the dorsal surface of the fifth toe. Some conditions demand
+the use of one of these and none other, but in most instances any
+method may be used with good effect. These five methods are as follows:
+
+  1. Narrow chiropodist strip.
+  2. Combination narrow and half-inch strip.
+  3. Half-inch strip (using one strip).
+  4. Half-inch strip (using two strips).
+  5. Inch strip.
+
+=Number 1.= In using the narrow chiropodist plaster, the strip is
+applied in a similar manner to that already described for toes,
+arranging the plaster so as to cover the anterior of the shield with
+two widths of the strip and the posterior surface with but one (Fig.
+6). As an alternative for this, the method described in the second
+instance in connection with interdigital shields may be utilized.
+
+[Illustration: Fig. 6.
+
+STRAPPING OF 5TH TOE SHIELD WITH CHIROPODIST STRIP]
+
+[Illustration: Fig. 7.]
+
+=Number 2.= The narrow strip and the half-inch combination consists
+of a narrow strip, about four inches in length, adhered to the inner
+surface of the toe and carried twice around the toe across the surface
+of the shield, anterior to the aperture. This, as will be seen, binds
+down the distal end of the shield. The half-inch strip, about three
+inches in length, is then cut as shown in Fig. 7-B.
+
+Taking this strip in both hands, insert it between the toes in such a
+manner as to allow the narrow portion of the plaster to fit into the
+narrowest part of the toe web. Then carry the outer broad end of the
+strip around on the dorsum of the toe and adhere it across that part
+of the shield posterior to the aperture, taking care, however, that
+the adhesive plaster is half on the shield and half on the integument
+adjoining it. Adhere the remaining broad end of the plaster (that
+coming from between the toes) over the first applied posterior strips,
+taking the same care that shield and skin are both covered by the
+plaster (Fig. 8).
+
+[Illustration: Fig. 8.
+
+SHOWING SHIELD STRAPPED WITH NARROW AND HALF-INCH STRIP]
+
+[Illustration: Fig. 8a.
+
+SHOWING DRESSING COMPLETE WITH COCOON OVER APERTURE]
+
+This alternate style of strapping is particularly useful in cases where
+the narrow strips of method No. 1 are found to irritate the skin of
+the toe web, or if there be a corneous excrescence developed there
+which cannot be covered by the plaster; instead of using the half-inch
+strip, as just described, a half-inch or inch strip, about two inches
+in length, is cut and placed across the posterior of the shield and is
+adhered to the integument on the dorsum and plantar of the foot. Should
+any portion of this posterior strip lap over the aperture, it should,
+of course, be cut away.
+
+[Illustration: Fig. 9.]
+
+=Number 3.= In this manner of strapping (using one one-half-inch strip)
+we have one of the most practical methods in vogue today. A strip about
+six inches in length is fashioned in the manner of Fig. 9. The wide
+portion in the strip’s centre is then adhered to the anterior surface
+of the shield and the ends are carried around, one on each side of the
+toe, in such a manner as to allow the narrowest portions to criss-cross
+in the narrow part of the toe web on the plantar surface. The wide ends
+are then carried around the dorsum of the toe and are overlapped on the
+posterior portion of the shield. This method of applying the plaster
+supplies a greater amount of adhesive surface than by the use of the
+narrow strip and is just as practical, or more so, in many ways.
+
+=Number 4.= In using two one-half-inch strips to adhere a shield to
+the dorsum of the fifth toe, the plaster is fashioned as shown in A
+and B (Fig. 7). The strip marked “A” is cut about two inches in length
+and split on the square end. That marked “B” is about three or three
+and one-half inches in length. The strip “A” is laid over the anterior
+surface of the shield with the split end toward the inner side of the
+toe. The anterior one of the two split ends is then drawn tightly over
+the anterior edge of the shield and adhered to the inner surface of
+the toe; the remaining split end is adhered over the first and should
+also be drawn tightly, so that the anterior portion of the shield
+is closely bound to the dorsum of the toe. The rounded end of the
+plaster strip is then carried around the outer side of the toe in such
+a manner as to allow the narrow portion of the plaster to rest over
+the corresponding narrow part of the toe on its plantar surface. The
+wide extremity is brought around to the inner side of the toe and is
+placed over the split ends already adhered. This binds them securely to
+the interdigital surface of the toe. Any loose ends showing after the
+foregoing is completed should be clipped off. One wide end of the strip
+“B” is then adhered across the posterior surface of the shield and
+the plaster carried around the toe (the narrow portion of the plaster
+fitting in the narrow part of the toe web) and the remaining wide end
+is overlapped on the posterior portion of the shield, thus securing the
+other wide end already adhered to the shield.
+
+Another method, differing merely in the position of the last wide
+end of the strip “B,” is as follows: instead of adhering this end
+criss-cross over the posterior portion of the shield, bring it further
+toward the anterior of the toe and adhere it directly across and over
+the aperture, fastening the end upon the inner side of the toe. This
+makes a waterproof dressing with none of the shield showing when the
+dressing is complete; it is contra-indicated when a soft dressing is
+desired over the inflamed parts.
+
+[Illustration: Fig. 10.]
+
+=Number 5.= The other method which may be used is to cut off about
+six inches of one inch plaster (although the length used depends upon
+the size of the toe), and fashion it as shown in Fig. 10. The split
+ends are then adhered on the inner side of the toe, so that the wide
+portion next to them is drawn tightly over the anterior surface of the
+shield. The narrow portion is then carried around the outer side of
+the toe and is placed, as previously described, on the corresponding
+narrow surface of the toe web, and the remaining wide end is brought
+between the toes and over the posterior surface of the shield, entirely
+covering the pad and adhering it to the integument on the outer surface
+of the shield, over the metatarsophalangeal joint. This also makes a
+practically waterproof dressing (Fig. 11).
+
+[Illustration: Fig. 11.
+
+SHOWING ANTERIOR PORTION OF ADHESIVE STRIP APPLIED]
+
+[Illustration: Fig. 11a.
+
+SHOWING DRESSING COMPLETED]
+
+=Fifth Digital, Built Up, Half-Moon Shield.= In strapping a “built up”
+half-moon shield in this connection there are one or two methods which
+will answer in all cases. The first method is the use of but one strip
+of plaster, either of one inch or of one-and-a-half inch width. This is
+placed transversely across the body of the shield so that no plaster
+extends over into the aperture, and it is adhered to the integument
+on the dorsal and plantar surfaces of the foot. As this shield is so
+much wider than the toe, it is not practical to encircle the toe with
+adhesive strips in fastening it. The other method at times employed,
+and the one that is advocated, in that it binds down the “points of
+the crescent,” situated laterally to the corn when the shield is in
+place, consists in the use of two strips of the one inch plaster. These
+are each cut about two inches in length, one being placed diagonally
+across the body of the shield in such a manner as to cover the outer
+lateral point of the shield, and the other in a like manner, so as to
+cover the inner lateral point of the shield and overlapping the first
+applied strip on the body of the shield. In many instances, however,
+this variety of shield is not strapped and is removed and reapplied by
+the wearer at will.
+
+It may sometimes be found advisable, when a small shield cannot be used
+and where the spot to be protected is nearer the distal part of the
+toe, and in consequence would not receive sufficient protection from
+a half-moon shield placed at its proximal end, to apply to the part
+a full oval shield, slightly modified as to its anterior edge. This
+shield is of the same shape as that shown in Fig. 1-E, except that
+it is larger. It is made from the thicker grades of buckskin and is
+fashioned so as to rest on the fourth toe and over the fifth nail, and
+for this reason these two contact surfaces of the shield must be well
+skived. This shield is seldom strapped and then only at its posterior
+surface, and in like manner to the strappings described for the fifth
+digital half-moon. A large shield of this kind evens up the whole
+surface of that part of the foot and so equalizes the pressure that it
+is distributed generally.
+
+=Lateral Surfaces.= Helomata on the outer lateral surface of the fifth
+toe are generally shielded in a manner similar to those occurring on
+the dorsum; the shield in the lateral location, however, should never
+be of great thickness. In most instances corneous developments of the
+small digit on these surfaces are situated adjacent to the nail and the
+shield, and to be comfortable, should not be allowed to overlap the
+nail structures. If, however, to obtain proper protection, overlapping
+must be allowed in order to cover these areas, the shield should be of
+paper thinness, especially at its anterior end.
+
+In this situation a shield is often used which gives protection from
+the anterior, posterior and outer lateral but not from the inner
+lateral surface, which would of necessity have to be adhered over the
+dorsum of the toe and the nail.
+
+This form of shield is practically of the same shape as the ordinary
+fifth toe protector but with the inner lateral surface next to the cut
+away aperture. It is particularly practical in cases where the spot to
+be protected is directly next to or in the corner of the nail. By a
+shield so fashioned, the protection of the part is derived from all but
+the nail.
+
+=Strapping.= The narrow chiropodist strip affords the most practical
+method of strapping a shield in this location, and the method is
+similar to that employed on the dorsum of the fifth or intermediate
+toes.
+
+In strapping the last mentioned form of shield, the strips are applied
+in a similar manner. Care is taken to adhere the plaster over both
+points of the shield, anterior and posterior to the affected part.
+
+=Interdigital Surfaces.= The shielding of helomata occurring on the
+inner surface of the fifth toe is similar in method to that employed
+in shielding like parts on the intermediate toes. This applies to the
+strapping as well. Thick shields are contra-indicated, as they force
+the fifth toe out against the shoe; if used on that part they will
+undoubtedly create trouble to the toe in question. Both hard and soft
+helomata often occur in this connection; they are located, not on the
+sides, but rather well down in the web of the toe. In such cases a
+specially fashioned shield is required which, from its shape, is known
+as a “boot shield” (Fig. 1-F). This shield is of material such as is
+used in making the ordinary interdigital pad, being the thinner grades
+of adhesive moleskin, buckskin, or chamois. It is applied usually on
+the adjacent side of the fourth toe, the narrow portion uppermost and
+the wider part with its concave surface directly above the uppermost
+ridge of the corneous area. This not alone prevents lateral pressure,
+but, by means of the tongue-like shape at one side of its base, it also
+prevents pressure on the part from the plantar surface.
+
+It is often found that helomata, developing in the interdigital web of
+these toes, are caused by pressure on the part, due to the dropping
+of the fourth metatarsal bone. To bring the head of this bone up into
+position, and in that way relieve the pressure, it is often found
+necessary to apply a felt or buckskin shield on the plantar surface
+of the foot under this articulation. This may be done in addition to
+applying a shield between the toes or each may be used separately, as
+experience dictates. Alfred Ahrens, of New York, one of the teaching
+staff of The First Institute of Podiatry, has devised a shield, known
+by its shape as the “duck shield,” which is so fashioned as to present
+a shielding surface between the fourth and fifth toes, as well as an
+expanded end which extends down upon the plantar surface and throws the
+head of the fourth metatarsal up into normal position.
+
+=Strapping.= The narrow strip is the most practical means of strapping
+a “boot shield” to the fourth toe. Two turns of the plaster are
+carried around the digit, the first covering the shield about at its
+centre and the second crossing near its uppermost end. One half-inch
+strip may also be used, its two ends crossing each other on the side of
+the fourth toe, opposite the shield; or in some instances, if the shape
+of the toe permits, the ends may be adhered to the dorsal and plantar
+surfaces of the foot.
+
+=Metatarsophalangeal Articulation.= In protecting a part in this
+location three styles of shield may be employed:
+
+  1. Oval.
+  2. Half-moon.
+  3. Modified half-moon.
+
+=Number 1.= The thicker grades of buckskin or felt are generally used
+for this protection, as the part, if affected, is usually considerably
+elevated above the surrounding integument. As in connection with the
+first metatarsophalangeal articulation, the oval shield is so fashioned
+that the principal protection will be derived from the upper lateral
+and posterior surfaces. The anterior and under lateral surfaces are
+made correspondingly thin and narrow, so that no undesirable pressure
+is brought to bear on the integument beneath these surfaces. In
+this instance, two reasons may be given for such a course: first,
+all unnecessary pressure is naturally contra-indicated; second, the
+protection from these sides is, in nearly every instance, useless and
+unproductive of results. Usually, if the point to be protected be
+near the band of the fifth toe, the shield must be scalloped so as
+to allow for the backward movement of this digit when in an extended
+position. Great care must be taken in applying all shields to allow for
+the natural movements of the parts in walking. In this position, more
+particularly, a cumbersome, ill-fashioned shield may become a source
+of irritation during the movements of the foot in exercise. Ninety per
+cent. of shield troubles are due to their being improperly fitted or to
+their imperfect fashioning.
+
+If a shield used in protecting the fifth metatarsophalangeal
+articulation is not scalloped, as previously mentioned, to allow
+for the backward movement of the proximal phalanges of this digit,
+irritation is not only bound to occur, but the movement of the toe
+will loosen up the anterior rim of the shield (despite strapping), and
+consequently shifting of the shield is sure to occur.
+
+In strapping an oval shield to this part, two strips about four or five
+inches long are cut from the one inch width plaster. They are adhered
+so as to cover the anterior and posterior portions of the shield and
+the upper loose ends, made to overlap on the dorsum of the foot, are
+carried firmly over the side to the plantar surface, overlapping also
+on the sole of the foot.
+
+From experience, the writer much prefers the substitution of the
+so-called half-moon, or the modified half-moon shields (Fig. 1-H) in
+place of the oval just described.
+
+=Number 2.= The metatarsophalangeal half-moon shield supplies all the
+necessary protection from its upper lateral and posterior surfaces
+without extending down around and under the plantar surface of the
+joint. It must always be remembered that the insole of the shoe joins
+its shank at this point and, in many instances, particularly if the
+shoe has been worn to any extent, the insole is inclined to curl up and
+to thicken, and in nearly every case where the shield is allowed to
+run over the edge of the foot, undue pressure, with its train of bad
+effects, is made on the parts.
+
+The half-moon shield is placed on the dorsum of the foot, the “points
+of the crescent” extending anteriorly and posteriorly to the part to be
+protected. The anterior is made narrower and thinner than the posterior
+point for, as is the case with the oval shield, the greatest amount of
+protection must come from the wide lateral surface (the main body of
+the shield) and from that portion lying posterior to the protected part.
+
+As is the case in any shield, the anterior part of the crescent or
+half-moon variety must be placed far enough forward so that if it does
+shift, there will still be sufficient normal integument for it to rest
+upon before it comes in direct contact with the anterior edge of the
+calloused area. However, care must also be taken and allowance made so
+that backward movement of the fifth toe does not tend to loosen up this
+anterior edge.
+
+In strapping the half-moon shield, two strips, four inches long and one
+inch wide, are used in like manner as that described in the strapping
+of the oval shield. In some instances the anterior point of the
+crescent is found to be narrow enough so that a strip of the half-inch
+plaster, cut the same length, may be substituted with equally good
+results. The inch width, or in some cases the inch-and-a-half width, is
+used across the posterior portion of the shield.
+
+=Number 3.= The modified metatarsophalangeal half-moon shield is
+practically the regular half-moon minus its anterior point. Many
+practitioners have suggested a shield of this nature for protection
+of the first and fifth metatarsophalangeal joints for the reason
+that the anterior point is of little or of no use and may become a
+decidedly detrimental feature should the shield shift in any way. Its
+application and strapping is similar in every particular to that of
+the half-moon. The writer, however, has often used two strips of one
+inch width plaster, each about three inches long, and has adhered them
+in criss-cross fashion over the posterior of the shield so as to cover
+the entire posterior portion and some part of the lateral edge, and has
+also found this method entirely satisfactory.
+
+=Plantar Surfaces.= The plantar surfaces of the foot, being subject to
+continued pressure and at times to considerable friction, are prone
+to develop many calloused and corneous areas. In many of these cases
+shielding is absolutely imperative to successful treatment.
+
+It must always be remembered that these excrescences are, in a
+measure at least, a protection to the underlying parts, and their
+removal often makes the patient conscious of their loss. Ofttimes the
+tissues so exposed become congested and decidedly tender. This, of
+course, is to be considered at all times, but particularly so on the
+plantar surfaces of the foot. Another point which must be taken into
+consideration in this connection is that the normal tissue padding (fat
+and muscles) of some people’s feet is very thin; in consequence, the
+heads of the metatarsal bones are unprotected. In most cases of this
+kind shields must be applied to take the place of nature in order to
+insure any degree of comfort to the patient.
+
+Shields to be placed on the plantar surfaces, and particularly those
+to be applied to the metatarsophalangeal regions on the “ball” of the
+foot, must of necessity be of decidedly heavier quality and contain
+more “body” than those applied to the dorsal or lateral regions. The
+reason is that the constant weight of the body quickly flattens the
+shields out to such an extent as to render them useless as far as
+protection is concerned.
+
+The full oval shield (Fig. 1-A) is the agent best calculated to protect
+sensitive areas on the plantar surfaces, and it can be safely said that
+it may be and is used in almost every case of this kind. Naturally
+the most general locality for the formation of helomata is under
+the metatarsophalangeal articulations. These areas, particularly in
+persons whose feet are thin and lack the proper natural padding, become
+the seats of severe callosities and helomata. The shield to be used
+should always be of sufficient size to allow surface enough so that
+the patient will rest upon the shield rather than on the integument;
+but they should never be allowed to extend up under the toes or be
+placed in any way so as to irritate the tender tissues surrounding
+the diseased area. For this reason many practitioners have advocated
+the use of the medio-plantar crescent shield (Fig. 1-I), so placed
+that the greater body of the shield is posterior to the heloma and
+the “points of the crescent” extend forward laterally to the heloma
+and point toward the toes. This variety of shielding is particularly
+efficient when the part to be protected is located rather anterior to
+the metatarsophalangeal articulations, as is often found in cases of
+blisters and verrucæ. However, in most instances where the trouble is
+situated directly over these joints, an oval shield may be used with
+perfect impunity and good results will usually follow.
+
+The long axis of the oval shield is placed, as a rule, crosswise on
+the foot, as the greater amount of protection is derived from the
+surfaces immediately adjoining the affected area, laterally rather than
+anteriorly and posteriorly. In cases of excessively arched feet (not
+necessarily _pes cavus_) and when the integument is quite thin, a great
+deal of protection may be afforded by “building up” the shield on its
+surfaces, which are to be posterior to the areas to be protected. This
+fills up, to some extent, the hollow caused by the high longitudinal
+arch and gives the patient a larger surface upon which to stand or
+walk. This same theory of shielding may be successfully applied in
+cases where the calloused area covers the whole “ball” of the foot,
+making it impractical to shield any one spot without jeopardizing the
+comfort of the rest of the integument by placing a shield over it.
+A large piece of felt may then be applied directly posterior to the
+callosity, the felt to be of sufficient thickness to allow the patient
+to rest upon the shield rather than upon the painful calloused area.
+
+=Strapping.= In strapping the plantar oval shield, the one inch width
+plaster is most generally used. Three strips are cut, one about two
+inches and the remaining ones approximately three or four inches in
+length. The short strip is then placed over the anterior edge of the
+shield and is adhered to the integument, adjacent laterally to the
+shield. One of the longer strips, placed diagonally over the shield’s
+lateral edge, starting from and covering the plaster strip already
+adhered transversely across the anterior end and running backwards and
+covering the whole lateral surface of the shield, is adhered to the
+integument immediately posterior. The remaining long plaster strip is
+then placed in like manner over the other lateral surface of the shield
+and is adhered so as to cover the posterior end of the first placed
+lateral strip. This lapping of the plaster ends lends reenforcement
+to the strapping and undoubtedly minimizes the danger of the plaster
+loosening and at the same time all the edges of the shield are bound
+down to the integument (Fig. 12).
+
+[Illustration: Fig. 12.
+
+SHOWING COMPLETE STRAPPING FOR MEDIO-PLANTAR OVAL SHIELD]
+
+It should be remembered that when applying adhesive strips in the
+strapping of a plantar shield, the toes should always be drawn backward
+towards the dorsum of the foot to their fullest extent, the straps to
+be applied whilst the toes are held in this position. This is to allow
+for the extension of the toes in the last position of walking and
+prevents the plaster from pulling on the sound integument.
+
+In several instances it has been advocated that but two one inch width
+strips be used on a shield of this nature, and the same method may
+well be applied to the strapping of the medio-plantar crescent shield
+previously described. These strips are cut of equal length, each about
+four-and-a-half or five inches. About one inch from one end, each strip
+is narrowed from the sides so as to allow the admission of the plaster
+between the toes. This one end is then adhered to the integument on
+the dorsum of the foot, the narrow portion being carried between the
+third and fourth or the fourth and fifth toes (as the size of the
+shield may indicate) and the remaining portion of plaster is adhered
+diagonally across the outer lateral surface of the shield. The other
+strip, adhered in like manner on the dorsal surface, is carried between
+the toes (usually the great and second) over the inner lateral surface
+of the shield, lapping over the end of the first strip applied. This
+method of strapping covers, to a considerable extent, the anterior
+portion of the shield and does away with the transverse strip which in
+many cases becomes an irritating agent to the tender integument under
+the toes.
+
+The argument against this method of strapping may be the danger of
+irritation between the toes. From the experience had in using this
+method, the writer has had no bad results, and if the strips are
+properly adhered, the normal movements of the foot being taken into
+consideration and the plaster lying between the toes cut sufficiently
+narrow, no bad results can take place and there is no doubt of the
+greater efficiency and lasting power of the strapping.
+
+=The Lateral Plantar Half-moon.= When the area to be protected is
+situated on the extreme lateral edges of the plantar surface, as
+often found in these locations, and the callosity extends to or
+sometimes over the lateral border of the foot, the full oval shield
+is contra-indicated. In its place the lateral plantar half-moon is
+substituted with better results in all cases.
+
+This variety is identical with the dorsal half-moon shield and is
+applied so that the main body of the shield lies laterally on the
+plantar surface, while the “points” are allowed to extend somewhat over
+the lateral border of the foot so that some protection is afforded from
+this source. The major protection, however, is, of course, obtained
+from the main body of the shield on the plantar surface.
+
+The anterior “point of the crescent” is generally fashioned so as to be
+narrower and thinner than the posterior, for in nearly every instance
+this must extend near the under surface of the great toe and of the
+small digit, and must in no way be allowed to interfere with their
+movements. Two strips of one inch width plaster are generally used in
+strapping the lateral plantar half-moon, although in some instances
+it will be found necessary (due to the close proximity of the digital
+webs) to substitute a strip one-half inch in width for the anterior
+strapping.
+
+The straps are so placed as to overlap both on the dorsal and plantar
+surfaces and to bind down the anterior and posterior edges of the pad.
+In all strapping the result to be obtained is the binding down of the
+edges of the shield rather than merely binding down the main body.
+
+=Lateral Borders.= Practically the only spot on the lateral borders
+of the foot where callous formations may be met is over the expanded
+base of the fifth metatarsal bone, although blister formations or other
+tender areas may develop anywhere along the edges.
+
+The full oval shield is almost entirely used in connection with
+protection in these locations and is usually strapped with three strips
+of the inch width plaster or, if the shield be small, three strips of
+one-half inch width plaster will answer.
+
+These are placed as follows: one strip slightly shorter than the other
+two is adhered transversely across one end of the shield and the
+other two are applied diagonally from the ends of the first, so as to
+completely cover the lateral edges of the shield and overlap each other
+on the sound integument beyond its end.
+
+=Os Calcis Region.= Many cases coming to the notice of the podiatrist
+require the application of a shield in the region of the os calcis,
+either on the plantar, lateral and posterior surfaces of the heel
+itself, or further upward on the prominence of the tendo Achillis. The
+oval shield is most generally used in these instances, and felt will
+usually be found to be the most practical shielding material. Felt,
+in particular, is advocated because it is softer and more yielding
+than most other materials, and in shielding a tender area on the
+tendo Achillis, nothing harsh can be used without danger of causing
+irritation to the surrounding and underlying soft parts.
+
+Strapping is similar to that used in adhering the oval shield to the
+lateral border, but naturally the operator must exercise his own
+ingenuity in the method of strapping to meet the conditions present.
+
+The art of applying a shield is not one to which any set rules can be
+applied. Each case is individual and the operator who goes about this
+branch of his work in a stereotyped manner will find his efforts devoid
+of results.
+
+Often a half-moon shield is used where the part to be protected is
+so located that a full oval shield may not be applied. Sometimes the
+“points” are applied upward and sometimes the main body of the shield
+lies above the protected area and the “points” are downward. The
+strapping is similar to a strapping for any such shield and the strips
+are applied in such a way as not to interfere with normal movements of
+the heel or of the tendon.
+
+There are many instances in which incipient bursal inflammations are
+developed adjacent to the tendo Achillis, due to the wearing of a new
+or stiff pump or boot. Many cases of this nature were found among the
+militiamen preparing to go to the “border” last Spring. The constant
+marching in new and stiff shoes, which was part of their training,
+caused a great amount of trouble just above and at the insertion of
+this tendon. In these cases two pieces of felt, shaped to the tendon
+and thick enough to fill up the hollows at its sides, were applied and
+then strapped securely in place by strips of adhesive plaster, one inch
+in width, which covered felt, tendon and all. This strapping served not
+alone to secure the felt shielding in place, but also to immobilize the
+part so that these deeper inflammations had a chance to subside.
+
+=Dorsal Surfaces.= On the dorsal surfaces of the foot, over the
+articulations of the metatarsal bone with the internal cuneiform and
+the cuneiform with the navicular, small and seemingly insignificant,
+helomata miliare (seed corns) are found to develop. In many instances
+the removal of these growths will not bring relief unless a shield is
+applied with the final dressing. This is due to the lack of muscular
+padding over these bones and the skin becomes irritated by tight lacing
+of the shoes.
+
+A small oval shield, not too thick and usually of thin buckskin, kid or
+adhesive moleskin, is usually applied, although the thinner varieties
+of felt may be used with good results. The shield is generally strapped
+in a manner similar to those applied to the lateral borders or to the
+os calcis region, that is, with three strips of one-half inch width
+plaster applied to cover all edges of the shield in triangular form.
+
+
+MORTON’S TOE AND METATARSALGIA
+
+The treatment of anterior arch trouble is usually and wisely
+recommended to the orthopedic specialist, but there are numerous
+incipient and advanced cases for which the podiatrist must necessarily
+give at least temporary relief. Shields, as well as strapping, play an
+important part in the rectification of these annoying conditions, and
+under this heading the shielding in particular will be discussed.
+
+The heads of the metatarsal bones forming the anterior metatarsal arch,
+having dropped from their normal positions, cause pressure upon the
+digital nerves and bring on the varieties of pain which are found in
+these conditions. It seems a logical theory that in order to alleviate
+these painful manifestations, support so designed as to return these
+bones to their normal position and hold them there would constitute a
+practical and efficient treatment.
+
+From the podiatrist’s standpoint, this may be accomplished by means
+of shields of felt or buckskin, adhered to the plantar surface of the
+foot in this region or by placing such supports in the shoe. These
+methods may at least afford temporary relief and in some instances,
+if their use be persisted in, permanent cures have been effected. The
+cure, however, is usually attempted by means of metal appliances which
+are worn in the shoe and which have a raised portion or “button” just
+posterior to the metatarsal heads.
+
+There are several forms of shields (or rather in this instance pads
+or supports) which are in general use for the correction of anterior
+arch trouble. These vary in size, shape, and thickness according to the
+number of bones involved in the displacement. Varying success is met
+with in the use of these supports and each individual case is usually
+found to demand changes or modifications in the support, so that the
+following description should be taken for the general points alone:
+
+=Morton’s Toe.= This affection, being limited to a displacement of
+the head of the fourth metatarsal bone with the lateral pressure from
+it upon the digital nerve, naturally does not need so large a shield
+as would be demanded were the bones of the whole anterior arch out of
+alignment.
+
+A pad of felt, about two-and-one-half inches long, an inch-and-a-half
+wide at the anterior point, made to taper slightly towards the
+posterior end, and three-eighths-of-an-inch thick, will be found to
+give relief in most cases. The felt is skived at the posterior end so
+that its thickness lessens gradually as it extends posteriorly along
+the metatarsal bone. The pad is applied directly to the rear of the
+head of the fourth metatarsal bone, and the thickness of the pad serves
+to force the depressed bone upwards and thus into proper alignment.
+It may be found necessary at times to use even thicker material in
+the manufacture of the pad or to place a small piece of felt upon its
+upper surface, so that as it is adhered to the part, this elevated area
+will come directly posterior to the depressed metatarsal head and thus
+elevate it.
+
+In strapping the piece of felt, two or three strips of one inch plaster
+are used. These are long enough to cover the width of the plantar
+surface and to extend upon the dorsal surface on each side. One end of
+the plaster is firmly adhered to the dorsum of the foot, the plaster
+being carried around under the foot over the pad, to be then adhered to
+the inner dorsum of the foot. Sufficient tension should be put on the
+adhesive strips to pull both borders of the foot down, thus aiding the
+pad in pushing the heads of the affected metatarsal bones up in place.
+In fact, in some cases a strapping of this nature with adhesive plaster
+will serve to give at least temporary relief to the patient without the
+use of a pad. Some practitioners advocate a pad of sufficient length to
+cover a greater portion of the metatarsal bone.
+
+If the pad is entirely covered by the three lengths of adhesive
+plaster, it will not alone last longer but the danger of its slipping
+out of place is minimized.
+
+=Metatarsalgia.= When the whole anterior arch is involved in a
+displacement, a pad of sufficient size and thickness to support the
+heads of all the metatarsals is necessary. There are two principal
+forms of support in general use. A strip of buckskin or felt of
+sufficient length (which will, of course, vary in different feet) to
+cover the four lesser metatarsal heads and about one-and-one-half to
+two inches in width, is adhered to the foot just posterior to the
+depressed parts. This is covered with adhesive plaster and serves as a
+support to the whole anterior arch region.
+
+In the writer’s experience, however, the fifth metatarsal bone is
+rarely involved in this general depression, and this seems natural when
+it is considered that the first and the fifth metatarsal bones act as
+pillars for this arch in the normal foot.
+
+Should complaint be made of a pain coming from the anterior arch
+trouble and occurring between the fourth and fifth toes, it usually
+will be found to emanate from the depression of the fourth metatarsal
+head. Keeping this in mind, a pad or support, which has found great
+favor, is fashioned from thick felt or buckskin (one-quarter to
+three-eighths) in such a way as to allow its anterior edge to come just
+behind the metatarsal heads. This pad should be about four or five
+inches long and the portion that extends back under the longitudinal
+arch should be skived so that it easily conforms to the contours of the
+foot in that region. In order to obtain support to the three middle
+metatarsal heads, the corners of this pad, which would extend over
+those of the first and fifth, are to be cut away; otherwise the pad
+would cause undue pressure upon parts requiring no support and thus
+prove detrimental.
+
+The pad is held in place with adhesive strips extending from the outer
+to the inner dorsum, applied in the same manner as described for the
+Morton’s toe pad.
+
+This pad practically gives the patient a new sole to walk on, and at
+the same time holds the depressed bones up in place. It will often be
+found advantageous to apply a pad of this kind, about one-eighth or
+one-quarter of an inch thick, in conditions where the patient complains
+of a burning sensation in the soles of the feet, even though there be
+no apparent lesion or displacement of the metatarsal bones.
+
+A number of devices are on the market for the relief of all forms of
+affections common to the arches of the foot. The relative merits of
+such contrivances will be fully discussed in the forthcoming volume on
+Podiatry Orthopedics (Schuster and Stafford), to be published under the
+auspices of The First Institute of Podiatry.
+
+
+
+
+CHAPTER IX
+
+LOCAL ANESTHESIA
+
+
+Local anesthesia is a condition of insensibility brought about in
+a part of the body by the use of agents called local anesthetics.
+The person in whom the local anesthesia is produced does not lose
+consciousness as in general anesthesia, the part alone being made
+insensible.
+
+There are many agents which, when applied to a part, by one means
+or another, cause that part to become insensible to pain, but for
+the podiatrist the following agents are best calculated to serve his
+purposes: cocaine, novocaine, alypin and urea hydrochloride, ethyl
+chloride, ethyl bromide, carbon dioxide snow, apothesine and ice. (See
+footnote page 148.)
+
+_Cocaine_ is an alkaloid extracted from coca leaves. These latter are
+not to be confused with cocoa, the seed of the chocolate tree. When
+cocaine is treated with hydrochloric acid, hydrochloride of cocaine is
+produced which occurs in a white crystalline powder, soluble in water
+and alcohol. When injected into the skin, or applied to an open wound,
+it acts as a paralyzant to the vasodilators and as a stimulant to the
+vasoconstrictors. When applying this drug, a tourniquet should be used
+wherever possible, so as to prevent absorption. This precaution is
+essential, as cocaine[2] is very toxic, and even small quantities may
+produce bad effects in some persons. There are cases on record in which
+¹⁄₁₀₀ of a grain of this drug has produced all the symptoms of toxemia,
+whereas there are persons who can stand doses up to one grain. It is
+therefore essential to use judgment and care in administering a drug
+which on account of the idiosyncrasies of some people, is likely, even
+in minute doses, to produce serious, if not fatal symptoms.
+
+In podiatry, a ¹⁄₂% solution is strong enough for general use, provided
+that time enough is allowed for the drug to be diffused. For an
+ordinary ingrown toe nail, two cubic centimeters of the above solution
+is usually sufficient to produce anesthesia of the part.
+
+_Novocaine_ is a synthetic preparation and occurs in colorless needles.
+It can be heated to 120 degrees Centigrade, without undergoing
+decomposition, which is not the case with cocaine hydrochloride.
+Although not quite as efficient as an anesthetic, novocaine is only ¹⁄₇
+as toxic as cocaine and therefore can be used with greater safety and
+podiatrists generally have abandoned cocaine for novocaine. It has a
+slightly irritating action while being injected, but on the whole it is
+preferable to cocaine for podiatry practice. Physiologically, it has
+the same action as cocaine, and is indicated wherever the latter drug
+is used. It is usually injected in one per cent. solutions.
+
+_Alypin_ occurs as a crystalline powder. It is a most efficient
+anesthetic and because of its non-toxic action, it is to be preferred
+in cases in which there is a fear of toxemia. Maximilian Stern, M.D.,
+Professor of Surgery at the First Institute of Podiatry, has used this
+drug extensively for producing local anesthesia, and his results have
+been very satisfactory. For use in podiatry, a ¹⁄₄ to ¹⁄₈ per cent.
+solution is often sufficient. It may be used freely in ¹⁄₄ per cent.
+strength without danger of toxemia. When injected, it produces no
+anemia, and consequently there is no danger of subsequent hemorrhage,
+such as might accompany the use of either cocaine or novocaine.
+
+_Quinine and urea hydrochloride_ is one of the quinine salts,
+consisting of one molecule of quinine hydrochloride and one molecule
+of urea. It has no toxic action when injected into the tissues, but it
+retards healing, and scar tissue forms over operated areas where it has
+been used. Many operators prefer this drug on account of its non-toxic
+action when used in large quantities, despite the likelihood of a scar
+and slow union. In parts of the body where contraction of the tissues
+is a desirable after-effect (such as would be the case in hemorrhoids),
+quinine and urea hydrochloride is to be preferred over other local
+anesthetics. David H. Levy, M.D., a well known surgeon of New York
+City, prefers it to all other local anesthetics.
+
+_Ethyl chloride_ and _ethyl bromide_ are clear volatile liquids, and
+upon their rapid evaporation depend their anesthetic qualities. When
+a substance evaporates rapidly, it extracts the heat from surrounding
+bodies in doing so, and, consequently, when such a substance is applied
+to the skin, it soon extracts the heat from the part and with the
+local anemia thus produced, sensation is lost. Ethyl chloride and
+ethyl bromide are manufactured in tubes so arranged as to eject a fine
+stream of the liquid. When this stream comes in contact with the skin,
+evaporation is rapid and gradually the part becomes numb; continued,
+it becomes frozen. This method is not as efficient as the hypodermic
+injection because the anesthesia is not so lasting, moreover, the
+reaction is severe and painful. Otto Sjogren and Fred Schmitt,
+practitioners of known repute, have entirely discarded both of these
+drugs from their list of local anesthetics, for reasons above mentioned.
+
+_Carbon dioxide snow_ is prepared by allowing liquified carbon dioxide
+gas to slowly escape from its container into a glove finger, where it
+solidifies into a mass, assuming the shape and form of the receptacle;
+it is called the _carbon dioxide pencil_. When this mass or pencil is
+applied to a part, it extracts the heat and anesthetizes by freezing.
+The dangers attending the use of the carbon dioxide pencil are the same
+as with ethyl chloride or ethyl bromide and, due to its extremely low
+temperature, there is danger of causing death of the tissues and of
+producing conditions giving rise to subsequent ulcerations that are
+slow to heal. As an anesthetic, it is not advised for podiatry.
+
+=Technic of Producing Local Anesthesia.= There are three methods of
+producing local anesthesia: (1) the hypodermatic method: (2) the
+pressure method: (3) freezing.
+
+The freezing method is of no great value to the podiatrist, and having
+been already briefly described, further comment is deemed unnecessary.
+
+The pressure method of producing local anesthesia is new, and although
+extensively employed in the practice of dentistry, podiatry offers but
+little opportunity for its free use. It is necessary to have an exposed
+nerve, such as is found in the cavities of painful teeth, or an open
+wound into which the drug can be absorbed, before this method can be
+used. In cases of ingrown toe nail, in which the groove is lacerated,
+either by the patient or by the nail itself, pressure anesthesia is
+often efficacious. Small pellets containing cocaine or novocaine,
+with adrenalin, are put on the market for this purpose. One of these
+pellets is placed in the nail groove, and a drop of alcohol is made to
+fall on it. The contents of the pellet are promptly dissolved by the
+alcohol, whereupon the operator places his thumb over the nail groove
+between the nail and the nail flap and exerts downward pressure. This
+forces the dissolved fluid into the tissues, where it acts the same
+as if it were injected. This procedure is painful for just a moment
+while the pressure is being applied, but the pain soon ceases and nerve
+sensibility is lost.
+
+The most generally used method of applying local anesthetics is by
+means of the hypodermic syringe and is called the [3]hypodermatic
+method. This is preferable to all other forms of inducing local
+insensibility, and if the technic is mastered, operations will be
+painless with the exception of the initial prick of the needle.
+
+=The Hypodermic Syringe= should be so constructed that it may be
+sterilized by boiling. There are many types of such instruments sold,
+and in making a selection, only those which will permit such boiling
+should be considered. The all-glass syringe or the glass and metal
+syringe with the metal piston are best, because the fluid contained
+therein is visible, thus preventing the injection of air. Needles
+should be of the rust-proof variety and for use in podiatry, they
+should be one-half or one inch long and have a twenty or twenty-two
+gauge lumen.
+
+After the syringe has been sterilized, it should be adjusted and the
+fluid drawn into it after the needle is attached to the barrel. The
+entire instrument is then turned, needle up, and the air that may be in
+the barrel is expelled by pressure on the piston. When this is done,
+the syringe is ready for use.
+
+If the needle is sterile, the only preparation necessary for the skin
+is to paint it with tincture of iodine, and then the injection of the
+anesthetic may be commenced. The area to be anesthetized is determined,
+and then at the most proximal portion, the skin is grasped between the
+thumb and forefinger of the left hand. The syringe should be held in
+the right hand with the barrel between the first and middle fingers,
+and the thumb on the piston. When the skin has been blanched by the
+pressure of the fingers of the left hand, the point of the needle,
+lumen downward, is thrust into the skin with a quick movement and
+immediately after, pressure is brought to bear upon the piston. As the
+fluid enters the tissues, it produces a blanched area which is called
+a wheal. As the wheal is formed, the needle is gradually moved forward
+in the derma until it is inserted as far as the base. It is then
+withdrawn, and a second injection is commenced, a little back of the
+distal end of the wheal. This second injection, being started in a part
+already anesthetized, will cause no pain. So the needle is gradually
+moved forward in the derma until the desired area has been covered.
+
+When the deeper tissues are to be anesthetized, the needle may be
+directed at an angle to the surface, pressure being borne on the piston
+of the syringe as the needle gradually moves deeper into the flesh. It
+must be remembered that if the needle is re-inserted into an area that
+is already deadened, there will be no pain. The fluid should be ejected
+from the syringe slowly, which insures an even distribution of the
+drug, as well as comfort to the patient, while the anesthetic is being
+administered. Most drugs cause a burning sensation if injected too
+rapidly.
+
+The most common lesion for which local anesthetics are used in podiatry
+is the ingrown toe nail, and to get good results in these cases,
+the technic must be followed in detail. After the derma has been
+anesthetized over the region of the nail root and groove, one deep
+injection should be made at the root, and vertically to the skin. This
+will insure loss of sensation when the root is cut and when the matrix
+at this point is curetted.
+
+To prevent the absorption of toxic drugs into the system, some means
+should be devised to cut off the circulation during the operation. This
+is accomplished by the tourniquet, which is usually made of flexible,
+solid rubber, about one-sixteenth or one-eighth inch in diameter and
+about a foot long. When this band is tied around the base of the toe,
+and pulled tight, it cuts off the circulation. Tourniquets cannot be
+used when operating upon the foot proper, and in these cases it is
+necessary to be guarded in the use of toxic drugs.
+
+After the use of cocaine[4] or novocaine there is a reaction, and
+occasionally the pains produced by this reaction are severe. These
+pains may be alleviated to some extent by the use of wet dressings,
+but they last only for a short time so that it is often unnecessary
+to treat them. The patient should be warned of the reaction. The
+local anemia produced by the injection of these drugs is subsequently
+followed by hyperemia, and it is therefore necessary to guard against
+hemorrhage in cases in which free incisions have been made. Wounds
+should be packed, and proper bandages should be applied to prevent any
+such possibilities.
+
+
+
+
+CHAPTER X
+
+HELOMA
+
+
+=Derivation.= The word has its origin in the Greek “_helos_,” meaning
+corn; (plural: _helomata_).
+
+[Illustration: BUILDING NAILS (HELOS) USED IN PRE-HISTORIC TIMES]
+
+In the accompanying cut will be found a photograph of two building
+nails bearing the name and time of the reign of King Gudea in Ur,
+Chaldea, about 2500 B.C. Plaster casts of the above were presented
+to The First Institute of Podiatry by Fridtjov Anderson, Colonel in
+the Norwegian Artillery. These nails were called helos and because of
+their semblance to the foot excrescences, commonly called corns, the
+latter were therefore named helomata.
+
+=Synonyms.= Corn, clavus, horn.
+
+=Definition.= An heloma is a circumscribed, conical, deep-seated
+overgrowth of the epidermis, the apex of which presses down upon the
+derma. Corns usually occur about the toes, but may appear upon any part
+of the body subject to friction or pressure. They range in size from a
+pinhead to a ten cent piece.
+
+According to their appearance, texture or composition, helomata are
+classified as follows:
+
+  Heloma durum, or hard corn.
+  Heloma molle, or soft corn.
+  Heloma vasculare, or vascular corn.
+  Heloma miliare, or seed corn.
+
+
+HELOMA DURUM
+
+=Heloma durum= is a hard circumscribed overgrowth of the epidermis and
+may occur as above stated, but is usually found on the outer side of
+the fifth toe, the dorsum of the second, third and fourth toes, and on
+the plantar surface of the interphalangeal joint of the great toe.
+
+=Symptoms.= The symptoms of an heloma durum may be classified as
+subjective and objective. The chief subjective symptom is pain in
+varying degrees. The formation of the growth produces a pressure upon
+the nerves which, in turn, gives rise to pain varying from a dull and
+mild sensation to a sharp and intense excitation. These pains are
+increased when the part affected is further irritated by ill-fitting
+shoes, by friction or by other pressure.
+
+It is a well known fact that the pain in a corn is increased when the
+weather is about to change. Helomata, which at other times cause no
+inconvenience, will prove a source of annoyance at this time. This
+is due to certain physiologic changes that take place in the body as
+follows: the atmosphere preceding a storm becomes more and more charged
+with moisture. As this increases, the function of the skin, namely the
+elimination of liquid waste, is gradually diminished. This function is
+taken up and performed by the kidneys, and as the air becomes fully
+charged with moisture, the entire work of elimination is carried on by
+these latter organs. This physiologic change requires a readjustment of
+the blood supply and the nerves which control it, so as to bring about
+a proper equilibrium. In this latter procedure the little nerve fibres
+are unfavorably influenced, and pain results. The gradually increased
+uncomfortableness that is experienced is due to gradual increase in the
+humidity and when precipitation takes place and the air is freed from
+this atmospheric pressure, relief is afforded.
+
+The patient will complain of pain while shoes and stockings are worn,
+but will feel relieved when they are removed, except in cases where
+inflammatory processes have commenced. The pains at these times are of
+the throbbing, pulsating variety, such as accompany all inflammations.
+
+A clinical examination of an heloma durum shows a horny mass of
+epidermic cells crowded together with no regular formation within
+the growth. There is a sharp line of demarcation between it and the
+surrounding tissues and it is also distinguished by its darker,
+yellowish color in contradistinction to the healthy pink of the normal
+skin. Within the growth, and usually at its centre, may be seen a
+darker, more compact mass, which penetrates deeper into the tissues.
+This is the radix or nucleus, incorrectly termed the root, or the
+eye, of the corn. The skin immediately surrounding the heloma usually
+presents a red line, due to the somewhat lessened irritation that
+originally produced the corn. The color is due to congestion in the
+derma.
+
+=Etiology.= Helomata dura are commonly caused by direct intermittent
+friction or pressure of ill-fitting shoes. The shoes may be too tight,
+thereby causing pressure, or they may be too loose, thereby causing
+friction. Helomata that appear on the plantar surface of the foot may
+be caused either by some roughness in the finish of the shoe or by
+soles which are too thin, or by downward displacement of the heads
+of the metatarsal bones beneath, caused by wearing shoes that are not
+anatomically correct.
+
+Imperfections in the stockings, such as knots in the worsted or poor
+workmanship in darning, are also factors in producing helomata. Any
+concentrated or undue local pressure is capable of causing this
+overgrowth, provided, however, that the pressure is not primarily
+of sufficient intensity to set up such an amount of congestion and
+consequent inflammation as to lead at once to an ulceration of the part.
+
+The same principle of intermittent friction and pressure, with
+counter-pressure, as a cause for helomata holds good on any part of the
+body surface.
+
+=Pathology.= The pathologic changes accompanying the development of an
+heloma are mostly morphologic. The intermittent friction and pressure
+produce first an irritation or excitation of the cutaneous nerves; this
+causes an increased blood supply to the part and congestion takes place
+in the derma immediately beneath.
+
+Were this pressure or friction to cease at this time, nature would
+restore the tissues to their normal condition in a very short time;
+but, as this pressure or friction is continued from day to day, the
+habitual congestion produces a chronic enlargement or hypertrophy of
+the papillæ of the derma.
+
+The epidermic cells originate from the material supplied by the blood
+plasma, which is conveyed through the walls of the capillaries to
+the surface of the basement membrane by endosomis, where it forms
+into granules which contain nuclei of unusual size. These granules,
+the first organic shape of the future cells, gradually develop into
+nucleated cells.
+
+Bearing in mind the development of the cells in the normal skin,
+with an increased blood supply, there will naturally be a more rapid
+proliferation or development of cells taking place over the enlarged
+papillæ than over the surrounding normal ones. This excessive
+development of cells causes an abnormal upward crowding of the
+preceding cells, with the result that the horny layer gradually becomes
+thickened. With this thickened layer acting as a counter-pressure from
+above, cornification of the tender cells takes place more rapidly with
+each succeeding new layer that is added to the under portion of that
+already formed. The growth at this time takes place at the interior and
+lateral portions of the heloma, principally the former.
+
+This process in due time causes the epidermis to become transformed
+into a dense homogeneous mass of cells which is called a _callosity_.
+The size of the callosity is determined by the area of the papillæ
+affected.
+
+The etiologic factors which cause the enlargement of the papillæ
+and the overgrowth of the epidermic cells continue, and that part
+of the growth which was first formed and is most usually central,
+becomes more dense than the surrounding callosity. This is due to
+the greater irritation to which it is subjected, and eventually this
+extends downward and penetrates the derma. The pressure of this new
+development, known as a “radix,” against the papillæ, causes these
+organisms to undergo progressive atrophy with the result that they are
+at times completely absorbed. Thus, we have the common heloma durum.
+The heloma now receives its nourishment from the lateral portions,
+which still continue to maintain their increased vascularity.
+
+It often happens that an heloma is subjected to unusual pressure during
+its formation, which causes serous effusion or even subcutaneous
+hemorrhage in minute quantities. This effusion is absorbed by the soft
+cells which are in the process of transition into horny tissue. These
+cells take on a laminated appearance which present different tints,
+from a light yellow to a dark red.
+
+The nerve filaments of the skin are also affected during the
+development of an heloma, and when this process is marked, the
+condition known as neuro-fibrous heloma is the result. These little
+neuromata very often become quite enlarged. The favorite location
+for this condition is the inner plantar edge of the great toe, and
+sometimes the outer plantar edge of the metatarsophalangeal joint of
+the fifth toe.
+
+These helomata consist of two or three little irregularly shaped
+structures extending downward into the derma and in juxtaposition to
+each other, the septum dividing these structures being made up of one
+or more rows of enlarged papillæ which have become highly vitalized
+through the enlargement of the nerve fibres contained in them. The
+condition is very painful and great care must be exercised when
+operating upon them. The most logical reason for their appearance
+upon the plantar edges seems to be the fact that the long papillæ of
+the plantar surface leave off abruptly and are joined by the shorter
+ones of the dorsum. The line of junction is undoubtedly subjected to
+a greater degree of irritation than where the size of the papillæ is
+uniform.
+
+=Diagnosis.= A typical heloma durum is a mass of epidermic cells, round
+in shape and varying in size. The color is usually yellow, but in cases
+where serous or bloody infiltration has taken place, the color may
+increase to red or even to dark purple.
+
+Heloma durum may be mistaken for heloma vasculare or verruca, on
+account of the dark blood stains which are often in evidence, but when
+the top layers of the heloma are removed, the dark spots which were
+mistaken for blood vessels are not found in the growth proper, but are
+deep in the structure resting against the derma. When these spots,
+which are clots, are cut with the knife, no bleeding occurs; whereas,
+if the condition were one of heloma vasculare or verruca, hemorrhage
+would be produced.
+
+Lesions of several skin diseases, such as eczema and psoriasis, very
+often produce scales or crusts on the feet which might be mistaken for
+helomata, for when the fingers are passed over them they feel as if
+they were an overgrowth of the skin. These scales or crusts, however,
+are usually loosened at the edges and the color is quite different,
+being red or white. Other indications of the presence of a skin
+affection will usually be found on other parts of the foot.
+
+The radix, or nucleus, of the heloma is a characteristic which
+differentiates it from the ordinary callosity. The radix is a dark
+solid mass of epidermic cells which has an almost transparent
+appearance. When cutting an heloma, the radix may be felt by the
+tension produced as the knife passes through it.
+
+Helomata dura found on the plantar surface of the foot over the heads
+of the metatarsal bones are not readily distinguished, due to the fact
+that they are covered by a layer of callous, which, when removed,
+exposes the nuclei to view.
+
+[Illustration: HELOMA DURUM ON PLANTAR SURFACE]
+
+=Prognosis.= The prognosis of heloma durum is uncertain. There are many
+cases on record which have disappeared after the first treatment and,
+on the other hand, some cases regularly recur notwithstanding many
+years of regular attention. This is due to two conditions: first, the
+cause of the heloma, namely, the continued wearing of the shoe, and,
+second, the papillæ beneath the growth remain enlarged and continue
+their function of excessive cell proliferation. The latter reason
+is more important than the first, for, even in cases where proper
+footgear is provided and no friction or pressure is permitted, the
+heloma may continue to grow. The only way to account for the total
+disappearance of some helomata, after treatment, is, that when the
+growth is removed, the size of the papillæ diminishes and normal
+function is restored. The situation of heloma durum is very important
+in considering the ultimate cure of the growth. Those on the outer
+aspect of the little toe rarely get well, due to the prominent position
+of that digit, while those on the plantar surface over the heads of
+the metatarsals are often completely cured after the proper treatment
+has been applied. When the heads of the metatarsal bones have been
+properly adjusted, the helomata produced by their downward displacement
+gradually disappear.
+
+=Treatment.= The treatment of heloma durum is divided into three
+classes, viz.: preventive, palliative and operative.
+
+=Preventive treatment= consists in securing freedom from friction of or
+pressure on the parts affected. Footgear of proper size and shape is
+essential. The shoes should be neither too tight nor too loose; they
+should fit snugly in the heel, and the toe box and front of the shoe
+should be broad enough to allow of freedom for the toes. The quality
+and kind of leather used for the shoe should also be considered.
+This should be soft and well seasoned, vici kid and calf skin being
+preferred. Patent leather and colt skin are undesirable, in that
+they are hard and almost air tight. Shoes made to measure on a last
+constructed from a plaster of Paris cast of the foot, are the best.
+In making a shoe, consideration should be given to other deformities,
+such as flat foot, metatarsalgia, etc., and means for correcting these
+ailments should be taken.
+
+The stocking should be large enough to prevent pressure on either
+lateral side of the foot. There are stockings on the market which are
+cut for each foot and are known as right and left stockings. These are
+very desirable, as they prevent distortion of the toes, which is often
+produced by the regular stocking cut to a point at the third toe. The
+material is of little consequence, except that wool or cotton absorbs
+moisture excreted by the glands better than silk.
+
+=Palliative treatment= includes the application of palliative agents,
+among which silver nitrate and salicylic acid are most serviceable.
+These remedies cause desiccation and shrinkage of the horny growth,
+which is thus made to shell out from the bed in which it lies. This
+method of treating an heloma durum is long and tedious, as many
+applications of the drugs are required to obtain a result. Great
+care must be exercised to prevent the applications from touching the
+surrounding normal skin. The virtue of so-called corn cures, which are
+very plentiful and are given artistic names, all depend upon some drug
+or chemical, chief among which is salicylic acid. The danger to the
+layman is readily seen, for when these agents are applied carelessly
+or in large quantities, the action is too severe, and ulceration and
+infection is the result.
+
+When the practitioner finds it necessary to resort to palliative
+measures in the treatment of an heloma durum the following procedure
+is advised: the tissues surrounding the horny growth are protected by
+painting with several layers of collodion or glycerine jelly (Unna). A
+piece of salicylic acid plaster is cut to the size of the heloma and
+placed over it and a proper protection applied. Or, a shield can be
+fitted around the part and in the aperture is placed a 25% salicylic
+ointment, and the entire dressing is covered with adhesive plaster.
+This dressing is allowed to remain in contact with the part for two
+or three days, when the dressing is removed and the white, macerated
+tissues are scraped or cut away. The treatment is again applied and
+repeated as often as necessary. (See chapter, _Shields and Shielding_.)
+
+=Operative treatment= may be divided into two classes, the radical and
+the non-radical. The _radical_ method is painful, but with the use of
+local anesthetics, good results are obtained without discomfort to
+the patient. Alypin, 1 : 2%, quinine and urea hydrochloride, 2%, or
+novocaine, 1% (the latter being preferred by the writer) may be used
+to produce local anesthesia[5]. The parts are thoroughly cleansed and
+made aseptic by washing with the tincture of green soap, followed by
+alcohol, 60%, and finally painting the entire surface, including the
+surrounding parts with tincture of iodine. The hypodermic needle and
+syringe and all the instruments to be used in the operation are boiled
+in water for at least ten minutes. A spot is selected for the injection
+of the anesthetic, and ethyl chloride is sprayed on it, to make the
+primary injection of the needle painless. The needle is forced into the
+derma and pressure brought to bear on the piston of the syringe, as it
+moves forward into the tissues. By following the wheal thus produced,
+the entire area surrounding the heloma can be anesthetized.
+
+When the anesthesia is complete, two semi-elliptic incisions, meeting
+at their extremities, are made through the skin, care being taken
+that they penetrate the subcutaneous tissue. These incisions should
+completely envelop the growth. The tissues between the incisions are
+seized with an artery forceps, and the entire wedge, including the
+derma and subcutaneous tissue, is dissected out. This produces free
+oozing, and it may be necessary to twist a small vessel. Hemorrhage is
+never severe. The edges of the wound are brought together (apposition
+should be perfect) by one or two fine sutures and primary union takes
+place in a few days, or, if the wound is not large, the part may be
+dressed and allowed to heal by granulation. Subsequent dressings should
+include shields for the prevention of friction or pressure.
+
+Dr. Robert T. Morris, of New York City, recommends skin grafting with
+this operation, in order to prevent the formation of scar tissue, a
+very desirable consideration. After the tissue has been dissected out,
+some skin is taken from the fleshy part of the leg and is attached over
+the wound. This eliminates drawing the edges of the wound together,
+which procedure often causes harmful after-effects.
+
+The _non-radical operative_ treatment of heloma durum is the most
+popular and practical method employed by chiropodists today. The growth
+is removed down to the true skin, care being taken that this layer is
+not punctured and bleeding thus produced.
+
+There are two general methods of procedure for the surgical treatment
+of callositas and helomata in vogue today. These are known as the
+paring or shaving method and the dissection or excision method. This
+nomenclature is derived from the operations themselves.
+
+As the term implies, the paring method consists of removing the
+callouses with the chisel, knife or scalpel by shaving away the growth
+with a series of knife strokes or cuts, and the subsequent removal
+of the cone body or radix with the point of the same or a similar
+instrument.
+
+=Technic of the Shaving Method.= The part is thoroughly cleansed with
+a standard antiseptic, such as phenol, 5%, lysol, 1%, or cresol, 1%,
+and this is followed by alcohol, 60%, which is allowed to remain in
+contact with the heloma for a few minutes. The instrument employed
+should be sterilized by boiling in water for at least fifteen minutes
+or by placing it in phenol, 95%, until the liquid clings to the blade,
+followed by alcohol, 95%.
+
+After thorough asepsis has been obtained, the tissues adjoining the
+area to be removed are held firmly between the thumb and index finger
+of the left hand and the knife is grasped firmly with the fingers of
+the right hand.
+
+By holding the tissues of the part firmly so that they may not move,
+the pain to the patient and the danger of invading the vascular tissues
+is minimized. A knife, no matter how sharp, is bound to pull the
+tissues overlying a tender and inflamed part unless these tissues are
+in some way prevented from moving.
+
+After the overlying callouses have been thoroughly pared away, and
+the part is found to be soft and flexible, the nuclei are removed.
+In removing these hard bodies the operator who shaves or pares,
+practically becomes a dissector. With a sharp pointed knife the heloma
+is loosened from the surrounding soft parts until entirely freed,
+when it is lifted out. Should there be two or more helomata under one
+callous, the same procedure is adopted for each individual growth until
+all are removed and the whole area is found flexible.
+
+The stroke of the knife in the shaving method is usually toward the
+operator, his fingers and thumbs being so arranged as to limit the
+distance which the blade may travel and so prevent cutting the patient
+or himself.
+
+In shaving an heloma on the dorsum of the intermediate toes, the index
+finger of the left hand is placed anterior to the hardened area and the
+thumb, posterior. The knife is then held as a penholder and the strokes
+are made toward the operator, the toe being moved or rotated to bring
+all the surfaces of the growth under the blade of the knife.
+
+On the plantar surface the operator, at times, is forced to work away
+from himself, but in most cases the blade is directed toward himself.
+
+For operating on helomata between the toes, the knife is held as a
+penholder and the blade is directed toward the toe or web. Many of the
+practitioners who “shave” use a distinct dissection method for the
+removal of helomata in this location. They employ what is known as a
+“spoon”--a shallow flattened curette--and starting from the outer edge
+of the calloused area, work under the hardened layers until the entire
+growth is loosened, whereupon it is deftly removed.
+
+The stroke of the chisel in the shaving method is usually away from
+the operator. This is in contradistinction to the stroke of the knife
+or scalpel. When operating on the dorsum of the toes, however, most
+operators using the chisel direct the blade toward themselves, unless,
+as is common, the operator moves around in front of the patient, when
+the cutting is done away from the operator.
+
+=Technic of the Dissection Method.= One of the oldest, yet one of the
+most popular methods of operation is that known as dissection. As
+will be understood by the term, this method is a procedure whereby the
+growth is excised by the helotomon, as a whole, from the underlying
+tissues. This is in contradistinction to the paring or shaving method.
+
+Two of the best known practitioners who use this method of procedure
+are E. C. Rice, M.D., of Washington, D. C., and Charles F. Stevens, of
+Elmira, N. Y. Dr. E. C. Rice has this to say on the subject:
+
+“The limited knowledge of the chiropodists of earlier years did not
+apply to their handling of instruments, which was professionally
+scientific to the highest degree. The dissecting method was the method
+of operating in the early days.
+
+“In the late fifties a practitioner by the name of Josiah Briggs
+taught many young men, among them Elliott W. Johnson, and the writer’s
+father, W. E. Rice. A Scotchman also instructed Nehemiah Kenison.
+They in turn taught others the dissection method. There will always
+be two professional methods of operating on helomata, the shaving
+(exfoliating) and the dissecting (excision) methods, and practitioners
+should understand both.
+
+“Those who have a light touch, if determined to learn, can become
+skillful in the art of dissecting, and, when acquired, their life’s
+work will become a daily fascination. The procedure calls for
+skill that compares with that employed by the eye, nose and throat
+specialists and is appreciated by the most eminent surgeons.
+
+“The word ‘dissect’ implies a separation, and this method permits the
+operator to separate the heloma from the normal tissue in one piece
+so that classification is made simple. In removing the growth in its
+entirety, it is possible to observe the various forms the nuclei take,
+and the classification the writer would make is as follows: granular,
+grain-like in appearance, sometimes called ‘surface corn’; crescent,
+forming a semi-circle about the joint; wedge, having a wedge-shaped
+nucleus, commonly found on the plantar surface; cone, from its shape;
+thumb tack, also named from its shape; multiple nuclei, resembling
+any of the above named and having numerous central points; soft, the
+gristly tissue between the toes; elevated, protruding, horn shaped;
+circular, because of the form of the nucleus.
+
+“The instruments used in this method of operating are the chisel
+(helotomon--Dr. F. Oefele, editor,) and the iris mouse-toothed forceps.
+
+“The original chiropodist’s instrument in this country was a cross
+between the surgeon’s scalpel and a chisel. The blade was shaped much
+like the human foot and was on a handle such as is used on the standard
+razor. From this first instrument of chiropody was evolved the only
+distinctive instrument of our profession, the chisel, which has been
+successfully used for more than half a century.
+
+“It is distinctly a chiropodist’s instrument, as much as the plane
+is the tool of the carpenter. With this chisel the dissecting method
+is made possible, for its cutting edge, as its name suggests, is on
+the end of the instrument, and permits of the most delicate work. The
+chisel should be five and one-half inches long and should have a rough
+hexagon handle. The round or oval handles do not permit perfect finger
+control. The blade or cutting edge may be oblique, straight or oval, as
+the operator desires.
+
+“The technic of the dissecting method of operating is as follows:
+
+“The chisel is held in the right hand and the forceps in the left. Hold
+each as you would a correctly held penholder; to support and to steady
+the hands, let them rest gently on the fourth and fifth fingers; when
+operating between the toes, the supporting fingers rest upon and press
+aside the toes so as to give plenty of room for operating.
+
+“The tissues at the periphery of the heloma are separated; with the
+forceps grasp the free edge and raise sufficiently to see the line of
+demarcation and use enough traction on the forceps to overcome the
+pressure of the chisel, not enough, however, to produce the sensation
+of pulling.
+
+“When properly performed, the gentle lifting of the tissue prevents the
+nerve being pressed upon or pinched between the blade of the instrument
+and the underlying bone. The line of demarcation is made by the union
+of the light and dark shades of tissue, the normal being the light and
+the darker shade belonging to the heloma.
+
+[Illustration: ILLUSTRATING METHOD OF SPREADING TOES APART BY USING
+FOURTH FINGER OF EACH HAND, MAKING OPERATION EASY]
+
+“Those who use the oval chisel find they can do more work and have
+fewer hemorrhages, and only occasionally do they find it necessary to
+use the nucleus dissector, which is required to remove an heloma of
+the thumb tack variety, as its shaft may extend to a depth of a fourth
+or a third of an inch. In dissecting this type of heloma, when the
+head of the same has been separated back to its shaft, the traction on
+the forceps is increased, the tissue being gently lifted and turned
+back. This tends to present the shaft toward the blade, and as cutting
+proceeds the shaft seems to be lifted up and out of the soft tissue
+into which it is embedded.
+
+“To beginners, the writer would suggest the oval-shaped chisel and
+would advise practising first on the plantar surface.”
+
+C. F. Stevens contributes the following:
+
+“Speaking generally and taking the average heloma as an example, my
+method of procedure would be somewhat as follows:
+
+“These growths are hardly ever deep, and are removed by the following
+process more easily than to chisel or pare. After the usual antiseptic
+precautions as to the operator’s hands, instruments and the patient’s
+foot have been taken, the operator grasps a sharp, pointed, slim
+instrument.
+
+“Holding this knife with the right hand and with a small forceps in the
+left, he grasps the free part of the growth with the forceps, carefully
+raising this part to determine if possible how much is free and how
+much is attached to the deeper tissues.
+
+[Illustration: PROPER USE OF FINGERS ELIMINATES NECESSITY OF TOE
+SPREADERS]
+
+“With a sharp blade he makes a series of slight strokes, cutting but
+little at a time, on a line between the growth and the skin (the growth
+being darker than the skin), thus separating the excess deposit of
+horny cuticle from the skin, following every curve, deep part or point,
+until all is separated in the one mass. In this manner he is enabled to
+remove all in one piece. Dressings vary, according to the prominence of
+the part and the shoe worn.
+
+“Since the writer was taught this method of procedure he has found it
+to be much easier to separate such a horny growth from its bed, than to
+try to pare it off in bits or shave it as the patient himself tries to
+do. Helomata being hard, very naturally resist the cutting of a knife,
+and the blade, therefore, when trying to pierce the hard mass, pulls on
+the sensitive tissues beneath, thus causing pain. Following the line
+between the normal and the abnormal tissues in operating, much softer
+integument is encountered; therefore, the cutting is easier and can be
+done with practically no pain.
+
+“The cautious, careful operator will seldom invade the healthy tissues
+beneath sufficiently to cause capillary hemorrhage. A paring or shaving
+process could, of course, first be employed to remove the indurated
+callous, then proceed to carefully separate the deep parts as described
+in the case of heloma. Simply raising gently with the thumb forceps
+and cutting a very little at each stroke with a sharp pointed blade,
+following each wave or indentation indicated, as the work progresses,
+until each piece or mass is separated and removed, will be found a
+preferable procedure. However, we have found it as simple and easy to
+dissect the mass as a whole as to operate by paring and then removing
+the deeper parts.
+
+“In case of a deep-seated hard corn where the toe is red, inflamed and
+very sensitive, the first described method (as in heloma) is usually
+best. Often upon reaching the lowermost layers, one finds a quantity
+of pus. When this escapes, as it does, the pressure on the inflamed
+tissues is lessened, and the patient will allow the operator to proceed
+faster.
+
+“With a deep-seated heloma on the sole of the foot, the same method is
+followed, no matter how deep or serrated. The operator (after one or
+two small cuts) gently raises the edge with the forceps, while with the
+same style of blade he cuts down and around the growth, until the whole
+piece with its radix is lifted out.
+
+“In connection with this the writer hears some one say, ‘even though
+you do remove the growth scientifically and without pain, severe pain
+will follow in an attempt to walk.’
+
+“Of course, comfort depends in many instances on the dressing. The
+writer is not a great believer in heavy shielding and the method of
+dressing he employs is as follows: take a pledget of cotton which, when
+rolled, is about as large as the heloma just removed; place thereon a
+small amount of sedative in ointment form; place this in the cavity
+left by the removal of the growth, then cover all with a goodly sized
+piece of adhesive plaster. Instruct the patient to wear this for
+twenty-four hours, when he may remove the plaster. By this dressing the
+tissues that had been held up by the large heloma, are still held up
+by the rolled pledget of cotton, at the same time the cotton gradually
+flattens down with the patient’s weight. Thus the tissues are allowed
+to resume their normal position slowly and easily.
+
+“When the adhesive plaster is removed, the cotton dressing comes with
+it. The tissues adjust themselves in from twelve to twenty hours and
+thus an equilibrium is painlessly established.
+
+“Several years ago the writer chanced on to this method of dressing
+and since then he has used it and found it to be very efficacious in a
+large majority of cases; he has termed it the ‘filling dressing.’
+
+“In operations on heloma molle the same surgical procedure is employed.
+It matters not whether the growth be on the side of the toe, or deep
+down between the toes on the web. The sharp, fine-pointed, narrow
+blade enables one to operate in a closely contracted space, and when
+used with short little cuts the blade reaches down, around and under
+the growth, thus loosening it completely and leaving its usually deep
+seat, clear and free from any parts which might remain, if chiseling or
+gouging were employed.”
+
+(The authors of this work all operate with the knife or scalpel and
+have found that form of instrument very satisfactory. The beginner
+is advised to study and learn both methods so that he may be able to
+use both at any time. The fact that there are two methods does not
+mean that one is better than the other. There are many successful
+practitioners of both classes.)
+
+Some persons have a great amount of dorsi-flexion of the toes, due to
+hammer toe or hallux flexus, and they usually develop an heloma on the
+distal end of the toe, under the nail. This is treated by cutting away
+the nail over the growth, and when the heloma is exposed to view it is
+treated in the same way as other helomata dura.
+
+The subsequent dressings for helomata depend upon the state of the
+tissues beneath. Care should be exercised in operating so as not to
+cut too close to the normal skin, otherwise the parts become extremely
+sensitive.
+
+The epidermis is a storehouse for bacteria, and when an heloma is
+removed, there is always a possibility that some of these bacteria may
+enter the body through some slight and invisible abrasion which does
+not necessarily bleed. It is, therefore, necessary to take precautions
+against this danger, and this is best done by painting all surfaces
+operated upon with a 4% solution of tincture of iodine (this may be
+made by diluting the official tincture with an equal amount of grain
+alcohol). This should be followed by painting these same surfaces with
+icthyolated collodion or nafalan collodion.
+
+If the toe is inflamed it is treated with an agent that has the power
+to reduce inflammation. In severe inflammations, a wet dressing
+of Burow’s solution may be used to good advantage. The principal
+ingredient of this solution is aluminum acetate, which is astringent
+in its action, and a wet dressing applied for twenty-four hours
+will usually reduce the condition. In milder cases of inflammation,
+ointments of ichthyol, 10 or 15%, may be applied. This means of
+medication is very desirable whenever the application of a shield is
+indicated, because the aperture of the shield is a suitable place for
+ointment dressings.
+
+When an heloma is found to be infected, the growth should be removed
+and the pus present evacuated. This should be followed by the
+application of hydrogen peroxide and the parts should then be irrigated
+with bichloride of mercury solution (¹⁄₄₀₀₀). The wound may now be
+treated with a wet dressing of Burow’s solution or, in severe cases in
+which there is an indication of the presence of cellulitis, bichloride
+of mercury solution (¹⁄₅₀₀₀) for twenty-four to forty-eight hours,
+should be similarly applied.
+
+Subsequent dressings to stimulate granulation and promote healing may
+be applied, balsam of Peru or silver nitrate ointment or colloidal
+iodine being very efficacious.
+
+The latest medication for infected areas, either great or small,
+and one of the many discoveries in surgical treatment since the
+beginning of the present war, is the Dakin solution. The worth of the
+application of this solution is based upon the helpful influence of
+free chlorine in small quantities, to tissues that have been mutilated
+either by injury or infection. Chlorazene tablets, purchasable in all
+drug stores, contain the elements desired for this treatment. Liquid
+chlorine ampules (J & J) also make an accurate Dakin solution.
+
+[Illustration: INFECTED HELOMA]
+
+If, upon examination, an infection shows that the deeper tissues, such
+as the periosteum or the bone, are involved, the patient should be sent
+to the surgeon, whose function it is to treat such cases, who will make
+incisions into the soft tissues so as to establish free drainage. The
+wound thus produced is packed with sterile gauze, and often with the
+aid of wet dressings, and nothing more, the wound is allowed to drain
+and heal.
+
+The protection of the parts after an heloma has been removed, so as
+to insure comfort to the patient, is an all important part of the
+treatment of this ailment and a special chapter has been devoted
+to this feature of chiropody practice. (See Chapter _Shields and
+Shielding_.) There are certain types of helomata dura that are never
+relieved of pain, even after operation, unless a well-fitted shield has
+been applied.
+
+
+HELOMA MOLLE
+
+=Definition.= Heloma molle is a soft, white, macerated growth found
+between the toes, principally in the web of the fourth interosseous
+space and on the lateral sides of the interphalangeal joints of the
+toes.
+
+=Symptoms.= The pain accompanying heloma molle varies with the degree
+of pressure brought to bear upon the toes. Where the heloma is situated
+in the web of the fourth and fifth toes, there is a sensation as if
+there were some foreign body, such as a pebble, between the toes, and
+as the growth develops the pain becomes gradually worse. The pain of an
+heloma molle, in other parts, is similar to the pain of heloma durum,
+and usually ceases when the foot is not encased in a shoe.
+
+Upon examination, an heloma molle presents a white soft mass, having
+the consistency of rubber. There is no sharp line of demarcation
+between the lesion and the healthy skin. This is due to the blanching
+of all the tissues that come in contact with the excretions. In some
+instances there is a yellow ridge surrounding the neoplasm. The growth
+is superficial, due to its anatomic position. There is very little soft
+tissue between the epidermis and the lateral sides of the extremities
+of the phalanges, and therefore there is no possibility of the growth
+becoming deep-seated, as in heloma durum. The radix, or nucleus, when
+present, is of a dirty white color.
+
+Helomata mollia found in the web of the fourth and fifth toes, have
+well defined nuclei which penetrate into the interosseous space between
+the metatarsal bones. These are easily distinguished since, as the
+surrounding callous is removed, they appear as a dirty white spot in an
+area of healthy pink skin.
+
+=Etiology.= Helomata mollia are caused by shoes, the same as other
+types of helomata, but in this case the footgear acts as a secondary
+cause. Normally the phalanges are placed so that the base of one bone
+is opposite the head of another. When lateral pressure is brought to
+bear upon the toes, these bones press upon each other and thus produce
+an overgrowth of skin cells.
+
+The sweat glands continue to functionate, but the parts being pressed
+together, do not allow the perspiration to evaporate; hence, there is
+an accumulation of moisture which acts upon the skin, producing a soft,
+white, macerated mass, with a rubber-like texture.
+
+In the case of helomata mollia found in the web of the fourth and fifth
+toes, there is an outward rotation of the head of the fourth metatarsal
+bone, due to the lateral pressure on this region, causing the bone to
+drop and rotate outward; this in turn presses upon the base of the
+fifth proximal phalanx.
+
+=Pathology.= The pathology of heloma molle is identical with that
+of heloma durum, except that the nucleus is rarely deep-seated. The
+epidermis composing heloma molle has no distinct cell formation,
+because of the macerated condition of the mass, but occasionally
+the nucleus of such a lesion, found in the web of the fourth and
+fifth toes, shows some of the original cell formation. Inflammation,
+terminating in suppuration, is very often encountered in this
+condition. Because of uncleanliness of the parts, bacteria thrive in
+this locality and the acidity of the moisture very often produces a
+fissure or abrasion in the tissues which may lead to infection and
+subsequent suppuration.
+
+=Diagnosis.= The typical heloma molle is a mass of epidermic cells
+rarely larger than half the size of a dime. The color is white, with a
+dark grey centre, denoting the radix.
+
+Very often an ordinary exfoliation of the epidermis between the toes
+may take on the appearance of an heloma molle, but careful examination
+will show that there is no overgrowth of epidermis. This exfoliation
+is easily loosened with a pair of forceps.
+
+Fissured toe webs, accompanied by exudation and exfoliation of skin,
+may be mistaken for heloma molle, and treatment inaugurated for the
+latter condition will produce bad results, particularly if chemicals
+are used.
+
+There need be no doubt about making a positive diagnosis if the color
+and texture of the growth be borne in mind. The finger passed over the
+affected surface will give the sensation of increased tissue.
+
+[Illustration: HELOMA MOLLE]
+
+=Prognosis.= The possibilities of the ultimate disappearance of
+helomata mollia is good. If the proper shoes are worn and the proper
+treatment be installed, the growths will gradually become smaller and
+will finally disappear.
+
+The helomata that appear between the toes on the interphalangeal joints
+are most easily cured, by simply keeping the adjacent sides of the toes
+separated. Those that appear on the outer lateral side of the great toe
+do not respond to treatment as readily as the other types, for there
+is more soft tissue over this joint and usually the great toe is in a
+fixed position and does not easily straighten.
+
+Helomata mollia that appear in the web of the fourth and fifth toes can
+also be permanently cured, but it is necessary to raise the head of
+the offending metatarsal bone, as well as to separate the toes.
+
+Bearing in mind the etiology of heloma molle, and installing treatment
+which will correct or remove these causes, time and conscientious
+treatment will ordinarily insure a favorable outcome.
+
+=Treatment.= Treatment of helomata mollia is divided into two classes:
+the non-radical surgical and the therapeutic. The latter method is the
+most popular, as it is very often impossible to use the knife. The
+texture of the skin, and the anatomic position of the growth often make
+it impossible to use an instrument with a cutting edge with a view to
+obtaining good results.
+
+The _non-radical surgical_ method consists of removing the corn in
+much the same way that an heloma durum is removed. The long cutting
+edges of knives and chisels are not well adapted for work between the
+toes, and for this purpose the “golf stick” and the “soft corn spoon”
+have been devised and are used extensively. The “golf stick” is an
+instrument which, as its name indicates, resembles the stick used by
+the golfer. Its cutting edge is almost at right angles to the handle
+and is about three-eighths of an inch long. This makes a very desirable
+instrument for removing helomata mollia on the lateral sides of the
+interphalangeal joints. The end of the instrument is rounded so as
+to allow for the removal of nuclei, if present. The cutting edge of
+the “soft corn spoon” extends almost around the entire instrument,
+and admits of a circular movement such as is employed in dissecting
+helomata dura. This instrument is used for removing soft corns that
+appear in the web of the toes, and is very efficient, inasmuch as by
+its use the operator is enabled to remove the growth without cutting
+into the tissues, as is often done with a knife or a chisel having a
+long straight edge.
+
+The _therapeutic_ method of treating heloma molle depends upon the
+caustic action of several drugs, among which may be mentioned salicylic
+acid, trichloracetic acid and silver nitrate. The two latter are used
+only occasionally, as they are powerful caustics, and unless applied
+with great caution they may produce harmful results.
+
+Salicylic acid finds great favor among practitioners of podiatry, and
+the usual technic is as follows: after asepsis has been practised and
+the growth cannot be removed by the use of the knife, an ointment of
+salicylic acid, 15%, is applied over the growth, care being taken that
+the medication does not come in contact with the surrounding normal
+tissues. This is covered with a protective cocoon dressing, or the
+ointment may be applied into the aperture of the shield, if one is
+used. The dressing is allowed to remain in contact with the part for
+from four to seven days, depending upon the thickness of the skin. When
+the dressing is removed, the entire mass will be found, as a rule, to
+be loosened from the tissues beneath. If all of the growth is not thus
+loosed, the treatment is repeated and the patient is instructed to
+return in the prescribed length of time.
+
+Shielding plays an important part in the treatment of heloma molle. For
+the type that forms on the lateral sides of the interphalangeal joints,
+a shield of the oval type with the aperture over the affected part, is
+most efficient, while for those that appear in the web of the toes, an
+oval shield with a semi-circular opening on the proximal end, which
+sets between the toes and protects the growth, is most desirable. In
+connection with a shield to protect the growth and separate the toes,
+it is necessary to raise the head of the affected metatarsal bone,
+which is the cause of this type of heloma molle. For this purpose,
+Alfred Ahrens, of New York City, has devised a dressing which he terms
+the “duck shield,” because of its resemblance to that animal. This
+shield has a dual function. It separates the toes and then passes down
+to the plantar surface of the foot over the metatarsal bone, and acts
+as a pad to raise the bone. The continuous application of this device
+to helomata mollia of this variety will produce good results.
+
+
+HELOMA VASCULARE
+
+=Definition.= Heloma vasculare, or vascular corn, is an overgrowth of
+the epidermis in which enlarged and elongated blood vessels are found.
+
+=Symptoms.= The growths usually appear on the plantar surface of the
+foot, but occasionally they may develop in old callouses and helomata
+situated on the dorsal surface of the fifth toe. Pain is more severe
+than in other forms of helomata, the patient complaining of a burning
+sensation when not in a standing position. This form of growth is
+similar in appearance to heloma durum, having in addition small dark
+red spots scattered throughout it, which bleed upon being cut. These
+spots are not blood clots, such as are found in helomata dura as the
+result of injury, but are distinct blood vessels. The composition of
+the tissues is very dense, particularly when the growth is situated
+over the head of a bone, as is ordinarily the case when it appears
+on the plantar surface. The color of the entire mass is somewhat
+darker than in heloma durum, being grayish, or sometimes brownish, in
+appearance.
+
+=Etiology.= As previously stated, helomata of all types are due to
+intermittent friction and pressure. The blood vessels that are found
+in this particular form are forced into the epidermis owing to lateral
+pressure of the shoes, or to the pinching of tight stockings. Why the
+blood vessels should be forced up into the epidermis is most peculiar,
+but helomata vasculare appear where the normal papillæ are longest,
+and this increased length of the vessels tends to force them up into
+the dead skin. Athletes, particularly runners and jumpers, are most
+commonly afflicted.
+
+=Pathology.= Heloma vasculare consists of an overgrowth of epidermic
+cells in which are found the elongated vessels. There is an increase
+in epithelial tissue, but there is no increase in the quantity of the
+connective tissue and blood vessels, as in verruca. The blood vessels
+leave the papillary layer of the derma and enter directly into the
+epidermis, without any elevation of the surrounding connective tissue.
+On some occasions a nerve ending is found embedded in the callous mass.
+This adds considerably to the pain, but is not the true neuro-fibrous
+corn described under heloma durum, which has no accompanying blood
+vessels. The area surrounding an heloma vasculare is usually inflamed,
+but the inflammation rarely terminates in suppuration.
+
+=Diagnosis.= The true heloma vasculare may be easily distinguished from
+verruca when the two conditions appear on the dorsal surface or any
+surface not subjected to extreme pressure, in that the latter is an
+overgrowth of all the layers of the skin, including the derma, and has
+a characteristic cauliflower appearance. However, when verrucæ appear
+on the plantar surface, they lose their cauliflower appearance and
+become flattened; they then resemble heloma vasculare, except that they
+are somewhat darker.
+
+The blood vessels in heloma vasculare are not so numerous as in
+verruca, but this diagnostic point may not always manifest itself to
+the naked eye. A differential diagnosis between these two conditions is
+of no great importance, as the treatment is practically identical.
+
+Heloma vasculare may be readily distinguished from heloma durum by
+the small red spots found therein which bleed when cut. Very often an
+heloma durum has a dark red spot at the base of the mass, due to the
+rupture of a small vessel and consequent clotting of the blood. This
+dark red spot does not bleed when the knife is passed through it,
+denoting the absence of blood vessels.
+
+=Prognosis.= Heloma vasculare will always respond when the treatment is
+thorough. There may be a recurrence of heloma durum over the spot where
+the original growth was located, but the vascular condition, when once
+eradicated, should not return.
+
+=Treatment.= The treatment of heloma vasculare may be divided into
+three classes, viz.: surgical, medicinal and mechanical.
+
+The technic of the _surgical_ method is as follows: the part is
+cleansed with tincture of green soap, followed by the application of
+tincture of iodine, 4%. The instruments having been sterilized, the
+part is anesthetized by the hypodermic method and a semi-elliptic
+incision is made a little to the outside of one-half the growth. The
+flap thus produced is seized with an artery forceps. The forceps are
+then raised and the rest of the growth is dissected out with a sharp
+knife or with a heavy pointed scissors. When the entire growth has thus
+been eradicated, a few layers of gauze should be placed over the part
+to produce pressure. A bandage should be applied over all to hold the
+dressing in place. This may be removed in three or four days, provided
+no inflammation is present, and the subsequent dressing should contain
+balsam of Peru or some other stimulant.
+
+The _medicinal_ or _chemical_ treatment of heloma vasculare consists
+of the gradual destruction of the growth by means of chemicals, chief
+among which are nitric acid, potassium hydroxide and salicylic acid.
+If nitric acid is employed, the callous is removed so as to produce a
+slight oozing of blood, and a drop of the acid is allowed to fall in
+the centre of the mass. This is allowed to remain in contact with the
+part for two days, when the eschar produced is removed, and the acid
+is again applied. This treatment is continued as long as necessary
+to completely destroy the growth; when a slight exudation of pus is
+noticed, the application of the acid should cease. The subsequent ulcer
+thus produced is treated in the same manner as any other ulcer (see
+chapter _Ulcers_).
+
+The salicylic acid method of treating heloma vasculare varies greatly
+depending upon the strength of the acid employed. If a weaker
+percentage is used, the treatment is practically the same as that with
+nitric acid. Several applications are necessary to completely remove
+the entire excrescence. The weaker solutions of this drug are the 10
+to 15% ointments. The stronger ointments contain from 50 to 60% of
+the acid. The treatment with the 60% salicylic acid is preceded by
+cleansing the parts and removing the superfluous callous. The acid
+is then applied and the part protected. The dressing is allowed to
+remain in contact with the part for from ten days to two weeks, and
+when removed, the entire mass may be easily scooped out. When the
+stronger acid is used, it is often necessary to warn the patient that
+if there should be any throbbing pain experienced, he must return for
+treatment at once. This pain is due to the rapid action of the drug,
+and to a mechanical inflammation which ensues. Examination will usually
+reveal a newly formed ulcer, which must be cleansed and treated in the
+usual manner. The salicylic ointment method is finding great favor,
+particularly on account of the few treatments necessary. Those inclined
+to nervousness and imaginary fears, regarding chiropodical or any other
+operations, are also usually highly pleased with this non-surgical
+method of treatment because the use of the knife is avoided and cure is
+not long delayed.
+
+In treating these cases medically, it is well to remember that the
+chemicals employed have a destructive action on the healthy tissue
+beneath the heloma as well as upon the heloma itself, and caution
+should be exercised in applying them. The case should be carefully
+watched and at no time should the operator allow the patient to remain
+away from the office for a greater length of time than above specified.
+It is also well to remember to warn the patient of the dull throbbing
+so characteristic of inflammation, which gradually increases as the
+pains become worse. These pains are due to a chemic inflammation
+produced by the action of the drug upon the normal tissue beneath the
+growth, and are always an indication to discontinue treatment, remove
+what is left of the destroyed tissue, and direct treatment to the
+healing of the parts.
+
+The _mechanical_ treatment of heloma vasculare consists of the removal
+of the growth by means of electricity. The fulguration spark and
+electrolysis are the two methods employed.
+
+The fulguration spark is a concentrated violet ray, or high frequency
+current. The current is concentrated by passing it from the coil
+through a narrow glass electrode, at the far end of which is inserted
+a small piece of platinum or copper wire. As the current passes
+through the tube and the charged wire is brought in apposition to
+the excrescence, instead of the usual blue spark that is produced by
+the high frequency current in an ordinary vacuum electrode, there is
+a yellow spark produced which is quite painful to the body tissues.
+This spark has a caustic action, and after penetrating the superficial
+layers it enters into the deeper structures and there causes a
+destruction of the tissues.
+
+Two, or at the most three, applications of this current, each of
+thirty seconds duration, will suffice for helomata vasculare which are
+situated on the dorsum of the foot. On the plantar surface, however,
+the tissues are more dense and many more treatments are required. It is
+on account of this density of the tissues that fulguration or any other
+form of electricity for the treatment of plantar growths is inadvisable.
+
+Electrolysis consists of inserting a needle or other sharply pointed
+instrument to which the negative pole of a galvanic cell has been
+attached, beneath and around the growth. The positive pole is attached
+to a spot near where the condition is found, usually the calf of the
+leg. As the current is passing through the foot, the water in the
+tissues undergoes electrolysis, and after a time, as the hydrogen goes
+to the negative pole, bubbles of this gas are noticed around the free
+surface of the needles. This is an evidence that the decomposition has
+gone on sufficiently and the needle may be withdrawn. If the growth is
+a large one, the needle should be re-inserted at right angles to the
+original insertion, and the process repeated. If this is done properly,
+after two or three days, the entire mass will separate from the
+surrounding tissues. The greatest care must be observed in practising
+asepsis, as the electrolysis method is not an antiseptic one. The
+needle must be thoroughly boiled, and the part cleansed in the same
+manner as if a surgical operation were to be performed. This method, as
+well as the previous one, is not practical for helomata vasculare that
+appear on the plantar surface of the foot.
+
+The carbon dioxide pencil may also be used in the treatment of this
+condition. This method, however, is not advised, as the parts become
+frozen from the contact and the pain of reaction is severe.
+
+As previously stated, the treatment of heloma vasculare is almost
+identical with that of verruca and the reader is advised to consult the
+chapter on verruca for further knowledge along this line of treatment.
+
+
+HELOMA MILIARE
+
+=Definition.= Heloma miliare, or heloma disseminatum, or seed corn,
+is a small excrescence usually found in large numbers on the plantar
+surface of the foot, around the heel, or over the dorsal and inner
+lateral surface of the great toe joint. The growth is about the size of
+a millet seed.
+
+=Symptoms.= This form of heloma does not produce the extreme pains
+caused by the other types of this growth, and only when they develop in
+great numbers do they become annoying. The patient then complains of
+an uncomfortable feeling, as if there were a foreign body in the shoe
+or stocking. Upon examination, several small helomata are seen, which
+appear to be all nuclei.
+
+=Etiology.= Wrinkles produced by wearing loose stockings are a factor
+in producing helomata miliare; nails which protrude from the plantar
+surface of the shoe are also a fruitful cause of this condition. The
+wrinkling of the stockings produces an uneven surface over the length
+of the wrinkle and the weave of the material, usually wool, causes
+these helomata to develop. The nails found in shoes are usually caused
+by imperfect repairing. They do not extend out more than just the
+smallest fraction; in fact they protrude just enough to allow the
+patient to go along for several days or weeks without noticing that
+something is wrong.
+
+=Pathology.= Hypertrophy of the epidermis takes place at the nucleus
+only, but the area immediately surrounding the heloma miliare feels
+hard and congested to the touch. Hypertrophy of the papillæ occurs, but
+only a small number are involved. There is no disturbance in the skin
+between the individual growths, each of the neoplasms having a distinct
+etiologic factor in its production.
+
+=Diagnosis.= The heloma miliare is characteristic and cannot be
+mistaken for any other condition. As stated, the growth is rarely
+larger than a millet seed and appears to be all nucleus. There is an
+area of normal skin between these helomata, when they occur in numbers.
+
+=Prognosis.= Careful operating and intelligent after-care will produce
+a cure in from four to five treatments. There are cases on record that
+have entirely disappeared after one treatment, but these are rare. The
+footgear, both shoes and stockings, should be examined and if found
+faulty should be corrected. This aids in a rapid cure and will, as
+well, prove a preventive.
+
+=Treatment.= The removal of these helomata may be accomplished with the
+knife, but the ordinary scalpel is useless. It is necessary to have a
+very finely pointed small knife, and the procedure is the same as that
+followed in the treatment of the nucleus of heloma durum, except that
+more care must be practised, because of the smallness of the growth.
+The helomata miliare occur in groups containing as many as twenty or
+even thirty distinct minute growths, and it is necessary to take as
+much care with each one of them as with the first one removed. This is
+trying both to the patient and to the operator, but as it is essential
+to the successful cure to have the growths removed individually and
+carefully, patience is necessary. The after dressings may consist of
+ichthyol ointment, 15%, applied on a piece of lint, or balsam of Peru
+painted on after the helomata have been removed, and covered by a lint
+or cocoon dressing. Some practitioners apply tincture of iodine to the
+part without further dressing.
+
+The therapeutic method of treatment consists of applying salicylic
+acid plaster, cut so as to fit over the affected area, and allowing
+this to remain in contact with the part for several days. This softens
+the tissues, so that the small growths may be easily removed, but
+care must be taken, as the acid will destroy the healthy tissue
+between the helomata unless each growth is isolated in treatment.
+The disintegrating process must not be allowed to continue to the
+extent that it does in the treatment of heloma molle or in the other
+conditions in which salicylic acid is employed. It is then often
+necessary to use the knife to remove the remaining tissue.
+
+Recurrence is the rule in helomata miliare, but after persistent
+treatment the condition usually disappears. It must be borne in mind,
+however, that the footgear of the patient must be carefully examined
+and necessary corrections made. This, in itself, without the thorough
+treatment prescribed above, will often result in a cure of the most
+annoying cases of heloma miliare.
+
+
+
+
+CHAPTER XI
+
+CALLOSITAS
+
+
+=Derivation.= The word callositas is derived from the Latin “callus,”
+meaning horn.
+
+=Synonyms.= Callus, callosity, callous, tyloma, tylosis.
+
+=Definition.= Callositas, or callouses, are a thickening of the
+epidermis, usually found on the plantar surface of the foot. They
+also occur on the dorsum of the toes, and are found on the hands of
+mechanics who continuously use hand tools involving pressure on the
+parts. Coachmen develop callouses between their fingers on account
+of the manner in which they hold the reins while driving. In rare
+instances, women have been known to have callouses on their hips, due
+to the pressure of the steel in their corsets, and cavalry men who sit
+in the saddle for long periods develop callous on the parts exposed to
+irritation.
+
+=Symptoms.= Callosities are composed of variously sized areas of
+yellowish or grayish, horny excrescences of epidermic cells. They
+are hard, dry and horn-like, thicker in the centre of the growth and
+gradually becoming thinner at the periphery. There is no sharp line
+of demarcation between a callous and the surrounding skin, such as is
+found in helomata, but the thickened cuticle gradually blends with the
+surrounding skin.
+
+=Etiology.= A callosity is the result of an irritation of some form
+and is nature’s way of protecting the delicate structures beneath the
+skin from the direct pressure or friction to the parts. The outer
+layers of the skin become thickened and act as a buffer, which absorbs
+shock and prevents inflammation and tissue destruction. When found on
+the soles of the feet, callouses are due to standing or walking in
+improper footgear. The ball of the great toe is a very common site for
+callosities; also the region over the heads of the metatarsal bones,
+due to high heels which force one to walk directly on these parts
+without equal weight distribution, is subject to them.
+
+Callosities may occur as the result of chronic skin lesions such as
+eczema, psoriasis, lichen planus and ichthyosis and after the prolonged
+use of arsenic.
+
+Callosities occurring on the dorsum of the toes are caused by the
+pressure of the skin against the top of the shoe. The parts beneath
+the callous at this point usually show the presence of bursitis, which
+causes a swelling and subsequent pressure on the skin.
+
+=Pathology.= The changes that take place in the formation of
+callosities are the same as those which arise in heloma, except that
+the deeper layers of the epidermis and the true skin are not affected
+unless accidentally infected or injured.
+
+There is no inflammation present except in cases of infection or
+injury. The upper layers of the epidermis are the only ones involved,
+and the condition is really a physiologic rather than a pathologic one.
+It is more of a protection than a true hypertrophy. The overgrowth may
+continue to a greater extent, and then even helomata may develop.
+
+=Diagnosis.= The callosity is yellow to grey in color and is composed
+of a horn-like mass of epidermic cells. It is easily distinguished
+from an heloma in that there is no nucleus present, and the part is
+not severely painful on pressure. It may be mistaken for some of the
+chronic skin lesions, previously mentioned, but the skin eruption
+presents a scale or crust which readily peels off, en masse, leaving
+the bare rete Malpighii exposed. The callosity comes off in layers and,
+as the deeper structures are reached, a healthy pink color is noticed.
+
+=Prognosis.= A change in occupation or a change of footgear often
+results in the disappearance of this condition. Unless the direct
+cause is removed there will be a recurrence, which is an indication
+that the part again needs protection and care. Persons who have been
+accustomed to standing or walking for protracted periods of time,
+such as policemen, floor walkers, etc., soon lose the callouses they
+developed, after they change their occupation.
+
+=Treatment.= If the growth becomes thick enough to cause discomfort, it
+may be easily removed, by softening it and then scraping or paring it.
+The foot may be soaked in an alkaline foot bath composed of one-half
+ounce of sodium bicarbonate to two quarts of hot water, or painting the
+part with a dilute solution of potassium hydroxide (caustic potash),
+5%, several applications every few minutes, the softened area being
+scraped away after each application. Salicylic acid plaster, 25%,
+placed over the affected area and allowed to remain in contact for
+forty-eight hours, will usually loosen the redundant mass. If the
+callosity appears over the head of the first or fourth metatarsal bone,
+mechanical adjustment should be made, whereby the pressure in walking
+is thrown upon the entire surface of the anterior part of the foot.
+Pads of felt or buckskin, properly skived and fitted, will accomplish
+this result.
+
+Care must be taken that too much of the induration is not removed when
+treating this condition. As previously stated, the calloused mass acts
+as a protective for the parts beneath and is nature’s way of preventing
+serious trouble, and if too much is removed, pain will be experienced
+when the foot is used in walking. If this should occur, the part should
+be painted with tincture of iodine, 4%, and covered with moleskin or
+adhesive plaster. If an abrasion has been made, it is important to
+dress the part with an antiseptic, followed by a stimulating agent, all
+of this to be covered with a cocoon dressing or a lint shield.
+
+Where callosities are caused by a displacement of the anterior
+metatarsal arch, or by any of its bony constituents, the bony lesion
+must be corrected before the callosities will respond to treatment.
+
+
+
+
+CHAPTER XII
+
+VERRUCA
+
+
+Verruca, sometimes called papilloma, is an innocent or benign tumor,
+containing many blood vessels, and is an overgrowth of all the layers
+of the skin including the derma. It is usually found on the hands and
+feet, but other parts of the body may become affected, particularly the
+face.
+
+Verruca, like other innocent or benign tumors, does not penetrate into
+the surrounding tissues, and is encapsulated. Those found on the foot
+are divided into two classes, (1) the verruca arida, or dry wart, and
+(2) the verruca humida, or moist wart.
+
+The common wart found on the hands and fingers, is a form of verruca
+arida and is called verruca vulgaris. There are many other names used
+to designate verruca, but these are only indicative of the location,
+shape or consistency of the growth, which, as stated, is either of the
+arida or humida variety, and additional nomenclature tends to confuse
+the student. Among these are the verruca plantaris, verruca calcis,
+verruca metatarsalis, verruca lobosa, verruca fibrosa, verruca digita,
+etc.
+
+=Synonyms.= Papilloma, Wart. Fr. verrue.
+
+=Derivation.= Verruca is derived from the Latin, meaning wart.
+
+=Etiology.= There is no general agreement among pathologists as to the
+cause of verruca. The older theory held that verruca was due to want
+of normal power within the integument. Some claim it to be due to a
+microorganism, while others assert that it is caused by irritation or
+injury. The latter reason seems to be the most reasonable one, since
+the patients who have been questioned thoroughly, all seem to give a
+history of trauma or of some chronic irritation.
+
+Some verrucæ seem to occur spontaneously and it becomes difficult to
+draw a line between those that grow in this manner and those that
+develop from an injury or from a chronic irritation. Predisposition
+seems to play an important part in the etiology of verruca, but
+irritation is surely a factor in most if not in all cases. This
+predisposition may lie in the peculiar structure of the tissues, which
+is of course, difficult to determine.
+
+[Illustration: VERRUCA HUMIDA OR CALCIS]
+
+The fall and early winter, seem to be the time at which most cases
+appear, and their history seems to indicate that either there has
+been an injury or an irritation, such for instance as is produced in
+walking barefooted on the beaches, which occurred during the previous
+summer. Those who walk distances over rough roads in the mountains, or
+who wear thin-soled shoes and sneakers or hob-nail shoes, or who have
+stepped on a sharp stone, are most likely to develop verrucæ.
+
+Verruca is found on the hands of young persons, and on the feet of
+adults, but only occasionally is this growth seen on the feet of
+children. This is undoubtedly due to the fact that young people use
+the hands in playing to a great extent, and in that way are subjected
+to irritation, whereas the shoes of adults, and the rigidity of the
+tissues in older persons cause the development of verrucæ on the feet.
+
+Observation has shown that those of athletic bent, such as golfers,
+tennis players, base ball players, etc., are affected to a greater
+extent than those who follow a sedentary occupation.
+
+=Pathology.= Verrucæ of all types are overgrowths of the derma covered
+with a somewhat hypertrophied epidermis, which is more granular and
+rougher than the normal skin. The wart may be only a simple, smooth,
+hemi-spherical elevation, or it may have a rough cauliflower-like
+appearance, sessile or pedunculated. These latter may be dry or moist
+and may be elevated above the level of the skin or flattened to the
+level of the normal surrounding tissue. The size varies from minute
+points to growths as large as a nut. They are somewhat pigmented and
+bleed easily.
+
+Verruca may occur singly, as it usually does on the foot, or it
+may occur in groups, and there may be several such groups in
+widely scattered parts of the body. The most common sites are the
+hands, feet, neck, back and face. Warts also occur on the mucous
+membrane, particularly in the bladder, larynx, nasal chamber and the
+gastro-intestinal tract, in which locations they are commonly termed
+papilloma.
+
+The structural essentials of verrucæ are the centre or ground
+work containing blood vessels and an epithelial covering. In the
+skin, the growth resembles the normal papillæ, all of these latter
+however, being greatly enlarged. There is hypertrophy of all the
+connective tissue cells, and in the growths that have a cauliflower
+appearance, a vertical section shows a branching arrangement. Each of
+the branches has a connective tissue frame work with an epithelial
+covering. The epithelium is of the striated-squamous type and shows
+a decided tendency to hornification. Distinct concentric whorls of
+horny epithelium, such as are seen in epithelioma of the skin, may be
+found in verruca. The amount of connective tissue ground work varies,
+in some cases being excessive, while in others the growth appears to
+consist entirely of proliferated epithelium. In these latter cases the
+resemblance to epithelioma is rather marked, but a distinction can be
+made by observing that the tumor grows outward while the malignant
+tumor grows into the deeper structures and there is always some
+connective tissue stroma present. This is important for the podiatrist
+to remember as it may often be necessary to distinguish between the
+benign and the malignant tumors of this type.
+
+
+VARIETIES OF VERRUCA
+
+Verrucæ of the hands and feet vary to a greater or lesser extent
+depending upon the location of the lesion. The shape of the growth
+differs with the amount of pressure brought to bear upon it, those of
+the hands being better defined than those of the feet.
+
+=The Verruca Vulgaris=, or common wart of the hand, is found on the
+palmar and dorsal surfaces, more usually in children than in adults.
+They often appear in large numbers, and very often the forearms and
+elbows are affected. The lesion is an elevated, rounded, conical
+hypertrophy having an uneven top and resembling a cauliflower. The
+growth develops slowly, and in its beginning has the same color as the
+surrounding skin. Later in its formation it becomes darker and takes on
+a cracked, rough cauliflower-like shape. There is no pain manifested,
+but the growth bleeds easily upon being injured, due to its great
+vascularity.
+
+=The Verruca Arida=, or dry wart of the foot, usually appears upon the
+plantar surface, over the metatarsals and on the ends of the toes. It
+is in reality a modification of the verruca vulgaris, which has been
+subjected to pressure. There is a distinct callous formation covering
+and surrounding the growth, and the entire mass has a flattened shape.
+At the ends of the toes on the dorsal surfaces and along the nail
+grooves, verrucæ which have a slight elevation often appear and are of
+the arida type.
+
+=The Verruca Humida=, or moist wart, is found on the foot, usually on
+the heel and between the toes. It has a spongy, soft appearance, with a
+sharp line of demarcation separating it from the surrounding tissues;
+the centre of the growth is white and has a crater-like shape. It is
+sometimes covered by a layer of callous, which is spongy and blanched,
+much the same as that of an heloma molle. The sudoriferous excretions
+in those suffering with hyperidrosis or bromidrosis are the cause of
+the color and texture of these lesions.
+
+=Diagnosis.= Verruca is an overgrowth of all the layers of the skin,
+and when it appears on places where it is not subjected to pressure of
+any great magnitude, its diagnosis is a simple matter. When, however,
+it appears on the foot, its true character is lost, and it may be
+confused with other lesions, notably epithelioma, syphilitic lesions
+and heloma vasculare.
+
+The malignant epithelioma is occasionally seen as a warty growth, but
+it generally has adherent scabs, ulcerates superficially, and has a
+disagreeable odor. The surrounding tissues are infiltrated and severe
+and persistent pain is common. Innocent tumors of this type, after a
+long period, may become malignant; increase in the size of the growth,
+implication of neighboring glands, infiltration of adjacent tissues,
+plus the other symptoms of epithelioma, should be sufficient to arouse
+suspicion as they are indicative of the more serious developments.
+
+Some lesions of syphilis taking on a papillary character, may be
+mistaken for verruca, but other indications of a specific condition
+are usually present so that when confusion as to diagnosis arises,
+the lesion may be readily distinguished if it be a luetic one. The
+smaller tertiary ulcers of syphilis that appear on the plantar surface
+of the foot often have cracked, uneven overgrowths around and on them,
+which upon superficial examination may be mistaken for verruca, but a
+negative Wassermann test (see Miscellaneous Foot Lesions--_Syphilis_)
+will make it possible for the practitioner to eliminate syphilis as a
+factor.
+
+Venereal warts occur on the genitals only and need not be considered in
+this chapter.
+
+Verruca and heloma vasculare are often confused, but inasmuch as the
+treatment is identical in both these lesions, an error in diagnosis
+is of no particular consequence. In heloma vasculare the affected
+papillæ, which are found in the hornified skin, are few in number and
+are confined to a limited area, whereas in verruca all the papillæ are
+affected and the entire growth is vascular.
+
+[Illustration: EPITHELIOMA]
+
+=Prognosis.= Some verrucæ disappear spontaneously, but those appearing
+upon the foot are persistent and painful, and require regular treatment
+to effect a cure. The growth will get well with proper attention
+and only when it changes its nature and becomes malignant, is the
+prognosis unfavorable.
+
+=Treatment.= The treatment of verruca is more varied than the treatment
+of any other chiropodical lesion, and the practitioners using these
+different methods all seem to favor the one particular form with which
+they have had the most experience and the best results.
+
+Treatment is generally effective, the percentage of failures being very
+small, notwithstanding the statement of those who expect immediate
+results, and not receiving them, claim failure on the part of the
+practitioner.
+
+The various treatments are as follows:
+
+[Illustration: MULTIPLE VERRUCA]
+
+Potential Cautery--including the following chemicals: Nitric Acid,
+Acetic Acid, Monochloracetic Acid, Trichloracetic Acid, Salicylic Acid,
+Silver Nitrate, Potassium Hydroxide, Sodium Hydroxide and Pyrogallic
+Acid.
+
+  Excision.
+  Fulguration.
+  Electrolysis.
+  Direct Cautery.
+  Carbon Dioxide Pencil.
+
+=Potential Cautery.= The treatment of verruca by the use of chemical
+agents which destroy the tissues to which they are applied, is
+unquestionably the most popular method of treating this lesion and is
+practised to a great extent by modern podiatrists. The tissues are
+destroyed in one of two ways, depending upon the chemical selected. The
+acid caustics destroy the tissues by oxidizing them, and the alkali
+caustics destroy the tissues by dehydrating them. Therefore the kind
+of tumor with which one has to deal is a factor in determining which
+caustic is best suited for rapid and certain cure. A verruca which is
+hard and dry will be easily destroyed by oxidation, whereas a verruca
+that is soft and moist will be easiest of removal by dehydration.
+
+The selection of a particular chemical for removing a certain type of
+growth, is more or less a matter of individual choice on the part of
+the operator, as any one of the recognized remedies will suffice if the
+technic of its application be properly followed. A podiatrist who uses
+nitric acid for verruca arida, may just as well use trichloracetic acid
+and obtain equally good results.
+
+Inasmuch as there are so many agents which one can use successfully,
+the authors have asked several well known practitioners of podiatry to
+state their technic in the treatment of verruca, and later on in this
+chapter their views will be found quoted verbatim.
+
+The method of procedure for the treatment of verruca by the use of acid
+caustics generally is as follows:
+
+The field of operation is rendered aseptic by means of a solution of
+bichloride of mercury (¹⁄₂₀₀₀) or a solution of alcohol, 60%. A sharp
+knife or chisel is employed to remove the callous that usually covers
+the growth. As soon as bleeding is observed, which is an indication
+that some of the capillaries of the tumor have been cut, a styptic,
+such as Monsel’s solution or powdered alum, is applied and readily
+controls the hemorrhage. The part is then thoroughly dried with sterile
+gauze or cotton, and the caustic selected is applied to the part. If
+an acid is used, a single drop is usually employed at each treatment.
+The patient, as a result, will complain of a burning sensation in the
+growth which persists from a few minutes to an hour, depending upon the
+amount of the acid absorbed. If the growth is dense, the absorption is
+lessened and more frequent treatments become necessary.
+
+A properly fitted and skived shield of felt is then applied, with a
+hole large enough to prevent pressure over the affected area. No other
+medicament is required, nor is it necessary to cover the verruca. The
+acid forms an eschar which seals the lesion and prevents bacterial
+infection. The second treatment should take place forty-eight hours
+after the first, and the same procedure should be practised, including
+the asepsis. The treatments are continued every other day, daily, if
+possible, until the entire growth has been destroyed.
+
+Unless great care is exercised, as the destruction of the growth
+continues and its size decreases, the acid coming in contact with the
+underlying healthy tissues creates pain of a throbbing character and
+later on pus is likely to form under the eschar. Some practitioners
+believe that both the pain and the pus are necessary precursors of the
+healing process, but neither is essential. They are both the usual
+concomitants of the later stages of this treatment merely because, as
+stated, it has been impossible to exercise the strict care desired.
+
+When the growth has been destroyed, the eschar is entirely removed and
+if pus is present it is drained. Hydrogen peroxide is a most efficient
+agent for this purpose. The lesion is now treated much the same as any
+other ulceration, that is to say, by stimulants, balsam of Peru or
+ichthyol being the mediums usually preferred. The balsam of Peru used
+for this purpose should be diluted with an equal quantity of castor
+oil; the best method of applying ichthyol is in ointment form (25%)
+with vaseline as a base.
+
+The treatment of verruca by means of the alkali caustics is much the
+same as with the acid caustics, except that the cauterization by the
+latter method may continue so as to destroy the entire growth at one
+treatment. This of course would prove even more painful than if done
+intermittently, therefore it is far better to treat the patient at
+several different times than to attempt anything quite so radical. The
+parts must be protected during the treatment and the subsequent ulcer
+invariably produced by this method, is treated the same as the ulcer
+frequently resulting from acid applications and previously described.
+
+_Nitric acid_ is extensively used in this condition in the pure state.
+The treatment of the eschar produced varies.
+
+S. Rutherford Levy, of San Francisco, California, uses the nitric acid
+pure, and reports very favorable results. He removes the eschar after
+each treatment.
+
+Alfred C. Moran, of Pawtucket, R. I., also favors nitric acid, but
+advises that the eschar be allowed to remain on the part until healing
+takes place or until signs of suppuration manifest themselves. He
+punctures the surface of the growth with a sharp instrument to assist
+the diffusion of the acid.
+
+Albert E. Smallwood, a well known and busy practitioner of podiatry, of
+Pittsburgh, Pa., reports good results with the use of trichloracetic
+acid (Merck) and his modus operandi follows:
+
+“_Trichloracetic acid_ is a safe caustic and should be used full
+strength. A tooth pick is wrapped with a small piece of cotton and
+the latter is saturated with the acid. (The crystals of the acid are
+permitted to stand exposed to the air for a few minutes when they will
+deliquesce.) Apply the cotton thus prepared directly over the verruca,
+allowing it (the cotton) to remain in situ; then cover the growth and
+the cotton with a thin felt shield and fasten it with adhesive plaster.
+To prevent the acid from coming in contact with the normal tissues,
+the latter should be protected with oil or vaseline. Have the patient
+return in two days for a second treatment, and if the pains were only
+of short duration, the same procedure is repeated. The white eschar
+produced is removed, care being taken that bleeding is avoided. It is
+better to remove only a little of the eschar, as this saves suffering
+in the interim of treatments.
+
+“Treatment is continued every other day until the entire growth is
+eradicated, which is usually indicated by the presence of pus. The
+subsequent treatment is that for ulcerations in general.”
+
+F. S. Sargent, of Providence, R. I., prefers _silver nitrate_ to any
+other of the potential caustics. He uses the pulverized salt, applied
+directly to the verruca, protecting the surrounding tissue with
+adhesive plaster and using felt shields during the treatment. When the
+part has suppurated he cleanses the wound, dusts with some antiseptic
+powder such as aristol, and to stimulate granulations he applies balsam
+of Peru, 50%, in castor oil.
+
+One of the best known practitioners on the pacific coast, Helen C.
+Sexton, has a very interesting technic for the destruction of verrucæ,
+which is as follows:
+
+“Place a small wad of cotton soaked with a 5% solution of _potassium
+hydroxide_ over the growth and apply the surface electrode of the high
+frequency current for five minutes, or until it is uncomfortable to
+the patient. Then dissect out as much of the dead tissue as possible
+and if bleeding should occur, do not attempt to check it for a few
+minutes. The hemorrhage is then easily controlled by digital pressure.
+A piece of moleskin, about the size of a fifty cent piece, with a hole
+in its centre, the exact size of the verruca, is next applied, and in
+the aperture a sixty per cent. salicylic acid ointment is placed. The
+ointment is covered with fish skin and the entire dressing protected
+with a well skived and properly adjusted felt shield. The patient is
+instructed to return in one week unless pains develop, in which case he
+should return immediately. The treatment is continued every week until
+the growth is destroyed, and after the skin surface is again normal,
+the patient is instructed to wear a protective, such as a piece of
+moleskin, for at least one week. If a case does not respond to this
+treatment in a period of three weeks, electrolysis is resorted to.”
+
+James Parker Buntin, of Boston, Mass., calls the following his
+“antiquated” treatment, but says he has had very good results with it
+and with very little, if any discomfort to the patient:
+
+“Take a small piece of caustic potash (_potassium hydroxide_) and
+allow it to stand in the open air until it slacks. Then thicken it to
+a paste with pulverized gum arabic, which will prevent it spreading to
+the surrounding tissues when applied. Carefully remove the superficial
+layers of the verruca and apply the paste and let it remain for ten
+minutes. Soak the part in sharp vinegar or sweet oil, either of which
+will neutralize the action of the caustic potash. This treatment is
+continued every other day until the entire growth is removed.”
+
+Oscar Klotzbach, of Cleveland, Ohio, is using _methylene blue_ for the
+treatment of verruca, applying the drug (once a week), and protecting
+the part with sterile dressings. This is a painless method.
+
+Bertha DeWolfe, of Denver, Colo., is using _ethylate of soda_ for
+verruca and reports gratifying results. The drug is dampened with
+a drop of absolute alcohol and placed in the centre of a piece of
+adhesive plaster, the size of a twenty-five cent piece, and then
+applied so that the sodium ethylate comes in direct contact with the
+warty growth. The treatment is repeated daily, at first, and then every
+other day, until a cure is affected. The pain is slight, being limited
+to one or two days of slight discomfort. If the ethylate of soda is
+employed for verrucæ of the dorsum of the foot or of the fingers, it
+should be diluted, varying from 15% to a saturated solution. The full
+strength of the drug should be used on the plantar surface of the foot
+only.
+
+Anna Moyde Savage, of Syracuse, N. Y., who has had experience with many
+treatments for verruca, has been using and recommends _pyrogallol_ for
+this lesion. Her statement follows:
+
+“Pyrogallol is a white, lustrous, bitter crystalline substance soluble
+in water, alcohol and ether. It is used extensively in diseases of
+the skin, and in all the cases of verruca in which it was used, a 30%
+ointment in a vaseline base proved sufficiently strong to remove the
+growth. Most of the cases respond to one treatment, and no case has
+ever required more than five treatments to effect a cure.
+
+“The treatments are given at intervals of from five to seven days, and
+at no time is it necessary for the patients to remain in bed or refrain
+from their usual occupations. A fairly thick pad of felt is applied
+with an opening large enough to protect the verruca. In this opening
+the 30% ointment of pyrogallic acid is applied, a cotton or gauze
+dressing being placed over it, and then the entire dressing is securely
+fastened with adhesive plaster. There is no pain or discomfort during
+the treatment, and only when the pyrogallol has destroyed the tumor and
+penetrates into the healthy tissues, is a drawing pain noticed. This
+is mild and lasts but one day, and when the final dressing is removed,
+the verruca is eradicated. The subsequent ulceration may be treated
+with any stimulant, after aseptic precautions have been observed, some
+iodine preparation for example. The pad should be worn until the entire
+lesion is healed. No case so far treated with this method has shown any
+signs of recurrence.”
+
+_Salicylic Acid_ is used to a great extent for the destruction of
+verrucæ, and is admirably adapted for this purpose, inasmuch as it is
+painless and does not require frequent changes of dressings. A piece of
+adhesive plaster is fitted to the part with a hole cut in it exposing
+the verruca. A piece of felt of the required thickness is then applied
+to the foot, which acts as a shield. In the holed-out portion of the
+felt, a 60% salicylic acid ointment is applied directly over the
+verruca. The adhesive plaster first applied prevents the acid spreading
+to the surrounding normal structures. The entire dressing is protected
+with adhesive plaster and the patient is instructed to return in a week
+or ten days. By this time the therapeutic action of the acid will have
+manifested itself, and a suppurative process will be noted at the base
+of the growth. The patient complains of throbbing in the part and when
+the dressing is removed, the part cleansed and a sharp knife inserted
+into the growth, oozing of pus will occur. The entire mass can be then
+removed, whereupon the abscess cavity should be thoroughly cleaned.
+This can be done by means of peroxide of hydrogen. The pyogenic
+membrane can be destroyed by the use of pure phenol followed by
+alcohol, after which a stimulant, such as balsam of Peru or ichthyol,
+should be applied. These latter dressings should be changed every other
+day until the wound is healed. This method is particularly adaptable
+for verrucæ around the nails.
+
+=Excision.= The removal of verruca by surgical means is a very simple
+procedure and, if properly done, should result in an absolute cure in
+every case in which it is employed.
+
+The part to be operated upon is rendered sterile by thoroughly
+cleansing with soap and water, and subsequently painting it with
+tincture of iodine. The instruments are boiled for at least fifteen
+minutes in water containing a little sodium carbonate and the hands of
+the operator are thoroughly cleaned and dipped in alcohol.
+
+Local anesthesia is induced by the hypodermatic injection of any
+approved anesthetic, preferably novocaine, 1%, and when the tissues
+around and beneath the verruca are thoroughly anesthetized, the
+operator makes a semi-elliptical incision a little outside of and
+beneath the growth. The flap thus produced is grasped with an artery
+forceps and raised. This affords room to dissect out the growth with a
+scalpel or with a pair of heavy, pointed scissors.
+
+The wound produced by the removal of the verruca should now be packed
+with sterile gauze and a bandage applied to prevent infection. If
+the gap is a large one it may be closed by taking one or two sutures
+(interrupted) and drawing the edges of the wound together in this
+manner.
+
+To afford relief from the reaction of the anesthetic, and as a
+precautionary measure against infection, a wet dressing of bichloride
+of mercury (¹⁄₅₀₀₀) should be applied for from twenty-four to
+forty-eight hours immediately following the operation. This, however,
+is unnecessary if asepsis has been practised throughout the operation.
+If no complications arise, the dressing should be left undisturbed
+for four or five days, when the bandage can be softened and removed.
+(Tearing a dry bandage from a granulating wound will destroy some of
+the newly formed granulations). If sutures have been used, they should
+now be removed, and a mild stimulant such as balsam of Peru, 50%, or
+ichthyol, 10%, should be applied to stimulate further granulation.
+Dressings should be changed every other day until the area is
+completely healed, a process requiring from one to two weeks. With
+proper shielding, the patient should be able to walk comfortably after
+the first dressing has been removed.
+
+=Fulguration.= The use of electricity in the treatment of disease has
+greatly increased in recent years. This is particularly true of the
+high frequency current, examples of which are the so-called violet ray
+and the X-ray. This form of electricity is quite different from the
+usual form encountered when using the faradic or galvanic currents,
+and although its voltage is expressed in the thousands, it is quite
+harmless when one knows just how to use it.
+
+For the purposes of the podiatrist, a small coil generator with one
+or two electrodes, will usually suffice. The fulguration electrode is
+a glass rod through the centre of which passes a piece of fine copper
+or platinum wire, terminating a little beyond the end of the tube.
+This free end of the wire is protected by a small glass cup which fits
+over the end of the tube. The tube itself is a vacuum. The rear of the
+electrode is set in a brass cup, which fits into the handle of the
+apparatus and makes direct contact with the wire conducting the current
+from the generator.
+
+For the destruction of verruca the part is cleansed with alcohol, and
+the electrode is placed directly over and in close contact with the
+growth. A small amount of current is then passed through the apparatus,
+and a yellow spark will be noticed leaving the free end of the wire and
+entering the verruca. If this is painful to the patient, the current
+must be reduced. When the entire area has turned white, the current is
+turned off. This takes from 20 to 40 seconds, depending upon the size
+of the tumor.
+
+The part should be dressed with a well skived shield, to afford
+protection, and should then be covered with dry, sterile gauze. This
+dressing is left unmolested for a few days. The growth during this time
+dries up completely and when the dressing is removed the growth can
+easily be separated. If all of the neoplasm has not been destroyed,
+another application of the high frequency current should be made over
+the remaining portion. When the entire growth has been thus removed,
+the tissues are protected with a piece of moleskin for one or two weeks.
+
+Rudolph Mertin, of Boston, Mass., has used the high frequency current
+extensively in the treatment of verruca and he says that two or three
+applications of from twenty to thirty seconds duration usually suffice
+to effect an absolute cure for even a large sized growth of this
+variety. He advises that, for nervous patients, the current be reduced
+and if necessary the treatment be extended to six or even ten different
+applications. This eliminates fright and nervousness.
+
+=Electrolysis.= The use of the galvanic current in the treatment of
+verruca is finding great favor among podiatrists, and is especially
+adapted to verruca vulgaris of the hands. The current may be generated
+in a few small wet or dry cells, and by passing it through a rheostat
+with a milliamperemeter attached, it can easily be regulated and
+controlled. There are many such machines on the market today, any one
+of which will answer the purposes of the practitioner. Ordinary direct
+lighting current, if properly reduced, is admirable.
+
+James R. Bennie, of Philadelphia, Pa., who uses this method of
+treating verruca exclusively, has developed a technic that is fully
+described in the following:
+
+“Eight years ago I began treating verruca with electricity and such
+was the success that invariably followed the use of this agent, that I
+quickly abandoned all other methods of treatment. I use the galvanic
+current, and the growth is destroyed by electrolysis. This is the
+quickest, the surest and the least painful method of treatment and is
+equally successful in treating helomata vasculare and moles.
+
+“Electrolysis is accomplished by the use of the negative or active
+pole. Through the action of the negative current, caustic alkalies
+are formed. The action of these alkalies, in conjunction with the
+current itself, causes the growths to liquify and disintegrate. Any
+galvanic current which will give from two to ten milliamperes during
+the treatment, may be used. An essential point to remember is that the
+negative pole is the operating pole whenever tissue is to be liquified
+and disintegrated. The positive pole contracts and hardens the tissues.
+
+“The procedure in the treatment of growths by electrolysis is simple,
+but the greatest care should be observed in carrying out all antiseptic
+precautions. Remove all calloused tissue on or about the growth.
+Saturate the positive pole, which should be a copper plate covered with
+felt, with an aqueous solution of common salt, then place the pole
+on the skin as near the seat of operation as possible. The negative
+pole should be a platinum needle or needles, as the case may demand. I
+have used as many as twelve needles at one time. The needles should be
+sharp, and platinum is the best metal for this work.
+
+“With the field of operation properly prepared, transfix the growth
+through its base with the platinum needle, taking care not to penetrate
+too deeply into the true skin about the growth. The current is then
+turned on and applied in the strength of from one to five milliamperes.
+The application is continued until the verruca assumes a pearly hue.
+A frothy substance will form in and about the needles; this is
+hydrogen gas mixed with a serous exudate and is positive evidence that
+disintegration is completed. If the growth is exceptionally large and
+painful, local anesthesia may be induced by hypodermatic injection.
+
+“The time required for each treatment varies with the character of the
+verruca. The more vascular the verruca, the quicker its disintegration.
+When the current is turned off and the needle removed, the part should
+be antiseptically dressed, and should be protected with a shield of
+felt or buckskin, properly fitted and fastened. At the expiration of
+one week the patient is requested to return for further treatment, when
+the dressing should be removed and the eschar cut away. If the verruca
+is not completely destroyed, the treatment is repeated.
+
+“The appearance of the part after the verruca has been completely
+destroyed is not always the same; in some cases coagulation occurs;
+again there may be present a small quantity of purulent fluid. When
+the products of the destruction of the growth are removed, a healthy
+granulating ulcer remains, which yields readily to antiseptic treatment.
+
+“When a large number of verruca are present, try to determine which is
+the original growth and treat it first. With the destruction of this
+lesion, the others will frequently disappear without further treatment,
+thus enabling the podiatrist to accomplish a brilliant result which
+will greatly impress the patient. I have frequently observed this
+singular result of the galvanic current and believe it to occur from
+the fact that the verruca develop within a definite nerve area, and
+that the current affects the enervation of this area and thus brings to
+completion the cure.”
+
+=Direct Cautery.= The destruction of verrucæ by means of heat is
+practised to a greater or lesser extent by a few practitioners of
+podiatry, but on the whole, other methods which are available are
+superior to it. Any implement which can be heated sufficiently hot,
+so that when applied it will burn the growth, may be used in this
+treatment. A small piece of carbon, pointed at one end, and small
+enough to be easily handled with the thumb forceps, is used by some
+practitioners. The pointed end is placed in an alcohol or other flame
+until the carbon is glowing. It is then applied directly to the
+verruca, and allowed to remain there until the pain becomes unbearable.
+One or two seconds should be the limit of each application. The carbon
+is again heated, and the application is repeated.
+
+For the convenience of the practitioner, an electric apparatus has
+been devised, which, with the aid of a platinum electrode, affords
+an opportunity to generate sufficient heat for this form of cautery.
+The platinum electrode is attached by two wires to the coil, and
+when the contact is made the fine metal end soon becomes red hot.
+The temperature is easily controlled by a little switch on the side
+of the handle of the electrode. The platinum point is brought in
+direct contact with the part to be destroyed, and after several short
+applications, this is easily accomplished.
+
+This method has several disadvantages, because the pain during the
+operation is intense, and the smell of the burning tissue is very
+disagreeable to both the patient and the operator. Further, the sight
+of the red hot metal being applied to the foot usually frightens the
+patient, so that, all in all, other methods are desirable.
+
+=Carbon Dioxide Pencil.= For the treatment of verruca by this method,
+the apparatus necessary is a small tank of liquified carbon dioxide
+gas, and some small cylindric receptacle in which the gas can be
+condensed into the solid form. A glove finger is very good for this
+purpose. The gas is allowed to escape into the glove finger, where it
+solidifies, forming carbon dioxide snow, or what is commonly called the
+carbon dioxide pencil. The temperature of this snow or pencil is very
+low, being much below the freezing point of water.
+
+The pencil is applied directly over the verruca and is allowed to
+remain for a few minutes, until the entire tissue has been devitalized.
+The extreme cold causes the blood supply directly beneath and around
+the growth to cease, much the same as exposure causes local anemia in
+chilblains and frost bite. The tissues around the part become blanched
+and the growth separates from the normal structures in a few days.
+There is usually a slough which will respond to treatment.
+
+Great care should be exercised, so that the application is not
+prolonged, as this will destroy normal tissue, and cause deeper
+ulcers which do not readily heal. This method is painless during the
+operation, but the pains of reaction are marked, varying with the
+duration of the application, and with the resistance of the individual.
+Wm. Golus considers this method of treatment extremely harsh. Monroe
+Redell and Irvin Mayer are similarly minded. All of these practitioners
+state that they give the preference to any and all other procedures
+whenever called upon to treat verruca--they will not use the carbon
+dioxide pencil because they fear the after-effects.
+
+
+
+
+CHAPTER XIII
+
+CALLOUSED NAIL GROOVE
+
+
+The formation of hardened, or calloused skin in the nail groove is,
+unhappily, a very common occurrence. In our present day of high-heeled
+and pointed shoes the nail grooves of all the nails, but particularly
+those of the great toe, are subject to a great amount of pressure and
+friction. This irritation develops conditions in these structures,
+ranging from a transient inflammation to the formation of distinct
+helomata, or the general callousing of the whole surface of the groove,
+both under and beside the nail.
+
+In many cases where an heloma has developed in the inner lateral nail
+groove of the great toe, the condition is judged and treated as an
+ingrown nail.
+
+Why this error in diagnosis should occur is hard to reason out, for,
+while the subjective symptoms of the two conditions may be and usually
+are similar, the objective symptoms are so entirely different that the
+only accountable reason for a mistaken diagnosis is carelessness or
+ignorance on the part of the practitioner. The true ingrown nail is not
+a particularly common occurrence and, as has been previously explained,
+a nail to be classified as ingrowing, must present an edge that has
+invaded and is imbedded in the softer tissues of the adjacent nail
+fold. In calloused nail groove, nothing of this nature has occurred and
+it is the maltreatment of cases of this kind that usually leads to true
+cases of ingrown nail.
+
+=Definition.= A calloused nail groove is a condition in which a
+localized heloma (sometimes several disseminated helomata), or a
+general calloused condition has developed in a lateral nail groove.
+
+=Symptoms.= _Subjective symptoms_: excruciating pain on the slightest
+pressure, heat, and throbbing in severe and neglected cases.
+
+_Objective symptoms_: swelling, usually localized in the nail fold
+involved; redness and general inflammatory condition; upon close
+examination the heloma or the callous is easily demonstrated in the
+fold by reason of its unyielding qualities.
+
+=Etiology.= This condition may be caused by irritation of the tender
+tissues of the nail fold brought on by persons who persist and delight
+in “digging” about the edges of the nail with some instrument. In most
+instances, however, a short or narrow shoe or stocking will cause
+sufficient pressure of the edge of the nail upon the tissues of the
+groove to cause nature to provide a protection which tends to prevent
+the nail from piercing these softer tissues; the protection appears in
+the form of callous. This callous will appear as a hard development
+throughout the whole nail groove, and we find those tissues to be
+unyielding and to have lost nearly if not all of the pinkish tint
+which the great amount of vascularity underneath normally gives to the
+tissues about the nail. The color is yellowish or sometimes greyish
+white. Where a distinct heloma is present, it may be found covered by a
+thin sheet of callous which covers some part of the groove, or it may
+be distinctly independent and isolated from any such development. When
+this latter condition is met, the heloma will usually be found to be
+circumscribed, its edges regular and its shape circular. These latter
+instances are not so common as the general callousing of the entire
+groove. Where the helomata are found disseminated, they will usually
+occur on the inside of the flap next the nail, although in some cases
+they will be found under the edge of the nail itself. In these first
+mentioned instances the pain will be greatest upon lateral pressure and
+in the latter upon dorsal or plantar pressure.
+
+=Treatment.= Various methods of treatment are employed for the
+alleviation or cure of this painful ailment. They may be divided, for
+discussion, into two general classes: surgical and medical.
+
+=Surgical Treatment.= This method consists in removing the callous or
+the heloma by means of a fine-pointed scalpel or a small curette. The
+nail groove is first well softened by the application of small pledgets
+of cotton saturated with warm water, or by the use of some epidermic
+solvent such as liquor potassae, after which the parts are dried and
+the operation is begun. With a sterile nail chisel sufficient of the
+edge of the nail is cut away so that the heloma or the callous is
+exposed. This not only gives the patient instant relief but also allows
+room for the operation and the subsequent dressing.
+
+With a pointed scalpel or bistoury, the growths are removed, much in
+the same manner as helomata in any location might be treated. If the
+calloused condition be general throughout the groove, a small curette
+is used and the callous is loosened from the anterior end of the fold
+and stripped backward toward the root of the nail.
+
+The subsequent treatment consists in applying an ointment, such as
+ammoniated mercury (5%), and packing the nail groove with sterile
+gauze. Should the operator prefer a liquid, the gauze packing may be
+saturated with bichloride of mercury, ¹⁄₅₀₀₀, or boric acid, saturated
+solution; but it will be generally found that the ointment is more
+effective in reducing the inflammatory symptoms present and also any
+irritation which may have been caused during the operation.
+
+Whilst this operation is being constantly performed and seems to be
+generally in vogue, much more satisfactory results are obtainable from
+local medical applications.
+
+In the first place, in using a scalpel or curette in the nail fold,
+the operator must be very skillful in order not to cause a hemorrhage
+and subsequently a tender digit. In many instances, no matter how
+skillful the operator, or how much care be exercised in the operation,
+it will be found a practical impossibility to strip the callous from
+a nail groove without capillary rupture. This latter, of course, is
+undesirable and usually, no matter how the lesion is dressed, the
+groove remains tender for days.
+
+In some cases the small helomata found in the nail fold should at
+once be at least partly removed, to give the patient relief. This may
+be done with a fine-pointed scalpel and local treatment may then be
+applied.
+
+=Medical Treatment.= There are two methods of medical treatment
+employed. One finds its efficacy in the use of salicylic acid as an
+epidermic disintegrant, and the other in the application of liquor
+potassae (potass. hydrox. 5%) as a cuticle solvent.
+
+_Salicylic Acid._ After a sufficient portion of the nail has been
+removed to give relief to the patient, the nail fold is thoroughly
+cleansed and dried and the following ointment applied in the groove:
+
+  Acidi salicylici          8.00
+  Camphorae
+  Chloral            aa     0.30
+  Ceratum                  30.00
+  M. ft. unguentum
+
+After a week or ten days has elapsed, the whole calloused area will be
+found to be entirely disintegrated and may be easily removed with a
+fine-pointed excavator. The groove is then packed with either gauze or
+cotton, and an appropriate ointment or solution is applied to alleviate
+the inflammatory condition.
+
+The treatment with salicylic acid is easily combined with the surgical
+treatment, if it be found necessary to remove a portion of the corneous
+formation in order to afford relief to the patient.
+
+In some cases it will be found efficacious, after the callous has been
+removed by means of the salicylic ointment, to apply silver nitrate
+(50%) to the groove. This will reduce the inflammatory conditions and
+at the same time act as an astringent to the underlying capillaries and
+as a sedative to the inflamed tissues. The alternate weekly use of the
+ointment and the silver salt is advocated, and gratifying results are
+usually obtained from this treatment in cases where it can be used.
+
+_Liquor Potassae._ Potassium hydroxide solution is most generally used
+in cases where the callous is general in the nail fold rather than
+where there is simply a localized heloma.
+
+An applicator is saturated in the solution and rubbed over the
+calloused area until the mass is softened, when it may be easily
+removed. While this mode of treatment is a popular one it has been
+the experience of many practitioners that the liquor potassae
+merely softens the calloused condition, failing to disintegrate it
+entirely, and allows the parts to harden, directly the application is
+discontinued. Joseph Renk, a well known New York practitioner, reports
+the best of results from this treatment, when carefully used.
+
+No doubt there are good features in both treatments and a wise
+practitioner, utilizing both, will adopt that from which he obtains the
+best results.
+
+In no instance should the nail fold be packed tightly in these cases.
+The operator should remember that if he removes a sliver of nail
+one-sixteenth of an inch in width and then packs the resultant space
+with a pledget of cotton, gauze or lamb’s wool one-eighth of an inch
+in thickness, he will cause more pressure to be brought to bear on the
+parts than there was originally present; this is, of course, to be
+avoided under all circumstances.
+
+On the other hand it must be remembered that sufficient packing should
+be used to retain the normal line of the nail fold and to keep these
+softer tissues in the proper place. Under no circumstances should they
+be allowed to crowd up and over the nail, for if this does take place
+we are merely setting the stage for a possible ingrown nail. Jack
+Grossman, M.Cp., makes this a strong point in his talks to the students
+of The First Institute of Podiatry.
+
+
+
+
+CHAPTER XIV
+
+ONYCHOCRYPTOSIS OR INGROWN TOE NAIL
+
+
+=Definition.= Onychocryptosis, or ingrowing or ingrown toe nail,
+is a condition in which the lateral edge of a nail has penetrated
+through the epidermic layers and has become imbedded in the adjacent
+or subjacent soft parts of the lateral nail groove. This abnormal
+condition gives rise to a number of complications, viz: simple
+inflammation, ulceration, circumscribed or diffused cellulitis
+and the formation of proud flesh. These may occur singly or as is
+commonly found, the last three in unison. The unclean condition of
+people’s footgear, the general unsanitary conditions of the foot, or
+maltreatment of ingrown nail in its incipiency, often give rise to
+the still graver septic complications which ultimate in a general
+septicemia.
+
+A nail then to be classed as an ingrowing nail must be specifically
+ingrowing. Mention is made of this fact, which many in their wisdom may
+deem superfluous, because so many conditions of callous or helomata in
+the nail groove are mistaken for ingrowing nail and their treatment
+as such is not only useless, so far as a cure is concerned, but is
+decidedly detrimental to the comfort of the patient and to the future
+general condition of the nail involved.
+
+=Etiology.= A large percentage, perhaps larger than most people
+imagine, of ingrown nails arise from the injudicious cutting of the
+part by an inexperienced person. Directly after an amateur operation
+upon a painful nail, acute symptoms of ingrowing nail do not
+necessarily develop--although it does happen in many cases; but the
+etiology of a great number of acute and well defined cases of ingrown
+nail, as stated, can be traced primarily to self-inflicted nail injury
+at some previous time.
+
+The changes taking place in the nail and in the tissues of the nail
+groove after the removal of the lateral border of the nail, are
+pronounced. Take, for example, the great toe nail, as this is the most
+easily studied on account of its size and at the same time is the most
+general seat of troubles of this nature.
+
+The nails are placed on the dorsal surfaces of the toes as a means of
+protection to the expanded extremities of the distal phalanges. Perhaps
+the Divine Providence in moulding his masterpiece, man, foresaw the
+advent of modern footgear and realizing its baneful effect upon the
+human extremity, developed upon the great toe a heavy nail from which a
+great deal of protection for the more tender tissues beneath might be
+obtained. At any rate, the great toe nail today bears the brunt of the
+pressure from our leather footgear and for that reason is probably the
+seat of so many painful afflictions.
+
+The free edge of the normal great toe nail is found to be more
+flattened and expanded than the posterior portions of the nail nearer
+its root. This flattened expansion holds the softer tissues of the end
+of the toe and of the lateral border of the nail groove in place under
+the nail and also prevents them, if allowed to remain untouched, from
+crowding up or around the nail at any quarter. But allow the free edge
+and the lateral border of the nail to be removed, and particularly
+by inexperienced hands--and observe what takes place. These softer
+tissues which were normally held in place by the free borders of the
+nail, fill up the spaces left by the removal of the nail borders. Even
+this condition, were the nail to remain stationary and cease to grow,
+would not be conducive to great pain or inconvenience. But the nail is
+being continually pushed forward by the formation of new cells at its
+posterior extremity. This is embedded in the posterior nail fold, and
+when the newly formed portion of the same width as originally found
+arrives at the point where the softer tissues are crowded up and into
+the space left by the removal of the borders of the nail, instead of
+growing over them and forcing them back into their normal position, it
+finds this impossible, and grows into them.
+
+From the foregoing we are not to take it for granted that all cases
+occur from injudicious cutting of the nail’s lateral borders. Short
+and tight shoes and hose are in some cases the exciting causes of
+ingrowing nails and, from observation, we are led to believe that
+while the actual ingrowing nail is not hereditary, nevertheless the
+predisposition toward nail inversion is manifest through an entire
+family or even through a generation.
+
+In the case of tight footgear or hosiery, the cause is the crowding
+of the great toe against its neighbor, forcing the softer tissues of
+the nail groove and flap to be crowded against the lateral edge of the
+nail. In these cases the principal site of occurrence will naturally
+be the outer sides of the great toe; in fact, in most cases, this
+groove will be found to be the most general site of occurrence. The
+soft tissues of the nail flap being crowded over and around the nail’s
+lateral edge, there naturally follows an irritation in the groove,
+caused by the nail rubbing upon these tissues which, in time no doubt
+leads to ulceration of the parts with the accompanying inflammatory
+symptoms.
+
+Uric acid diathesis may in one sense be said to be the cause of some
+cases of ingrown nail in that when patients so suffer, the nails
+are prone to chip off at the edges leaving the latter ragged and
+so allowing a chance for irritation from the saw-like projections,
+ultimating in an ulcerated condition of the wounded parts.
+
+=Complications.= Other than the general inflammatory conditions
+brought about in connection with the ulceration caused by the edge of
+the nail penetrating the softer tissues, proud flesh is probably the
+complication most generally met with in these cases.
+
+Proud flesh, thus produced, is due undoubtedly to the constant
+irritation of the nail upon the exposed surfaces of ulcerated area.
+It forms in many shapes and the mass developed depends largely upon
+the length of time the condition is allowed to progress without proper
+treatment. The excess growth is usually found covering the whole
+exposed area, or only forming in a teat-like prominence with a small
+circumscribed base and expanded extremity. The pain to the patient is
+undoubtedly augmented by the presence of proud flesh and the discharge
+from the ulcerated areas is thereby increased. Hemorrhage from the
+movement of the toe in walking is prone to occur and the general
+unwholesomeness of the part is thus exaggerated.
+
+In some cases the production of these exuberant granulations takes
+place under the body of the nail as well as in the groove or on the
+flap and they are not clearly discernible until the imbedded portion of
+the nail is removed, when they will be seen to crowd upward into view.
+
+Any open wound upon the surfaces of the foot is very liable to septic
+infection. Regardless of the cleanly care one may give his feet and
+regardless of the washing of hose, infection will still take place,
+and only naturally so. The feet are coming constantly in contact with
+septic surfaces and the inside of a shoe presents large areas for the
+resting place of countless microorganisms in that it combines the three
+elements which are best suited for the growth of bacteria, viz: heat,
+moisture and darkness.
+
+Ingrown nails are even more prone to infection than is a lesion in
+connection with an heloma or a fissured toe web, and in many instances
+where cases have been allowed to run for some time before the surgeon
+or podiatrist is called into consultation, infection has already
+occurred.
+
+In connection with septic cases, abscess cavities are often found
+immediately in the nail groove, under the body of the nail itself or
+with a suppurative sinus burrowing backward under the posterior nail
+fold and involving the whole of the matrix in an acute suppurative
+process. In exaggerated cases, the cellulitis may be diffused
+throughout the whole digital region. However, these cases are rare, as
+walking has become well-nigh impossible long before this takes place
+and the patient will have been under scientific treatment before the
+case has reached such proportions.
+
+=Treatment.= From the standpoint of the podiatrist, there are two
+distinct methods of operative technic in ingrown nail cases, the
+radical and the palliative. They differ as to the exact technic of the
+removal of the ingrown portion, but agree on practically all other
+points.
+
+In that but for the first part of the operation these two methods
+are similar, they will be discussed separately as to that alone, and
+the post-operative procedures and dressing of both will be combined
+into one general discussion. Under each heading the treatment of the
+surrounding tissues is mentioned, but the reader is referred to the
+heading “Prophylaxis” for a thorough and comprehensive discussion of
+the various procedures necessary to their proper care.
+
+=Asepsis.= Proper aseptic precautions must be observed in all lesions
+and particularly so with ingrown nail cases. As has already been
+stated, conditions of this nature are prone to infection because the
+surfaces and recesses or the nail groove present excellent lodgment for
+bacteria, and this point should always be borne in mind.
+
+The parts should first be thoroughly cleansed with ether. This removes
+all greasy or oily matter from the field of operation and allows the
+antiseptic solutions subsequently used to come in direct contact with
+the affected surfaces.
+
+Some effective antiseptic should then be used as a spray to prevent the
+washing in of bacteria from the surrounding parts. There are a number
+of solutions which are useful for this purpose; liq. zinci et alumini
+compositus, N.F., and liq. zinci et ferri compositus, N.F., are both
+highly recommended. Liq. cresolis compositus may also be used with
+excellent results, although it carries the somewhat disagreeable odor
+of the cresols. These solutions are all active in strengths ranging
+from two to five per cent.
+
+Iodine is unquestionably the best antiseptic that can be applied to the
+field of operation, but as its discoloration of the tissues prevents
+the operator from visually observing geographic points he may need for
+further diagnosis, and as this drug also acts as a corrosive to metal
+instruments, it is found advisable in many instances to refrain from
+its use.
+
+As a substitute for iodine, alcohol is the next most efficient
+germicide. Sixty per cent. strength is recommended, as in that
+proportion it has greater penetrative and antiseptic value than the
+stronger solutions.
+
+The alcohol, applied by means of a cotton wound applicator, is rubbed
+into the parts, or a pledget of sterile cotton or gauze, saturated in
+the solution, may be applied over the field and allowed to remain for
+two or three minutes prior to operation.
+
+When the operator has followed the foregoing, or a similar line of
+procedure, the removal of the ingrown portion of nail may be begun.
+For simplicity’s sake, the methods of treatment will be discussed,
+beginning with the uncomplicated case, and the various complications
+will be considered under separate headings.
+
+
+UNCOMPLICATED CASES
+
+=Removal of the Ingrown Portion.= Having obtained thorough asepsis of
+the affected and surrounding areas, the operator by means of a small,
+blunt sterile probe, should endeavor to locate the exact position and
+size of the ingrown portion of nail, which should then be removed by
+means of a sterile nail chisel.
+
+=The Nail Chisel.= This instrument is a narrow steel blade set in a
+long or short handle, as the operator desires, the operating end of
+which is slightly oblique so that, upon direct pressure, the blade cuts
+in a diagonal manner. This is for the purpose of minimizing the danger
+of penetration into the nail bed. In the radical operation a broader
+and heavier chisel is sometimes used so that the softer tissues may be
+included in the incision.
+
+=The Radical Method.= Proper antiseptic precautions having been
+taken, the circulation is cut off at the base of the toe by the
+application of a tourniquet. Under local anesthesia, induced preferably
+by the hypodermatic injection of novocaine, 1%, the nail is split
+longitudinally to the root with an ingrown nail chisel, care being
+taken not to split the nail at or near its centre--a procedure
+practised by some surgeons. When the nail has been cut through the
+root, the free portion is grasped with an artery forceps and is lifted
+out of the nail groove. It is often necessary to dissect the nail from
+adhesions which have formed.
+
+The proud flesh, should any be present, is now snipped off with a pair
+of curved scissors and if necessary a portion of the enlarged nail flap
+is also included in the cut. The soft tissues should be cut so that the
+structure remaining appears normal in size.
+
+The nail matrix is thoroughly curetted over its entire exposed area,
+as is the nail bed along its whole surface to the distal end. This
+procedure must be thorough to insure against recurrence. Bleeding is of
+a capillary type and is easily controlled by digital pressure.
+
+=The Palliative Method.= With a sterile nail clipper, a small cut is
+made on the affected side in the free edge of the nail. The chisel is
+then placed in this notch and gentle yet firm pressure is exerted so
+that the instrument cuts through and splits the nail.
+
+The cut made is in the shape of an arc, following as nearly as possible
+the normal line of the lateral edge of the nail. The broadest part of
+the arc is at the anterior or free edge of the nail, gradually reducing
+the width of the piece to be removed until the lateral edge is reached.
+In this way a clean sweeping cut is made which does not invade and
+consequently does not irritate the tissues about the nail root.
+
+The palliative method of operative technic in ingrown nail cases is
+based on the theory that the condition is not one of a misdirected
+growth of the nail, but rather a case of the soft tissues adjacent to
+the nail crowding up, around and over the nail proper; and that the
+nail body as it pushes continually forward, cannot force this mass back
+into its normal position and, of necessity, must grow into it.
+
+There is no lateral hypertrophy of the nail nor does it present any
+misdirected growth.
+
+[Illustration: ONYCHOCRYPTOSIS (SUPPURATING)]
+
+Keeping this theory in mind, it would seem unnecessary and poor
+surgery to remove the portions of the matrix of the nail from which
+the affected side develops when in reality it is not the nail that is
+at fault but rather the soft tissues adjacent to it; and the ingrowing
+of the nail body is purely secondary to the displacement of these soft
+tissues. As ever in surgery, however, it remains a matter of judgment
+as to which operation should be done so as to obtain the best results.
+When the palliative methods fail to be effective, the radical operation
+is permissible--never the reverse.
+
+The palliative method has for its object the removal of the portion of
+nail whose irritant free border is embedded in the tissues and, this
+accomplished, to treat these softer tissues in such a manner that they
+will become normal as to position and all else. By such a manner and
+method of treatment, sufficient space is obtained at its lateral edge
+for the nail to grow to its full width and in time to become perfectly
+normal as to appearance, function and feeling.
+
+The straight nail chisel, in most instances, can be used, but where
+the ingrown portion of nail is deeply embedded, a right or left curved
+chisel can be substituted with greater success. The curve in this
+variety of chisel aids the operator in lifting the nail out of its bed,
+while at the same time the cutting process is not hindered.
+
+=Dressing.= Following the removal of the offending portion of nail, the
+operator should make sure that no nail slivers, previously existing
+or of his own making, remain in the nail fold. Assured of this, the
+parts should then be thoroughly irrigated either with alcohol, 60%, or
+mercuric chloride, ¹⁄₄₀₀₀. Hydrogen peroxide may be used as an irrigant
+where pus is present, but it should not be depended upon as a germicide
+as its action is very transient and superficial. A final dressing is
+then put in place.
+
+There seems to be a wide diversity of opinion as to what constitutes
+a proper dressing after the nail has been removed. Whatever else
+individual experience may show to be useful, the dressing should be
+one embodying antiseptic, astringent and healing properties. The
+antiseptic, surely regardless of what other action is to be desired;
+the astringent, so that inflammatory symptoms may be speedily combated
+and the ulcerated areas contracted; and the healing so that granulation
+may be the more speedily promoted.
+
+Three forms of dressings may be classified: the wet; the dry; the
+ointment.
+
+=The Wet Dressing.= The nail groove is packed with a small piece of
+sterile gauze. Care should be exercised that a thin fold of the gauze
+be placed under the edge of the nail between it and the tissues into
+which the ingrown portion of nail was embedded. A piece of sterile
+gauze, of about three or four thicknesses and about two inches square,
+is then placed over the affected fold of the nail, covering the
+inflamed area and extending over the nail itself. This pledget is then
+saturated with a solution of the operator’s choosing to meet the needs
+of the case under treatment. Two solutions seem to be favored above all
+others in this connection: mercuric chloride, ¹⁄₅₀₀₀, or weaker, and
+liq. aluminum acetate. The latter solution is at most times preferable,
+as it possesses antiseptic qualities (nearly, if not equal to corrosive
+sublimate without exhibiting the toxic properties of the latter) and
+produces an astringent and antiphlogistic action on the tissues. Strong
+germicidal solutions such as the mercuric chloride are at times found
+to be decidedly detrimental, in that they not alone cause maceration
+and desquamation of the skin, but in some instances, if too strong,
+they destroy the newly formed connective tissue granules.
+
+The gauze square which covers the whole end of the toe, and which is
+saturated with either solution just described, is held in place by a
+roller bandage or by adhesive strips.
+
+The usual method of applying these strips is to place one on each side
+of the gauze square, adhering them over the end of the toe and to and
+on the skin, and one over the centre of the dressing, carrying it over
+the end and down to and on the plantar surface of the toe. A circular
+strip is then carried around the toe, over the posterior end of the
+dressing, thus binding down the ends of the three strips previously
+applied.
+
+No impervious covering such as gutta percha, oiled silk, etc., should
+be used in this instance, or, in fact, in any condition where the skin
+is broken. The warmth and moisture produced by such a covering is
+congenial to the growth and development of hostile bacteria.
+
+The wet dressing, then, should be left uncovered so that evaporation
+may take place and a quantity of the solution used should be
+prescribed for the patient, so that the dressing may be moistened with
+it from time to time. The dressing without impervious covering is
+antiseptic and heat reducing because of the evaporation and frequent
+replenishment of the solution.
+
+=The Dry Dressing.= Dry dressings in this sense consist in the
+application either of plain, dry, sterile gauze packed in the nail
+groove and unmoistened, or dusting the affected parts with some
+antiseptic powder to maintain asepsis in the wound and to bring about
+normal granulation.
+
+Of these two forms of dry dressing, that constituted by the plain dry
+gauze is productive of better results than are obtained by the dusting
+powders. A lesion caused by the nail penetrating the soft tissues of
+the nail fold, in the process of healing, necessarily discharges a
+certain amount of waste material produced in the tissue repair. In
+consequence, where a dusting powder is used, the serous discharge at
+times combines with the particles of the powder to form a crust which,
+in the confined areas of the nail groove, often becomes equally as
+irritating as was the ingrown nail itself.
+
+However, in some instances dusting powders may be used with impunity
+and many practitioners favor and report success in their use.
+
+Aristol (thymol iodide), dermatol (bismuth subgallate), bismuth
+subnitrate and boric acid (powder), preferably the first two named,
+may all be safely used in the treatment of ingrown nail cases. Aristol
+depends upon the liberation of iodine for its antiseptic action while
+the two bismuth salts, the subgallate and the subnitrate, combine
+marked astringent properties with their antiseptic qualities.
+
+After the powder is dusted into the affected groove, a thin layer of
+sterile gauze is packed lightly under the lateral edge of the nail and
+a cocoon dressing is placed over the whole.
+
+This form of dressing is applied until resolution of the inflammatory
+process and granulation of the wound has taken place.
+
+=The Ointment Dressing.= All ointments are necessarily of fatty or
+oily consistency and, in consequence, when applied over a surface
+excreting a serous discharge, are liable to confine this discharge
+to the affected areas rather than allow it to be absorbed by the
+gauze dressing, and so drain the wound. For this reason the use of
+ointments on discharging surfaces is not particularly recommended. Many
+practitioners use them, however, and presumably with beneficial results.
+
+Two classes of ointments may be used in this connection: antiseptic and
+stimulating. Under these headings the following are suggested: sulphur,
+10% (vaseline or lanolin base); ammoniated mercury (white precipitate),
+5%; balsam of Peru, 10%; scarlet red (medicinal Biebrich), 4%.
+
+The ointment is placed in the nail groove by means of a spatula, and
+sterile gauze is packed lightly under the nail, holding the ointment in
+place. This is covered with a cocoon dressing and is renewed until the
+parts regain their normal condition.
+
+
+COMPLICATED CASES
+
+=Proud Flesh.= The development of unhealthy, exuberant granulations is
+a common occurrence in connection with ingrown nail cases, especially
+when they have been allowed to progress before proper treatment has
+been inaugurated.
+
+In all cases the primary steps in the treatment are essentially similar
+to those described under “uncomplicated cases.” Proper asepsis and
+antisepsis are at all times to be strictly observed, and any ingrown
+portion of nail should in all cases be first removed before additional
+treatment is administered.
+
+The speedy and complete removal of the unhealthy granulations is at
+all times essential. This may be accomplished either by excision, by
+the actual cautery or by the use of escharotics. The operator must
+always remember that the presence of proud flesh in a wound not alone
+retards the normal healing process, but also prevents the wound from
+healing without the formation of an abnormal amount of new tissue. If,
+for instance, a mass of proud flesh the size of a pea were present
+in connection with an ingrown nail and allowed to remain without
+further treatment, the tissue would in time present a perfectly normal
+appearance. That is, the exuberant granules would sooner or later
+develop an epithelial covering which would be of like appearance to the
+normal surface of the skin. But in doing so, the tissues would still
+retain the shape and size of the original mass of exuberant granules
+and we would find a teat of tissue, the size of a pea, jutting out of
+the normal surface of the nail groove.
+
+Keeping in mind, then, that to obtain a speedy and normal healing
+action in a wound the proud flesh present must be eradicated, it should
+appeal to the operator that the quickest means for its removal must be
+the best. Two quick and complete methods for obtaining this desired
+result are found in (1), excision (by the use of the scalpel or curved
+scissors), and in (2), the actual cautery.
+
+[Illustration: BEGINNING INGROWN TOE NAIL]
+
+=Excision.= Excision of the proud flesh cannot be resorted to in all
+cases, but in most cases at least the larger portion of the exuberant
+granulations can be removed in this manner.
+
+The condition in which the use of the curved scissors is particularly
+advocated as most efficient is that in which the mass of proud flesh
+is found in pendulous form, where its base is narrow and covers but
+a small area and where the mass expands into an enlarged extremity.
+In cases where the proud flesh is found generally throughout the nail
+groove, and in some instances under the lateral edge of the nail
+itself, the scissors or scalpel cannot be used with good effect, if at
+all. Then of course other means must be employed.
+
+=Method of Procedure.= After the field of operation has been thoroughly
+sterilized and the ingrown portion of the nail has been located and
+removed, the exact situation and amount of proud flesh is ascertained.
+If at all practical, a sterile scissors (preferably of the curved
+variety) is inserted under the granulating mass and the whole is
+quickly snipped off at its junction with the normal integument. Where
+the mass is considerable, it will be found advisable to ligate the toe
+at its base by means of a few tight turns of adhesive tape or by the
+use of a rubber ligature. This precaution will lessen the resulting
+hemorrhage and it can be more readily controlled.
+
+Where the amount of proud flesh to be excised is small, the blood flow
+is easily arrested by digital pressure.
+
+It will generally be found conducive to the best results to anesthetize
+the parts by hypodermatic injections of novocaine or by means of the
+ethyl chloride spray. This is not necessary in every instance, however,
+as the advisability of producing anesthesia depends upon the amount of
+tissue involved and the nervous condition of the patient.
+
+After the exuberant granulations have been cut off, Monsel’s solution,
+adrenalin chloride or some other styptic is applied to the bleeding
+capillaries.
+
+It may be found advisable to apply silver nitrate, 50%, or even nitric
+acid, c.p., to the bleeding parts. This serves not alone to check
+the hemorrhage, but the escharotic action tends to destroy whatever
+remaining shreds of the proud flesh may still be present.
+
+The oozing arrested, the ligature is removed. The nail groove is packed
+firmly with sterile gauze (firmly, so as to further check the vascular
+supply to the parts) and a wet dressing of liq. aluminum acetate is
+applied. In the event of no further recurrence of the proud flesh,
+the case is treated in any of the ways described under “uncomplicated
+cases.”
+
+=The Actual Cautery.= The electric cautery presents a quick and sure
+means by which proud flesh may be destroyed. Local anesthesia should
+first be induced by means of a hypodermatic injection of novocaine,
+1%, or by use of a freezing spray, such as ethyl chloride. In most
+instances the use of the ethyl chloride will be found sufficient
+for the needs of the case although its anesthetic effect is quite
+superficial and transient. Novocaine, on the contrary, is both lasting
+and complete in its effect.
+
+The argument against the use of the actual cautery is one of humaneness
+rather than one of science. Regardless of the lack of sensation
+produced by the anesthetic, patients will rebel at the sight of a white
+hot cautery. The mental shock of seeing one’s flesh seared by a hot
+iron is pronounced, and at the present time no podiatrist can take
+liberties with the patient’s feelings as does the surgeon, without
+jeopardizing his reputation and diminishing his clientele. On the other
+hand, while the mental anguish of the patient may be greater during the
+use of the actual cautery, the subsequent suffering is much less than
+that following the application of an escharotic.
+
+After the use of the cautery, a wet dressing of liq. aluminum acetate
+or a solution of boric acid and alcohol, equal parts, may be applied
+and renewed until all acute inflammatory symptoms have subsided when a
+dressing may be employed to hasten granulation.
+
+=Escharotics.= The use of caustics for the destruction of proud flesh
+is probably the most generally used method in vogue today. Nitric acid,
+caustic potash and silver nitrate, either in fused or in solution form,
+may all be used in most every instance.
+
+Inability for any reason to resort to the use of a curved scissors,
+the scalpel, or the cautery compels us to look among the caustics
+for an agent to accomplish the desired results. Keeping in mind the
+aforementioned fact, that the quickest means for proud flesh removal or
+destruction is the best, we naturally lean toward the strong corrosives
+as a means to bring about this end.
+
+=Nitric Acid.= Nitric acid (aqua fortis), in all probability, is the
+most efficient member of this class of drugs, as its action is both
+energetic and penetrating. In cases where the exuberant granulations
+are found involving the entire nail fold and in no particular localized
+area, aqua fortis is found very useful. Usually one application is
+sufficient to destroy all vestige of the unhealthy tissue, but in
+extreme cases added treatment may be necessary.
+
+Care is taken to cover the surrounding healthy integument with some
+greasy substance (vaseline is generally preferred) to prevent the acid
+from coming in contact with it and avoiding the consequent bad effects.
+The acid is then applied by means of a cotton wound applicator (wooden
+applicators are preferred, as they are inexpensive and may be thrown
+away after being used) or a glass rod. The nail groove should be firmly
+packed with sterile gauze and a wet dressing of liq. aluminum acetate
+or of bichloride of mercury, ¹⁄₅₀₀₀, or a boric acid and alcohol
+solution, equal parts, should be applied over the affected parts. At
+the next examination, any remaining shreds of the unhealthy granulation
+are to be looked for and, if found, another but lighter application of
+the acid should be applied. It is wise to remove the eschar caused by
+the previous application so that deeper penetration and more efficient
+action from the drug may be obtained.
+
+This is continued until all remnants of the proud flesh are destroyed,
+when the toe should be dressed to induce speedy and healthy granulation.
+
+=Caustic Potash.= Potassium hydroxide (caustic potash) may be used
+in place of nitric acid for the destruction of proud flesh. The
+preference for the latter seems to be due to the fact that wound’s
+caused by the action of nitric acid are prone to heal more rapidly than
+those due to the use of caustic potash; also because the action of aqua
+fortis can be more readily counteracted should the need for such action
+arise.
+
+Caustic potash should be used with care, the same precautions to
+protect the healthy tissue being taken as in the use of nitric acid.
+Apply caustic potash on a small cotton wound applicator, packing the
+nail fold with sterile gauze to be followed by a moist dressing of liq.
+aluminum acetate.
+
+=Silver Nitrate.= The use of the silver stick or a strong solution of
+the salt to destroy any great amount of proud flesh is not advocated.
+In the first place the caustic action of silver nitrate is due solely
+to the nitric acid generated by its use, and so the aqua fortis
+should be used to obtain a speedier and more energetic removal of
+the unhealthy tissue. Secondly, silver nitrate coming in contact
+with the albuminous tissue, decomposes, oxidizing it and forming a
+metallic deposit on the surface which becomes an impermeable eschar.
+This hard crust not alone prevents the silver salt from penetrating
+into the tissues--the action of silver nitrate is thus called
+“self-limiting”--but also being unyielding, acts as a direct irritant
+to the denuded tissues.
+
+Silver nitrate is, however, particularly efficacious after the great
+amount of the proud flesh has been removed by means of excision; in
+this situation it acts as a styptic to arrest the capillary flow of the
+bleeding stump, and as a mild caustic to destroy the remaining shreds
+of the unhealthy granulation. It is also a beneficial application for
+hardening the tissues of the nail fold to prevent further recurrence
+of the ingrowing nail. This subject will be fully discussed under
+“Prophylaxis.” After excision of the proud flesh, silver nitrate should
+be used in solution of fifty per cent. and the toe dressed as has been
+previously described.
+
+=Burnt Alum.= Burnt alum is still another remedy used in podiatry for
+the destruction of proud flesh. Its use is not now favored for that
+direct purpose, but there are some situations in connection with the
+treatment of the condition in which it may be used with good results.
+It is the least energetic of all the escharotics herein mentioned,
+and many prefer to class it rather as an astringent. The burnt alum
+is dusted in the nail groove directly on the mass of proud flesh and
+the groove is then packed with sterile gauze. Because of its extremely
+mild action, comparatively speaking, burnt alum will not accomplish its
+work of destruction with the rapidity nor the completeness of the other
+mentioned drugs; moreover it causes considerable irritation and pain to
+the patient. The modern practitioner is inclined to relegate this drug,
+as a caustic, to the shelf, to be used only in cases where a strong
+astringent action is desired.
+
+=Liquor Ferri Subsulphate.= Monsel’s solution has been used to dry up
+unhealthy granulations because of its astringent action rather than on
+account of its caustic properties.
+
+=Treatment of Acute Infective Inflammations.= Infection is in all
+probability more generally met with in connection with ingrown nail
+cases than in any other ailment primarily occurring on the foot. The
+state in which the toe may be found is dependent upon the length of
+time the case has progressed without proper treatment. Cellulitis may
+be circumscribed or diffused, and lymphangitis, both of the reticular
+or tubular variety, may be present.
+
+Following the usual antiseptic and aseptic precautions relative to the
+field of operation, the operator’s hands and the instruments, drainage
+of the suppurated areas must first be obtained.
+
+In the average case, an abscess cavity is usually found in or adjacent
+to the lateral nail fold, and in many instances the pus sac will be
+punctured during the removal of the ingrown portion of the nail. It
+is sometimes found necessary to remove an overlying portion of nail,
+other than the ingrown portion, to give free access to the suppurating
+process and to afford drainage for its purulent discharge. A sterile
+chisel of the straight variety is generally used to accomplish the
+removal of the ingrown portion of nail, care being taken that the
+cutting edge is inserted deep enough to penetrate only the nail and not
+to pierce the underlying soft parts.
+
+Some practitioners do not advocate the removal of portions of the
+nail and prefer rather merely to drill a hole through the nail body
+and excavate the pus through this channel. No doubt circumstances
+alter cases, but the writer would prefer having the septic tract
+wholly exposed so that thorough irrigation and proper treatment may be
+accomplished.
+
+Having given free drainage to the pus cavities, the parts should again
+be sprayed with alcohol, 60%. Hydrogen peroxide, which manifests its
+greatest efficacy in pus cases, should then be freely applied until
+ebullition ceases.
+
+In cases where the sinus is small and deep and an ordinary cotton wound
+applicator is too large for insertion into its recesses, a wooden
+applicator tipped with iodine (these applicators already prepared are
+now on the market) will be found fine enough for this accomplishment.
+
+There is also on the market a fine, hollow, flexible needle, with
+a bulbous extremity in which there is an opening, that fits any
+hypodermic syringe. Two or three drops of iodine are drawn into the
+barrel, the needle is inserted into the sinus, and its contents are
+evacuated by piston pressure. This enables the operator to get the
+drug down into the sinus so that it comes into direct contact with its
+deepest surfaces. This needle is made of a non-corrosive metal.
+
+The next point to be considered is the form of dressing to be used.
+If the case has progressed to a point where the operator feels the
+necessity of a surgeon’s advice, the latter should by all means be
+called in as a consultant. The writer feels, however, that in most
+instances the modern practitioner of podiatry is well equipped to
+successfully treat even severe cases of this nature.
+
+The affected nail groove is packed with sterile gauze and a large
+piece of the fabric, of several thicknesses, is placed over the whole
+inflamed area. This is saturated with a solution of mercuric chloride,
+¹⁄₅₀₀₀, and is remoistened at intervals by the patient so that it is
+constantly wet. In some cases it may be wise to have the patient remain
+in the office several hours to make sure that the infected parts are
+kept constantly immersed in a solution of mercuric chloride, ¹⁄₅₀₀₀.
+This treatment has been found to be extremely beneficial in reducing
+the inflammation so that a moist evaporating dressing, as described
+above, may be safely applied. Rest is another feature to be employed
+in the treatment of these cases. The patient should be instructed to
+refrain absolutely from the use of the affected parts until such time
+when the inflammatory conditions have subsided or are under control.
+The podiatry patient as a rule is loathe to have his or her energies
+in any way curtailed, but the mention of “blood poisoning” is usually
+sufficient stimulus to send the patient to bed when so ordered.
+
+=Prognosis.= The prognosis in all cases of ingrown nail under proper
+treatment is favorable. The length of time elapsing before a cure is
+affected is of course dependent upon the condition of the toe and the
+general condition of the patient.
+
+In cases where the nail penetration is slight, and the inflammatory
+conditions are in their incipiency, one or at most two treatments will
+be sufficient to heal the ulceration and to restore the toe to its
+normal condition. Complicated cases necessarily take longer to relieve
+and longer to cure.
+
+The surgeon is still rather reluctant to believe that an ingrown
+nail can be cured without removal of the affected half of the nail,
+the lateral nail fold, and a portion of the matrix. This method of
+procedure in nearly every instance incapacitates the patient for fully
+two weeks and it is doubtful whether anything is gained (taking all
+matters into consideration) over the methods of ingrown nail treatment
+as here outlined.
+
+The surgical argument is based on the contention that unless the matrix
+underlying the affected nail be removed, the nail will again grow into
+the tissues. This is unquestionably so, but in a majority of cases, as
+explained previously, the trouble is not due to a misdirected growth
+of the nail, but rather to the tissues surrounding the free edge and
+lateral nail border crowding up, around and over the nail.
+
+It may then be safely stated that an ingrown nail properly treated and
+which has been subjected subsequently to proper prophylactic measures,
+is curable; not temporarily, but permanently.
+
+
+PROPHYLAXIS
+
+In considering the measures employed by which the general condition
+of the nail may be improved so as to prevent a further recurrence of
+the ingrowing tendencies, we will make, for simplicity’s sake, six
+divisions. Five of these relate to the nail itself and to the subjacent
+tissues, and one to the footgear and hosiery of the patient.
+
+=1. Thinning the Nail Through Its Long Axis.= When the acute
+inflammatory symptoms have subsided and the ulcerated areas healed, in
+other words when the toe and the nail have returned to normal, measures
+should be taken to prevent the latter from becoming again ingrown.
+With a rotary file, the centre of the nail should be ground to a paper
+thinness through its long axis. What is accomplished by this procedure?
+
+The nail is normally convex on its outer surface and the apex of its
+dome is the centre of the nail body. This portion, being the greatest
+point of elevation, naturally receives the brunt of the pressure
+from the shoe. If the nail, then, is allowed to remain thick in the
+centre of its body, the shoe pressing upon it will find the nail
+unyielding and in consequence will cause its lateral borders to be
+forced down into the nail grooves. By thinning the body of the nail
+to such an extent that it becomes thin and flexible, the shoe presses
+upon a yielding surface, in consequence of which the nail “gives” or
+spatulates at its centre and the pressure upon its lateral borders is
+decreased if not prevented entirely.
+
+Having done away with any untoward pressure which might be brought to
+bear on the nail, we next turn to:
+
+=2. Hardening the Nail Groove, and Shrinking the Flap.= In many cases,
+after all acute symptoms of the disturbances have subsided, we find
+that the flap of tissue adjacent to the once affected nail and forming
+the outer side of the groove, is greatly thickened and enlarged.
+
+This must be reduced in order that the new-forming nail will have
+sufficient room to develop to its normal width and we must also harden
+and toughen the nail groove so that it will present a surface that the
+nail, as it grows out, will not be able to penetrate, should it be so
+inclined.
+
+Silver nitrate is the most generally used and most efficient agent to
+carry out a treatment of this kind. Solutions varying in strength from
+5% to 50% are recommended, and the selection depends on what is to be
+accomplished and the length of time which may be given to the treatment.
+
+By persistent use of silver nitrate solution, 50%, an enlarged and
+thickened nail flap may in time be reduced to normal. Applications
+about one week apart--in some cases ten days or two weeks to
+intervene--will usually work wonders in conditions of this kind. The
+groove should be thoroughly cleansed and dried and the silver solution
+should be applied on a small cotton wound applicator and painted well
+down under the nail and over the tissue in the enlargement. A dressing,
+usually cotton and collodion, is then applied and allowed to remain
+undisturbed until the patient’s return. The action of this solution is
+astringent and sedative. It is bound to reduce the chronic inflammatory
+symptoms that may be present and, acting as an astringent, it gradually
+shrinks the enlarged flap until the normal line of the lateral nail
+fold is reached.
+
+During the treatment, there is absolutely no pain nor inconvenience to
+the patient. Care should always be exercised that the silver solution
+be not applied if any hemorrhage has been caused in the removal of a
+previous eschar, as it is sufficiently caustic to cause ulceration
+should it come in contact with such a denuded surface. Packing of the
+nail groove will be discussed under the sub-heading “Packing.”
+
+Subsulphate of iron (Monsel’s solution) may be used in the treatment
+of cases of this nature, but its action as an astringent in this
+connection is so mild that it is of necessity a slow process to effect
+a complete cure.
+
+The solution, usually applied to the groove on gauze, is allowed to
+remain. In fact, the patient is often advised to procure a quantity of
+the drug and keep the gauze moistened.
+
+The patient should be seen at periods of about a week or ten days, when
+both the dressing and the eschar caused by the action of the iron salt
+are removed. Fresh gauze is packed under the nail and the treatment
+continued.
+
+Ferric chloride has much the same action in this connection as the
+subsulphate, but this drug has never been so popular, for the reason of
+its greater irritant qualities, few of which are to any degree manifest
+in Monsel’s solution.
+
+Ointments or collodion containing large percentages of salicylic
+acid--as high as sixty to seventy-five per cent.--are sometimes used
+to destroy an enlarged nail flap by strong disintegrative action. The
+ointment is usually prepared on a cerate base and sufficient wax is
+added to thicken the paste so that the tendency to melt and run over
+portions of the integument, where its action would be detrimental, is
+minimized.
+
+The ointment is applied in the groove and over the top surface of the
+mass to be destroyed and is allowed to remain for a few days when
+the disintegrated portion is removed and another application made.
+This action of salicylic acid, used in considerable strength, is at
+times painful and cannot be borne by every patient. The treatment is
+a good one, however, and is rapidly coming into the prominence and
+popularity it deserves. Salicylated collodion is similar in action to
+the ointments containing salicylic acid, and the same general procedure
+holds good for both applications. The collodion is applied on all
+surfaces of the mass, is covered with a cotton and collodion dressing
+and a second application is made upon the removal of the disintegrated
+portion.
+
+It is sometimes advantageous to alternate the silver nitrate treatment
+with that of salicylic acid. An application of the ointment or the
+collodion is made and upon removal of the disintegrated portion, the
+silver solution is applied. After the lapse of about two weeks, the
+salicylic acid is again applied and the treatment continued alternately
+in this manner until the desired result is obtained.
+
+=3. Packing.= We here come to one of the most important procedures
+necessary to a successful prophylactic treatment of an ingrown nail.
+Whether the nail groove is to be packed loosely or tightly is a
+question of great import and should be given careful consideration by
+the operator. Often the comfort of the patient and always the ultimate
+outcome of the case is dependent on the proper packing of the nail
+groove as an after-treatment.
+
+There appears to be a great tendency to pack the groove full to
+overflowing with gauze, cotton, or what not, and, although there are
+some instances where a procedure of this kind is necessary, it is
+usually conducive to a great amount of pain to the patient and has a
+decidedly deleterious effect on the tissues under treatment.
+
+In general, it is wise to pack the groove as lightly as possible, using
+only a small pledget of gauze or cotton and taking care that the fabric
+is well under the nail and interposed between it and the tender areas
+underneath. It must be remembered that no matter what fabric be used
+for packing, it rapidly hardens and becomes more or less irritant to
+the tissues. Should the nail groove be packed to such a degree that at
+the time of dressing it is unyielding and hard, it is easily realized
+what the condition of this dressing will be in the course of a few days.
+
+The only time a nail groove might be tightly packed is in connection
+with the treatment of proud flesh when the tight packing tends to
+interrupt the circulation to the part and thus aids in retarding the
+growth of the superfluous granulations. Another instance when a groove
+may be packed tightly is in a case where no inflammation is present
+and when it is the desire of the operator to hold the softer tissues
+down and away from the edge of the nail so that sufficient room may be
+allowed for the nail to grow out and attain its normal width. A word in
+connection with this theory. Silver nitrate solutions, twenty-five to
+fifty per cent., applied to the groove hardens the tissue by means of
+the eschar developed on its surface and a tight packing to hold these
+tissues in place is an ideal combination for the prophylactic treatment
+of a previously acute ingrown nail case, when by such tight packing
+no noticeable inconvenience is caused to the patient. If cotton is
+used as a packing it should be rolled into a loose thin pledget, the
+finer “point” of which is inserted under the edge of the nail near its
+posterior fold, and the thicker end is packed under the nail at its
+distal portion. One thickness of gauze is generally sufficient and, at
+most, two thicknesses may be used, unless, of course, tight packing is
+required.
+
+In connection with this prophylactic treatment it may sometimes be wise
+to place a shield of felt or buckskin between the tender part and the
+adjacent toe to hold that member away from the affected areas and so
+that the medications applied may be allowed a chance to complete their
+therapeutic action undisturbed. This shield is not strapped but is
+merely placed between the toes, resting on the interdigital web, and is
+just high enough to reach the base of the nail and so does not come in
+direct contact with the area under treatment.
+
+=4. Allowing the Nail to Grow Long.= The nail should be allowed to
+attain as great a length as possible, particularly at its lateral
+points, without interference with the continuity of the patient’s
+hosiery, and yet not long enough to cause pressure from the toe of the
+boot.
+
+This can be best accomplished by cutting the free edge of the nail
+in a concave manner. The lateral points are kept, if possible, long
+enough so as to extend to a point slightly beyond the distal end of the
+nail fold and the rest of the free edge is cut in a circular manner so
+that at its centre it is no longer than just sufficient to cover the
+anterior edge of the nail bed. This manner of cutting, combined with
+thinning the nail body through its central longitudinal axis, prevents
+any great amount of pressure from being exerted by the shoe upon the
+apex of the nail’s convexity. It will also, to a great extent, prevent
+the nail from cutting through the patient’s hosiery. If the whole nail
+is allowed to grow long, and its free edge to extend over the end
+of the toe, some leverage is bound to be brought upon this extended
+portion and in consequence there is a tendency to press the lateral
+edges of the nail into the grooves, which, of course, is to be avoided
+at all costs.
+
+=5. No Lateral Cutting.= In connection with the length which the nail
+is allowed to retain, it is absolutely imperative that no lateral
+cutting be done. Some cases of ingrown nail have been observed in even
+very young children (in one instance a baby of fourteen months). The
+primary cause in every case was found to be the overzealous care on
+the part of the parents to prevent just the condition they had caused
+by injudiciously removing from time to time the lateral edges of the
+sufferer’s toe nails.
+
+=6. Proper Boots and Hosiery.= In addition to the various means for
+preventing the recurrence of an ingrowing nail, great care should be
+exercised in the selection of the patient’s footgear.
+
+Shoes of sufficient width and length should of course be advocated so
+that at no time will the toes be cramped by any degree of pressure.
+
+The wearing of a pointed boot or slipper in which there is not
+sufficient width at the ends of the toes to allow those members proper
+latitude, should be discouraged. When footgear is worn in which this
+cramped condition of the digits is brought about, it will be generally
+found that the soft tissues lying adjacent to the lateral edges of the
+nail are crowded up alongside the latter and an enlarged and thickened
+flap, which is the cause of so much trouble, is formed. Lace boots are
+probably the most practical of any in that they may be firmly fastened
+about the ankles and over the instep, and thus prevent the foot from
+sliding forward and coming in contact with the toe of the boot. Pumps
+of all varieties are without a doubt the most detrimental footgear worn
+today--for they have absolutely no support or anchorage at the ankle
+and, in some cases, patients find themselves flexing the toes in the
+endeavor to retain the slipper on the foot.
+
+Hosiery, too, should be neither tight nor short, as a short stocking or
+sock may cause pressure upon the toe nails and so be the forerunner of
+trouble.
+
+
+
+
+CHAPTER XV
+
+DISEASES OF THE NAILS
+
+
+The nails of the hands and feet are subject to various diseases. The
+chief of these are:
+
+  Onychocryptosis, or ingrown nail.
+  Onychophosis, or calloused nail groove.
+  Onychia, or inflammation of the matrix.
+  Paronychia, or inflammation around the nail.
+  Onychauxis, or club nail.
+  Onychatrophia, or atrophy of the nail.
+  Onychoptosis, or falling off of the nail.
+  Onychorrhexis, or brittle nail.
+
+Some of these diseases of the nails are the result of a general
+systemic disturbance, but only the local treatment of such conditions
+becomes the province of the podiatrist. It is often necessary to
+distinguish between a local chiropodical condition and a local
+manifestation of some serious systemic disease; it is then necessary
+for the medical practitioner and the podiatrist to join hands in making
+a diagnosis for the proper guidance of both practitioners.
+
+=Onychocryptosis=, or ingrown toe nail, is a common affliction of the
+nail, and is thoroughly described in a separate chapter.
+
+=Derivation.= From the Greek, onyx, nail, and krypto, I hide or conceal.
+
+=Onychophosis=, or calloused nail groove, is also one of the common
+types of nail lesions, and is discussed separately. This lesion
+is often mistaken for ingrown toe nail, and treatment, improperly
+directed, often causes bad results.
+
+=Onychia or Onychitis= is an inflammation of the matrix with
+suppuration and final shedding of the nail.
+
+=Derivation.= From the Greek, onyx, nail, and itis, inflammation.
+
+=Etiology.= Onychia may be due to trauma, causing malformation of the
+nail, and subsequent inflammation, but is most usually due to bacterial
+infection. Removal of ingrown toe nails under septic conditions, or
+the entrance of bacteria through self-inflicted or other wounds offer
+opportunities for infective processes on a part of the body none
+too clean at best. Syphilis, tuberculosis and eczema are also often
+etiologic factors.
+
+=Pathology.= Bacterial infection or trauma causes the nail matrix
+to become inflamed, with the accompanying pathologic changes that
+occur in all inflammatory processes. There is a gradual solution of
+the continuity between the nail proper and the matrix, and as the
+degenerative processes continue, namely the formation of pus and the
+solution of the tissues which comprise the matrix, the grooves in the
+nail matrix, which hold the corresponding ridges of the nail, are lost
+and the mechanical union of the two parts cease. The nail subsequently
+falls off. If the entire matrix has been destroyed, no new nail will
+grow, but this does not usually occur. Malformation of the new nail is
+quite common, due to partial destruction of the matrix.
+
+=Diagnosis.= The matrix of the nail is inflamed and severe pain is felt
+when pressure is brought to bear on the nail plate. The nail bed and
+the nail grooves are often involved and the inflammation may continue
+to such an extent as to involve lymphatics and cause destruction of a
+large area of tissue.
+
+Pus forms at the root of the nail, and the nail itself gradually
+becomes loosened from its bed. In cases due to injury or local
+infection, one or two toes may be involved, but when the cause is of
+systemic origin, all of the nails, including those of the hand, may
+become infected.
+
+=Treatment.= The treatment of simple onychia consists in protecting
+the part from further injury and irritation and it often becomes
+necessary to cut the shoe to accomplish this. In severer cases, shoes
+should not be worn until resolution commences.
+
+Wet dressings are valuable, Burow’s solution or boric acid solution
+being all that is necessary in mild cases.
+
+When pus manifests itself, it is necessary to remove the nail over the
+abscess and to establish free drainage. Wet dressings of bichloride
+of mercury (¹⁄₅₀₀₀) for 48 hours may be used, and when drainage is
+complete, the cavity may be swabbed with silver nitrate, 5 to 10%. Dry
+dressings of thymol iodide or boric acid powder will usually suffice to
+complete a cure.
+
+The parts should be packed with sterile gauze so as to keep the soft
+tissues separated from the nail and to prevent irritation and pressure.
+This packing should not be too tight otherwise pus absorption with
+subsequent infection, is likely to occur.
+
+In extreme cases, in which the surrounding tissues are involved and
+destruction has gone on to a greater extent, the entire nail must be
+removed, and the matrix destroyed by caustics or by curettage.
+
+=Paronychia, or Paronychitis=, is an inflammation of the tissues around
+the nail, and may involve all the tissues of the distal phalanx,
+including the bone.
+
+=Synonyms.= Felon, panaris, whitlow.
+
+=Derivation.= From the Greek, para, beside, and onyx, nail.
+
+=Etiology.= Paronychia is usually caused by local bacterial infection,
+due to treating the nail grooves with unclean instruments, or it may be
+of systemic origin. It is often associated with onychia and in these
+cases is due to a spreading of the inflammation of the matrix to the
+surrounding tissues. Pressure of an ill-fitting shoe or stocking or of
+a foreign body may be a cause, and ingrowing toe nail may later develop
+into a paronychia. Syphilis often causes this lesion.
+
+=Pathology.= The pathology of paronychia is much the same as that of
+onychia. The tissues surrounding the nail become inflamed, either by
+bacterial infection or by trauma, and all the signs and symptoms of
+inflammation manifest themselves. Swelling is marked and pus may or may
+not be present. Tissue destruction continues unless proper treatment is
+given, and the bone is often involved, causing periostitis or osteitis.
+
+=Diagnosis.= Simple paronychia may exist without any hypertrophy
+of the nail itself, and may be due to pressure of a shoe or to a
+chronic ingrowing toe nail. The great toe is most commonly affected.
+The inflammation may be only slight and superficial, or it may be
+quite severe with great pain and swelling, terminating in a general
+intercellular infection with suppuration. Nourishment is interfered
+with and the nail may be shed much the same as in onychia. Pain is of a
+throbbing type which is immediately relieved when the abscess cavity is
+opened and the pus drained.
+
+=Treatment.= Like onychia, paronychia should be treated with wet
+dressings and stimulating medications. In cases in which there is no
+suppuration, the following ointment will give good results:
+
+  ℞ Acidi salicylici      grs. X
+  Ung. hydrarg. amm.       Oz. 1
+  M. ft. ung. Sig. Keep on affected part constantly.
+
+
+The corners and lateral edges of the nail should be separated from the
+soft tissues by means of sterile gauze, or they may be removed. Pus
+should be drained, with the assistance of antiseptic wet dressings such
+as bichloride of mercury, ¹⁄₅₀₀₀, and if excessive granulations are
+present, they should be snipped off or destroyed with silver nitrate.
+If necessary, free incisions should be made, which will relieve the
+pain as well as assist in draining the pus.
+
+In chronic paronychia it often becomes necessary to remove the entire
+nail, including the root, and under local anesthesia, this is easily
+accomplished. Rest is essential in these cases, and after suppuration
+has ceased, stimulants such as balsam of Peru or ichthyol may be used
+to good advantage.
+
+In cases of paronychia, due to syphilis, it must be remembered that
+the treatment must be constitutional as well as local and the family
+physician of the patient should attend to the former feature of the
+treatment. Mercurial ointments, applied twice daily, are usually
+employed locally.
+
+[Illustration: ONYCHOGRYPHOSIS]
+
+=Onychauxis=, or hypertrophy of the nail, is an overgrowth or
+enlargement of the nails of the fingers and toes. When the hypertrophy
+is accompanied by deformity, the condition is called onychogryphosis.
+
+=Derivation.= From the Greek, onyx, nail, and auxe, increase.
+
+=Etiology.= Enlargement of the nail is a result of hyperplasia of the
+papillæ of the matrix, the thickening occurring at the base, front,
+lateral edges or over the entire area of the nail depending on the part
+diseased.
+
+Pressure is no doubt a causative factor, and lack of care of the nails
+will also cause a thickening. Injury to the matrix will cause the nail
+to become hypertrophied, producing in most cases a true club nail
+(onychogryphosis).
+
+Chronic cutaneous lesions, such as eczema or psoriasis and other
+diseases such as syphilis, gout and rheumatism, and nervous diseases
+or injury to the nerves supplying the nails, may act as causes for
+onychauxis.
+
+=Pathology.= Pressure or injury causes a widening of the nail fold
+which allows the formation of a thicker nail. The nail bed is irritated
+at the same time and a horny mass forms on it below the nail, which
+acts as a barrier to the forward movement of the nail cells, and by
+raising them up, determines more or less, the degree of deformity. The
+papillæ of the matrix become enlarged, and may be seen protruding above
+the normal structure, when the nail is removed.
+
+The thickened and deformed nail thus produced, is often the cause of
+other nail lesions, due to its pressure on the soft tissues. Bacterial
+infection is also common at this point, due to the fact that the mass
+of epithelial cells is a good breeding place for microorganisms.
+
+=Diagnosis.= Onychauxis may be congenital or acquired, usually the
+latter. Simple hypertrophy of the nail is rarely found, but overgrowth
+with deformity is quite common. The nail becomes hardened, due to a
+closer cohesion of its component cells; its transparency is lost, and
+it assumes a dirty brown or even black color. The surface becomes
+rough, due to the presence of longitudinal and wavy transverse ridges.
+
+One or all of the nails may be affected; there may be a simple
+thickening or there may be a lateral overgrowth, which may result in
+paronychia. The inflammation may be slight or it may be severe and
+purulent. The nail, as it continues to become thickened, may assume
+various shapes resembling claws, talons, horns, etc. The big toe
+nail is the one most usually affected and often only the one foot is
+involved. This is indicative of a traumatic etiology.
+
+Tuberculosis patients have a moderate onychauxis in most cases,
+particularly on the nails of the fingers, while hypertrophy is often
+seen in the inflammatory lesions such as eczema, psoriasis, etc.
+
+Older persons are more liable to be affected with hypertrophy of the
+nail than younger persons, as there is a natural tendency to epithelial
+overgrowth in the aged.
+
+[Illustration: ONYCHAUXIS]
+
+=Treatment.= To affect a cure in case of hypertrophy of the nails it
+is necessary to recognize the cause. Thus, in cases of onychauxis,
+in which the general systemic condition is at fault, treatment must
+be directed by the family physician along constitutional lines and
+includes the taking of tonics, arsenic, mercury, etc. If a cutaneous
+lesion is the etiologic factor, it becomes necessary to treat the
+case both generally and locally. If the cause be an external one
+alone, local treatment is sufficient. For these latter conditions, the
+treatment is divided into palliative and radical procedures.
+
+The _palliative_ treatment consists in keeping the nail properly cut.
+For this purpose, the rotary file, or surgical drill, as it is called,
+is very efficient. Suitable burrs are used, and care is taken that the
+skin of the nail grooves is not injured. Infections are easily caused
+through the careless use of this instrument. After the nail has been
+thinned and is as nearly like a normal nail as is possible, the part
+should be cleansed with alcohol, and tincture of iodine (4%) should be
+applied. The grooves may be packed with sterile cotton and covered with
+collodion (cocoon dressing) which will avoid any tenderness that may
+be felt after the nail has been cut down. The hard nails may also be
+softened by the application of sodium sulphide or liquor potassae and
+when softened, may be scraped away.
+
+If thickened or club nails become very painful, it is often necessary
+to resort to _radical_ measures, as this is the only permanent cure
+for this trouble. The entire nail must be completely removed under
+local anesthesia, and subsequently the entire nail matrix should
+be thoroughly scraped away by means of a sharp curette. The wound
+thus produced is kept in sterile dressings and is allowed to heal
+by granulation. It is quite common to find only a small area of the
+matrix that is vital, particularly in chronic cases of club nail, so
+that curettage is really a simple procedure. A complete cure should be
+effected in from two to three weeks, the patient being able to walk
+with a cut-out shoe two or three days after the operation.
+
+=Onychatrophia=, or atrophy of the nails, is a condition in which the
+nails of the toes and fingers become smaller and often are shed from
+the grooves in which they are contained.
+
+=Derivation.= From the Greek, onyx, nail, and atrophia, atrophy.
+
+=Etiology.= Atrophy of the nails may be caused by any one of many
+factors, among which are the inflammatory skin diseases, nervous
+diseases, constitutional disorders and injuries.
+
+Injury to the nail matrix causes complete or partial cutting off of
+nourishment. If the nourishment is completely cut off, the nail matrix
+will disintegrate and cause the nail to be shed. New nails usually
+grow in these cases. If the injury is less severe, there is only a
+temporary arrest in the nail growth, and the nail becomes thin and
+small discolorations are seen in the nail substance.
+
+Inflammation of the soft tissues around the nail which is accompanied
+by suppuration, may cause atrophy and shedding of the nail. The nail
+will grow again as a rule, but often when the etiology is systemic, the
+new nails shed as soon as they are formed (onychia maligna).
+
+In nervous diseases, such as cerebral paralysis, tabes dorsalis,
+syringomyelia, leprosy, division of the nerves, etc., from the
+vasomotor disturbances due to the nerve lesion, a bleeding may occur
+about the posterior nail fold, and atrophy of the nail may result. The
+nails, as a rule, usually grow again.
+
+In stasis of the blood stream in the extremities due to heart lesions,
+in venous congestion from emphysema, or in any lesion in which the
+circulation is impaired, the nails may undergo atrophy, particularly
+the nails of the fingers.
+
+Diseases causing scarring of the nail matrix, such as pustular
+syphilides, gummata and variola, give rise to a partial destruction
+of the matrix and a shedding of the nail. Subsequent scarring may
+completely destroy the matrix, so that no new nail can grow.
+
+In systemic diseases that cause wasting of the tissues, such as chronic
+tuberculosis, nephritis and diabetes mellitus, the matrix is usually
+under-nourished and the nails become discolored, soft and brittle, and
+often crumble.
+
+Chemical poisons, such as arsenic, silver and lead, may cause atrophy
+of the nails. Those who work with chemicals and are compelled to put
+their fingers in acids and in alkalies often develop brittle, opaque
+nails. In general toxemias, the affliction of the nail is caused by
+interference with the nail nourishment at the matrix.
+
+=Pathology.= When the nourishment of the matrix has been interfered
+with, the cells do not develop as rapidly as they should, and the nail
+becomes thin and streaked. The lustre is lost and the nails become gray
+or yellow, and often also become brittle. If the grooves in the nail
+bed are destroyed, the mechanical attachment between it and the nail is
+lost and the nail is cast off. Infective processes cause complete or
+partial destruction of the matrix by solution, and this in turn causes
+complete or partial loss of nail. White spots (leuconychia), said to
+be due to the entrance of air under the nails, are often seen, and
+gradually move toward the distal end of the nail.
+
+=Diagnosis.= Atrophy of the nails may be congenital or acquired, the
+former being rare and usually accompanied by imperfect development of
+the phalanges and scantiness of the hair throughout the body (alopecia
+universalis). Acquired atrophy in some form is the usual condition.
+
+The nails present various appearances. They may be thin, soft,
+brittle, lustreless or opaque, split very easily, may be streaked or
+even worm-eaten in appearance. One or all of these conditions may
+be present. Thinning and splitting of the free ends may accompany
+systemic diseases, and some chronic inflammatory (especially scaly)
+skin lesions. Some nails are thinned at the ends with a central fissure
+extending toward the root. Transverse thinning or furrows are met
+with in fevers. The nails are always affected when nutrition has been
+lowered, due to depression of the general health.
+
+In wasting diseases, such as chronic tuberculosis, diabetes, etc., the
+spoon-nail is observed. This is a condition in which the lateral and
+free margins are raised, leaving a spoon-like depression in the centre.
+
+Trauma, parasites, lowered nutrition and nervous diseases cause a
+crumbly, brittle nail. This is fairly common, and may be limited to one
+or more nails of the toes and fingers or it may be general. The atrophy
+may begin at either end, and extend forward or backward.
+
+=Treatment.= Treatment of a local nature is worthless if the cause
+be systemic. Much like hypertrophy, the cure of atrophy depends on
+an exact determination of the etiology. Systemic treatment along
+proper lines will usually effect a cure. Local treatment consists in
+protecting the nails from irritation and sometimes even from water.
+The nails should be cut even and smooth and mollifying ointments
+and lotions are advisable. Cocoon dressings are very efficient
+for affording protection. In atrophy, due to local circulatory
+interference, balsam of Peru (50%), in castor oil, or even pure, will
+stimulate nail growth. This should be applied once a day and can be
+retained by cocoon dressing. As a soothing agent the following may be
+employed.
+
+  ℞ Acid. boric.
+    Bismuth. subnitratis   aa    0.60
+    Ung. aquae rosae
+    Unc. zinci oxidi       aa   16.00
+
+M. Ft. ung. Sig. Apply to the nails morning and night.
+
+=Onychoptosis=, falling off of the nail, and =Onychorrhexis=, brittle
+nail, are atrophies and have been discussed as such in the preceding
+sub-head.
+
+
+
+
+CHAPTER XVI
+
+FISSURES, BLISTERS, AND BURNS
+
+
+FISSURES (_Fissura_)
+
+=Definition.= Fissura or fissures, as used in this sense, are cracks or
+clefts in the surface of the skin, some involving only the epidermic
+layers, some penetrating deep into the corium.
+
+=Etiology.= Fissures occurring on the foot, due to trauma, are far in
+the minority as compared with those occurring as secondary lesions
+in hyperidrosis, uric acid diathesis and other systemic conditions.
+They are usually due to a too strenuous drying of the interdigital
+surfaces with a rough towel. They may also be caused in like locations
+by excessive walking, but the condition of the skin of the patient has
+much to do with their formation. If the skin be dry and a great amount
+of its elasticity is gone, these lesions are much more prone to develop
+than where the skin tension is practically normal. The interdigital toe
+webs are often cracked or fissured in spreading the toes too far apart,
+and this has been caused, at times, by the podiatrist working between
+the toes and stretching them to obtain room for his instruments or
+dressings.
+
+=Treatment.= The natural treatment for a condition of this kind
+would be to obtain astringent action. This may be accomplished by a
+number of drugs, principal among which is silver nitrate. Tannic acid
+preparations are also frequently used, but they cannot compare in
+efficiency with the silver salt. A number of mild vegetable astringents
+of the same group are similarly employed by podiatry practitioners.
+
+If the fissure is superficial, involving only the epidermic layers,
+compound tincture of benzoin, painted freely over the parts, after they
+have been thoroughly cleansed and dried, will be found advantageous
+in inducing rapid healing. Dusting powders such as tannoform,
+bismuth subgallate, bismuth subnitrate and thymol iodide, may also
+be successfully employed in these cases, but where the fissure is
+deep, the edges angry and red, and the whole area is involved in the
+inflammatory process, none of these are, as a rule, of avail, and more
+radical methods must be employed.
+
+Nitrate of silver presents the most efficient means whereby astringent
+action may be obtained in the parts. Weak solutions, from 1% to 10%,
+are most generally employed, but it is often found necessary to use
+stronger solutions, even as high as 50%.
+
+[Illustration: FISSURED TOE WEB]
+
+=Technic.= The parts are first thoroughly cleansed and any callous
+around the edges of the fissure is carefully and completely removed.
+This is an essential procedure, for no lateral granulation will take
+place, nor can direct apposition be obtained if this callous be allowed
+to remain.
+
+Small particles of material from the hosiery or other foreign bodies
+should also be thoroughly removed. The recesses of a deep fissure
+present excellent places of lodgment for minute particles which are
+always to be found in footgear, and it is these bodies which produce
+infective processes. The above precautions having been observed,
+alcohol, 60%, should be freely applied and the parts thoroughly dried.
+Silver nitrate may then be painted deep down into the floor of the
+fissure, by means of a cotton wound applicator. This will produce some
+smarting, but it is transient and there will be no great amount of
+irritation. The silver solution should also be applied to the surfaces
+adjacent to the edges of the fissure, for it must be remembered that
+silver nitrate is sedative and this action is desirable in reducing the
+local inflammation.
+
+Where the fissure is deep and of long standing, it may be found
+necessary to resort to a 25% or 50% solution or even to the fused
+stick. When cases are observed where proud flesh has developed in
+the fissure, due to continued irritation, it is necessary to use the
+stronger solutions or the stick at once. The proud flesh may be in such
+form as to permit of surgical removal. Where this can be accomplished,
+the bleeding stump is usually cauterized with silver solution, 50%. If
+a surgical procedure is impractical, the fused stick may be used to
+cauterize the neoplasm and thus eradicate it.
+
+A dressing should be applied over the parts after the fissure has been
+treated. This may consist of several thicknesses of gauze, fashioned to
+fit between the toes, if the fissure be in that location; if the lesion
+be upon a plane surface, a square of gauze should be applied and held
+in place by adhesive strips.
+
+A cocoon dressing may be substituted for that of gauze, and in many
+instances will be found more practical. It has been found necessary
+at times to apply some ointment or grease over the fissured area to
+aid in softening the parts and rendering them more flexible. Massage,
+at intervals, with olive oil or mutton tallow, will also be found
+advantageous in bringing about this result.
+
+No dressing is applied over the parts after the use of compound
+tincture of benzoin, for this drug forms its own coating, which is
+practically impermeable. If a dusting powder be used alone, the parts
+are first thoroughly dried, whereupon the powder is dusted lightly into
+the fissure, and a wisp of cotton is placed over the part and held in
+place with collodion.
+
+Pure ichthyol has also been found efficient in these instances; a drop
+is placed in the fissure and is retained there by means of cotton or
+gauze.
+
+Astringent treatment, as described, should be continued until the
+fissure has entirely healed, and in the use of silver nitrate it will
+be found advisable to remove all remnants of the previous application
+before the drug is again used. The eschar is easily removed, but it
+must also be remembered that in some instances it may be advisable
+to allow the eschar to remain, and the wound to granulate under its
+protective covering.
+
+This article has been confined almost entirely to fissures occurring in
+the interdigital webs for the reason that these parts are their usual
+sites of occurrence. At times, however, they do form in other parts of
+the foot--on the heels along the sides of the foot, and on the ends
+of the toes. The treatment in any locality is similar. When infection
+is present it should be arrested; if proud flesh has developed, that
+must be eradicated; in all cases astringent treatment is necessary to a
+successful outcome.
+
+
+BLISTERS (_Bullae_)
+
+=Definition.= A blister is a collection of fluid in the skin beneath
+the outer epidermic layers, which latter are raised to form the upper
+wall of the sac, the base of the blister being formed by the mucous
+layers of the epidermis or by the corium.
+
+=Etiology.= The cause of practically all blisters met with in podiatry
+is traumatism. Those occasioned by the friction brought to bear on
+the surfaces of the foot by a new or unyielding shoe predominate, but
+occasionally the podiatrist is called upon to treat these lesions
+arising from a burn. In discussing the subject of blisters under this
+heading, those of traumatic origin only will be considered. Those
+occasioned through burns, or superficial vesicular developments of
+specific origin will be discussed in chapters dealing with the disease
+or diathesis in connection with which they may develop.
+
+=Pathology.= The pathologic process causing the formation of a
+traumatic blister is a simple one. Due to the constant rubbing of a
+shoe, the superficial epidermic layers are loosened up, one layer from
+the other, and, owing also to this external irritation, the serous
+elements of the blood are caused to leave the vessels and thence find
+their way into the intercellular spaces caused by this loosening.
+Collections of fluid of this nature are known as bullae or blisters.
+The so-called “blood blister” is of a similar origin except that the
+injury (in this case usually a severe trapping or pinching of the
+tissue) is sufficient to cause the rupture of one or more capillaries
+whose blood contents extravasate into the overlying epidermic layers.
+
+=Usual Points of Location.= Blisters developing upon the pedal
+extremities are most common in the spring of the year when people
+begin to wear Oxford ties or other styles of low shoes. They occur
+principally upon the posterior surfaces of the heel at the upper
+extremity of the os calcis, or upon the tendo Achillis, just above this
+point, and are caused by the rubbing of the stiff heel of the shoe upon
+these parts.
+
+Bullae are also often found to develop over or immediately adjacent to
+the prominent extensor tendon on the dorsum of the hallux. In these
+locations the stiffness of the shoe in “breaking” over this point is
+found to be the irritant agent.
+
+Whilst the two foregoing locations are the most general sites of
+occurrence, they are, at times, also found to develop upon the plantar
+surfaces, and in some instances upon the ends or between the toes.
+
+=Treatment.= The method of treatment to be accorded these cases depends
+upon the condition that the affected part may be in at the time of
+observation.
+
+=Ordinary Conditions.= When the blister is found to be unbroken and
+no great degree of inflammation is present, the sac should be opened
+and its contents evacuated. This is best accomplished by means of a
+fine-pointed, sterile scalpel or bistoury. The blister is punctured
+through the unaffected epidermis immediately adjacent to its base,
+and thereupon gentle yet firm pressure is exerted until all the fluid
+contents are evacuated.
+
+Once the contents have been removed, thorough asepsis should be
+inaugurated. The parts should be swabbed with alcohol, 60%, and
+allowed to dry by evaporation, or be dried with a sterile wipe. In
+dressing these conditions it must be remembered that protection must
+be obtained as well as granulation induced. Recognizing these to be
+important factors in treatment, the choice of a proper dressing should
+be carefully made.
+
+The cocoon dressing (see “_Dressings and Bandaging_”) is practical in
+these cases, as the cotton serves to afford great protection to the
+parts and also to confine whatever medication is to be applied as a
+curative agent.
+
+Dressings of sterile gauze or surgeon’s lint may also be used, and
+consist of a square of gauze or lint applied over the part and held in
+place by means of adhesive strips.
+
+The cocoon dressing may or may not be reinforced by adhesive strapping,
+as the judgment of the operator determines. If strapping becomes
+necessary in this connection, half-inch or one inch width plaster is
+generally used. The strips (each about three or three and a half inches
+in length) are applied in the form of a triangle, binding down the
+edges of the dressing. It is also found advisable to avoid using too
+much collodion on the cotton. These dressings should never be hard; it
+is, therefore, preferable to bind down the edges and then merely paint
+the collodion in one narrow strip across and with the fibre of the
+cotton. If adhesive strapping is to be used for the adherence of gauze
+or lint, the one-half inch plaster is the most practical in almost
+every instance.
+
+The strips are each cut about three inches in length, unless the size
+of the gauze or lint squares makes it desirable to have them longer,
+and they are placed in rectangular fashion over each of the four sides
+of the dressing. It should always be the endeavor, when possible, to
+bind down the edges of the fabric to the skin, and to accomplish this
+the adhesive strips are made adherent, half on the dressing and half on
+the underlying skin. This serves to hold the dressing more firmly in
+place and also to prevent foreign matter from getting under its edges.
+
+Ointments are generally found to be the most advantageous applications
+in cases of ordinary bullae. There are several of these from which we
+may choose. Ammoniated mercury, 10%, and ichthyol, 10%, are probably
+the most generally used and are efficient.
+
+=Broken Conditions.= In many instances the blister, through neglect
+and improper puncturing, has become broken and the affected epidermic
+layers are stripped off, being attached at one point only, or are
+entirely gone.
+
+The parts should be thoroughly cleansed with alcohol, 60%, and all
+loosened epidermis removed. Never leave any flaps of skin about the
+edges of the denuded area, for they not alone serve as excellent places
+for the lodgment of hostile bacteria, but are also apt to curl up and,
+becoming thickened, may irritate the denuded surfaces by pressure.
+
+The lesion being thoroughly aseptic, a dressing should be applied. If
+infection be already present in the part, the treatment should consist
+of the application of wet dressings of mercury bichloride, ¹⁄₂₀₀₀,
+or weaker, until all inflammation has subsided. If no infection be
+present, a dressing which will be protective, healing and sedative
+should be placed over the parts. A shield is usually a necessary
+adjunct to every successful treatment in cases of this nature.
+
+It will always be found advisable to have the aperture of the shield
+sufficiently large, not alone to protect the denuded area, but also to
+include some of the surrounding integument.
+
+In locations about the os calcis region and along the surfaces of the
+tendo Achillis, an oval pad of a soft grade of felt is found to afford
+the best protection. In cases where the blister has developed over the
+extensor tendon on the dorsum of the great toe, a strip of white felt,
+about one inch long and one-half inch wide, placed parallel to the
+tendon, and of sufficient thickness to be higher than its elevation, is
+found to be the most practical means of shielding the affected area.
+An oval shield, if used in this latter instance, should have a groove
+fashioned on its under surface in which no adhesive is placed and which
+allows for the free play of the tendon in movements of the foot.
+
+The choice of an ointment, if one is to be used, should be carefully
+made, for asepsis is to be at all times maintained and granulation must
+be induced.
+
+Ammoniated mercury, 10%, and sulphur, 10%, are to be highly recommended
+as antiseptic ointments, and the latter, in particular, has tissue
+stimulating properties. Ichthyol, 10%, balsam of Peru, 5%, or scarlet
+red, 3%, may also be used, the latter two where the lesion shows signs
+of indolence and needs stimulation.
+
+At times a dry dressing, either of plain sterile gauze, or gauze,
+combined with a dusting powder, secures good results in these cases.
+Thymol iodide and bismuth subgallate probably lead the list in
+popularity but a very efficient substitute is found in a combination of
+equal parts of bismuth subnitrate and powdered calomel.
+
+The areas should be thoroughly dried before any dusting powder is
+applied. This is best accomplished by applying alcohol and allowing
+it to dry by evaporation, which may be hastened by blowing air upon
+the area. A practical means of applying dusting powder is afforded by
+compressed air. Under low pressure any powder may be blown from the
+nebulizer upon the parts in a thin and even coating.
+
+Both the ointment and the dry dressing should be changed in from
+twenty-four to thirty-six hours until complete granulation is observed
+and the structures of the denuded corium are entirely covered.
+Dressings which are allowed to become stale and which harden, are apt
+to act as irritant agents to the tender granulating surfaces and not
+only retard normal healing but further break down the tissues.
+
+Cocoon dressings may also be employed to apply either ointments or
+dusting powders, as just described for gauze. They will remain in place
+for much longer periods of time than will gauze or lint, but in these
+cases, as the dressing must be changed daily, this is not an important
+consideration.
+
+=Prognosis.= The tissue lost in blister cases properly dressed and
+protected should be replaced rapidly and stimulation is seldom found
+necessary. The course is active but short. It is advisable to have
+the patient refrain from wearing the shoe which originally caused the
+disturbance so that no untoward irritation is brought upon the part
+during treatment. After the epidermis covering is complete, it will be
+found advantageous to paint the parts with silver nitrate, 50%. The
+eschar so formed will act as a protective agent to the parts until the
+skin regains its normal strength.
+
+
+BURNS
+
+The podiatrist is not called upon to treat many burns on the foot, and
+when these conditions are present they are, as a rule, not extensive.
+The subject is so important, however, and so much progress has been
+made in recent years along the lines of burn treatments, that a
+thorough knowledge of this subject is of great interest to the modern
+practitioner.
+
+=Definition.= A burn is a lesion caused by heat or by caustics. The
+lesion may be superficial in the tissue involvement or it may have
+penetrated to the deeper tissues and, if extensive, may cause permanent
+injury or death.
+
+=Pathology.= Intense heat being applied to the surface of the body
+destroys the vascular supply, and so shocks the nervous sensibility
+of the part that the nerves are temporarily, sometimes permanently,
+paralyzed. This causes the tissue to slough and a more or less deep
+ulceration is formed. The edges are found to be a dark, angry red in
+color and the floor of the ulceration is usually a pale, unhealthy
+yellow or white. In small areas the pain is intense, while if large
+areas be involved to such an extent as to include the main trunks, the
+parts rapidly become anesthetized and gangrene ensues. Discharge from
+the ulceration is generally profuse.
+
+As the podiatrist will only come in contact with the smaller burns the
+discussion in this chapter is confined to their consideration.
+
+=Treatment.= The burn, whether caused by direct heat or by chemical
+reaction, is at first aseptic and this asepsis must be maintained
+throughout the entire treatment. If the burn is very recent, an
+immediate application of carron oil (equal parts of linseed oil and
+limewater) will be found to relieve much of the pain, and to keep
+the tissues in fairly healthy condition. If this medication is not
+obtainable, a paste of sodium bicarbonate will also prove efficient.
+All air should be excluded as soon as possible, and many advocate the
+application of a simple grease smeared freely on the abraded surfaces.
+These are purely first aid procedures, however, and have no part in
+scientific treatment.
+
+After the acute pain has been reduced or entirely relieved, treatment
+should be instituted which will at once induce granulation and maintain
+asepsis. Strong germicides, particularly those with toxic properties,
+should be studiously avoided, for it must be remembered that the
+vitality of the part has been severely shocked, even in a superficial
+burn. Nothing must be done to retard the healing process.
+
+Ointment or dusting powder dressings are advocated in these cases,
+but the most efficient treatment lies in the use of one of the newer
+paraffin preparations (see _Dressings and Bandaging_). The method
+of application of these paraffins is as follows and is the original
+technic as formulated by Dr. de Sandfort, who is the originator of this
+method of treatment:
+
+=Method of Use.= Paraffins are used warm, consequently in a liquid
+state (158°-176° F.).
+
+=Heating.= Place a piece of the material in a bowl, tin cup, or other
+convenient receptacle, set in any vessel containing a little water,
+which should be kept on the point of boiling for ten minutes.
+
+=Precautions to Be Taken.=
+
+1. Care should be taken to prevent the splashing of the boiling water
+into the container holding the paraffin. When the water begins to boil,
+reduce the temperature to avoid drops of water being thrown into the
+wax. It must be remembered that these compounds, completely devoid of
+water (anhydrous), do not burn the tissues at 176° F., while even the
+smallest quantity of water added would have the contrary effect.
+
+2. While the mixture is being heated, cut a piece of absorbent cotton
+of sufficient size to amply cover the burned area, and divide it into
+layers as thin as possible. At the same time, have ready the gauze and
+band, needed to bind and keep the waxen shell in place.
+
+=The Dressing.= When the paraffin is in a liquid state, and is at a
+temperature of from 140° to 150° F., take a soft camel’s hair brush,
+dip it into the mass and spread it on the wound, without pressing;
+that is, as much as possible dabbing it on and not brushing it on.
+This operation is repeated until the glazing is complete, taking care
+to leave no spot uncovered. Immediately afterwards, place quickly on
+the first wax glaze one of the thin layers of absorbent cotton already
+prepared, as explained above, so that it becomes easily impregnated
+with the wax, and then, with the same dabbing movement, brush on
+several more applications of the paraffin.
+
+If the wound is extensive, the operation is done on small square
+surfaces, successively and close together (about 4 by 4 inches). These
+little surfaces become, by the application, part of one another. This
+proceeding is to avoid the first coat of glaze, because it is essential
+to form (on the whole surface of the wound) a shell uniformly warm
+which keeps its warmth a long time, thanks to the close attention of
+the wax with absorbent cotton. Two layers of cotton can be applied
+successively, saturated with the mixture, although this is not
+indispensable.
+
+When the application is complete, the dressing is finished by binding
+with ordinary gauze or cotton, kept in place by bands. If desired,
+gauze can be replaced in part by oiled silk, or even paper.
+
+=Note.= In not following the precise instructions already given, grave
+errors can be committed. Thus, should the layer of absorbent cotton be
+applied directly to the wound and afterwards covered with the first
+layer of the paraffin it causes:
+
+1. A very painful burning sensation. These applications on a wound
+are very soothing, while cotton impregnated with the paraffin applied
+direct to the wound causes a distressing, burning sensation.
+
+2. At the moment of removing the dressing, a pulling and even tearing
+of the tissues is caused. If the wound has not been previously glazed
+by an application of a first layer of paraffin, as explained above, the
+cotton will adhere.
+
+=Removing the Dressing.= For the first few days the waxen shell must
+not be left in place for more than twenty-four hours, on account of
+an abundant secretion of lymph, which takes place beneath it. The
+sero-purulent liquid flows under the wax covering (which proves that
+the waxen layer does not adhere to the tissues like collodion, with
+which paraffin has been wrongly compared) and exudes from under the
+edges of the dressing. After a few days, this exudation diminishes and
+the dressing can be left in place for forty-eight hours at a time and
+even longer.
+
+To remove the dressing, untie the bands and take off the ordinary
+gauze or oiled silk, thus exposing the “shell.” An incision is made
+in the “shell” by means of a blunt knife or scissors and it is easily
+peeled off. The dressing is removed more easily than a glove. The wound
+is afterwards bathed with boiled water and the cleansing is further
+perfected by washing with absorbent cotton soaked in boiled water. Then
+it is dried, either by a current of warm air or by a piece of cotton
+wool, care being taken not to rub, or cause the granulations to bleed.
+The new dressing is not applied until the surfaces are thoroughly dry.
+
+=Important Recommendations.=
+
+1. In washing the wounds, antiseptic solutions must not be used, unless
+extremely weak.
+
+2. Anxiety need not be occasioned by the grey aspect and fetid odor
+which emanates from the wound when the waxen shell is removed. In fact,
+after this washing, it is seen that beneath this purulent liquid, the
+tissues present an intense vitality and an excellent appearance. In
+order to properly proliferate the elements of healing, it even seems
+as if they have need to bathe in this purulent liquid, which might be
+termed auto-serotherapia.
+
+3. In application, the wax should be brushed on with strokes or daubs
+all directed the same way, and these should commence at the top of the
+part and be carried downward, never starting at the bottom and going
+upward.
+
+After several days of treatment, skin granulation will be observed,
+white spots appearing more especially at those points, where the
+sero-purulent liquid has remained in the greatest abundance.
+
+Care should be taken not to apply paraffin at a temperature of more
+than 105° F.
+
+Contrary to the usual practice, the abundant granulations must never be
+cauterized with nitrate of silver or any other caustic. In spite of
+their development, at times considerable, little by little they begin
+to be strangled by the regenerating elements of the skin, which finally
+replace them.
+
+In case of persistent atony of the wound or of excessive growth of
+granulations, the paraffin treatment can be interrupted every three or
+four days by a wet dressing (water slightly alcoholized) for a period
+of twenty-four hours. Paraffin treatment is afterwards resumed, which
+the patient often requests himself, on account of the comfort derived
+from the waxen shell.
+
+After some days of treatment, there appears sometimes on the healthy
+skin surrounding the wound an eruption of sudamina, caused by the
+perspiration confined under the waxen shell. To make it disappear,
+cover it with an ointment of oxide of zinc, then powder with talc,
+always continuing the paraffin application over the wound.
+
+=Conclusions.=
+
+1. Paraffin preparations instantly alleviate the pain.
+
+2. They constitute a warm shell, a heat retainer, under which the
+tissues, protected against outside contamination and maintained at a
+temperature always constant, rapidly heal.
+
+3. They become non-adhesive after a short period, thus rendering
+removal instantaneous, without pain, without hemorrhage and without
+tearing the tissues of neo-formation, thus permitting the integral
+healing of the tissues, without apparent scars, without contraction of
+the skin or of the tendons.
+
+4. Without causing persistent and incurable functional weakness.
+
+=Important.= Heating these preparations in a bath of boiling water
+raises the temperature to nearly 212° F., therefore, before applying to
+the wound, they should be removed from the water bath and allowed to
+stand for a minute or two so as to reduce the temperature below 105° F.
+
+If an ointment be used, a bland healing type should be chosen.
+Among these ichthyol ointment, 5% to 10%, is probably found to be as
+efficient as any, although zinc oxide, 10%, balsam of Peru, 5%, and
+various sulphur ointments, 3% to 10%, may be substituted with equal
+results.
+
+On a freely discharging surface, of course, an ointment is
+contra-indicated and a dusting powder must be resorted to or merely a
+dry aseptic gauze dressing applied. The dusting powders to be used are
+the two bismuth salts, subgallate and subnitrate, although the latter
+is found to be irritant at times; thymol iodide may also be used and
+its antiseptic and healing action makes for its general popularity in
+these cases.
+
+The ointment or dusting powder is covered with a cocoon, gauze, or
+lint dressing which is held in place by collodion or adhesive strips,
+respectively.
+
+The dressing should be changed daily until granulation is complete.
+Burns are stubborn lesions to heal and the podiatrist should not slight
+them in any way. They are prone to infective processes, and the least
+neglect is apt to cause the undoing of all that previous treatment has
+accomplished.
+
+
+
+
+CHAPTER XVII
+
+BURSITIS
+
+
+Bursae are closed sacs or pouches containing fluid, found in all
+parts of the body, covering and protecting exposed or prominent bony
+surfaces, and interposed between tendons and parts over which they
+play. They serve as protective cushions to prevent physiologic wear and
+tear.
+
+There are two varieties of bursae found in the human body: the bursae
+mucosae, those secreting a mucous or a gelatinous substance, and the
+bursae synovia, those secreting a thin, viscid substance, and which are
+similar in structure to synovial membranes.
+
+The principal form of bursae found in the foot is of the synovial type
+and for this reason the treatment of this variety is that discussed
+in this chapter. Bursae may be either deep-seated or subcutaneous and
+the latter variety are those which, through trauma, usually become
+inflamed and troublesome in the regions of the foot. The deeper seated
+bursae, however, often become involved in a pathologic process, and
+the podiatrist is called upon to treat these cases as well as those
+involving subcutaneous variety.
+
+=Definition.= Bursitis is an inflammation of the bursa sac. The
+inflammation may be acute, subacute or chronic. Acute bursitis is a
+condition in which the general inflammatory symptoms are active, the
+course short, and in which the overproduction of synovial fluid has
+found an outlet and is discharging on the surface of the skin. Subacute
+bursitis is a condition in which the inflammation has not reached a
+true acute stage, but in which it is more in evidence and more active
+than in the chronic form. Chronic bursitis is a condition in which the
+inflammation is long standing and of an inactive nature and where no
+great amount of overproduction of synovia is in evidence. In chronic
+cases the walls of the sac itself are generally found thickened and
+leathery; where this condition occurs in the bursa over the first
+metatarsophalangeal joints it is often inadvertently called a “bunion”.
+
+[Illustration: ACUTE BURSITIS]
+
+=Etiology.= Bursitis occurring in the foot is in nearly every instance
+due to trauma. A blow, a knock, a part being stepped on, or the
+continued pressure of an ill-fitting shoe, may be the exciting causes
+of this disturbance. Malalignment of a joint may be a secondary cause,
+such as would occur in hallux valgus. In this instance the deep-seated
+bursa would be affected. Bursitis would hardly develop from this alone,
+however, and the exciting cause is found in the pressure of footgear or
+some other injury to the part.
+
+=Location.= As bursa sacs are only found covering a bony prominence,
+or interposed between the sheaths of tendons and muscles, or between
+these structures and the skin, serving in each capacity to prevent
+physiologic wear and tear, bursitis occurring in the foot will be found
+in these locations.
+
+The first and fifth metatarsophalangeal joints (metatarsophalangeal
+bursitis); the interphalangeal joints of the toes (interphalangeal
+bursitis); the posterior and outer surfaces of the os calcis
+(retrocalcaneal bursitis); and the tarsometatarsal region on the dorsum
+of the foot (dorsal bursitis) are the principal sites of occurrence.
+The base of the fifth metatarsal is also a spot over which bursal
+inflammation will occasionally develop.
+
+=Pathology.= The pathology of bursitis is primarily that of any
+inflammation. Due to trauma, the parts are subjected to a severe
+irritation which causes an engorgement of blood in that location.
+Serous infiltration of the tissues takes place and the functional
+activity of the sac is increased. Materials from the blood for the
+production of synovia, are secreted in abnormal amounts, and in
+consequence the sac becomes distended from the superabundance of fluid.
+In time this fluid must find some outlet, for synovia is secreted
+so rapidly that the lymphatic system cannot absorb the excess. This
+outlet must naturally develop toward the point of least resistance,
+which, in these cases, is outward toward the periphery. The tissue
+is broken down to a small extent and a minute sinus is formed which
+permeates the tissues and opens upon the surface of the skin. From the
+peripheral opening the excess of fluid is thrown off, and when this
+stage is reached the distension in the part is naturally lessened and
+the patient is fairly comfortable.
+
+=Symptoms.= _Objective Symptoms._ The parts will be found considerably
+swollen, red and hot. Loss of function is noted and fluctuation is
+present.
+
+_Subjective Symptoms._ Pain on slightest pressure and at times upon
+forced movements; impaired function; heat, and a feeling of fullness or
+distension in the part.
+
+=Characteristics.= The characteristics of bursitis, whether acute or
+chronic, are so plain that no error in diagnosis should ever be made.
+However, many of these cases are mistaken for suppurated helomata,
+probably through the fact that both are conditions in which a discharge
+is present. Why this error should be made is a mystery, for while it is
+true that there is an exudation in both instances, the characteristics
+of the discharges are so different that only a careless or
+inexperienced person could mistake one for the other. The important
+characteristics are:
+
+(1) The distension in the bursa sac proper causes a swelling of the
+parts adjacent and superjacent so that the whole area over and around
+the affected part will be found enlarged and puffy. Fluctuation is
+present and often the sac itself may be grasped in the fingers, so
+distended are its walls.
+
+(2) Removal of the overlying calloused area, should one be present,
+brings to view the sinus opening, in the acute stage. The tissues
+are blanched in appearance and are leathery and hard to digital or
+instrument touch. The opening of the sinus is usually very small
+and its edges are circumscribed and even. The sinus itself has the
+appearance of a healthy granulating surface and at no time is there
+apparently any membranous lining. Probing will determine that the sinus
+follows an almost vertical course with no sub-borrowings or offshoots
+in any direction. There is no loss of tissue upon the surface of the
+skin, such as would be found in connection with an heloma involved in a
+suppurative process, except at the opening of a canal.
+
+(3) Digital pressure exerted laterally and anterio-posteriorly usually
+is rewarded by the oozing of a thickish, viscid, almost colorless
+fluid from the sinus opening. There is nothing in the appearance of
+this fluid that should lead one to mistake it for pus. Very often this
+fluid oozes from the part of its own volition, due probably to the
+pressure of the excess fluid in the sac beneath. The fluid causes no
+active decomposition of hydrogen dioxide and the ebullition caused by
+the contact is almost negative. This constitutes one more point of
+differentiation between the changed synovial fluid discharged from an
+acute bursitis and a pyogenic exudation.
+
+=Treatment.= The treatment of bursitis varies according to the degree
+of inflammation, and the general conditions present. We may divide the
+treatment into three classes: the radical operative, the non-radical
+operative, and the palliative. The first mentioned is a purely surgical
+procedure, complete in itself, and consists in the removal or curettage
+of the inflamed sac. The last two are usually combined and are
+procedures which are generally practised by the podiatrist.
+
+=The Radical Operative Treatment.= Under proper aseptic conditions an
+incision is made in the overlying tissues and the sac is removed in its
+entirety; the parts are then sutured, and a few days rest and elevation
+of the foot brings complete union. This method may be varied in that
+the sac is not removed, but a free incision is made into it and the
+parts thoroughly curetted. One other of the purely surgical procedures
+is to make a free incision into the sac to accomplish thorough
+drainage. This latter procedure is generally practised in cases of
+infected bursitis.
+
+Inasmuch as the non-radical operative and the palliative methods of
+treatment are purely podiatry procedures and are usually combined, they
+will be discussed as one subject.
+
+=The Non-Radical Treatment.= There are several methods by which
+bursitis in its various stages may be successfully treated. They vary
+in some details but all agree on two most important points: rest and
+the absence of pressure.
+
+A bursitis developing over a bony prominence upon the foot, usually
+occurs in connection with some form of superficial callosity or an
+heloma. The inflammation of the sac may be due to the neglect of a
+growth of this nature, or, as previously explained, to some distinct
+injury to this part.
+
+To successfully treat a condition of this nature it is found necessary
+at all times to accomplish the removal of the excrescence. This is done
+in the usual manner by either the shaving or dissection method. These
+growths must be removed for several reasons:
+
+(1) To remove all hardened and thickened epidermis so that no further
+irritation from that source will be present.
+
+(2) To allow the operator a chance to effect drainage for the
+overproduction of bursal fluid.
+
+(3) To allow the medications used to come in direct contact with the
+underlying tissues without the necessity of penetrating several layers
+of epidermis and expending their action upon and through them.
+
+Under proper aseptic conditions, the superficial thickened epidermic
+layers are removed and the excess fluid is allowed to drain off. It
+will often be found that the callous forms a “plug” which extends down
+into the surface opening and prevents this excess fluid from being
+thrown off. Once this drainage is accomplished, other procedures,
+dependent upon conditions present, should be utilized for the
+alleviation and cure of the bursitis.
+
+=Rest.= By far the most effective means of bringing about a speedy
+cessation of the inflammation occurring in the bursa sac is to procure
+absolute rest for the part involved. It has been noted that in a number
+of cases when no medical or surgical treatment has been afforded,
+inflammations of this nature resolve themselves speedily upon complete
+rest. There is nothing remarkable or supernatural about this for
+inasmuch as the bursa is only used during the movements of a part, it
+is easily understood why a trouble of this nature will clear up rapidly
+if the part is kept immobile.
+
+=Removal of Pressure.= There are many cases of bursal inflammation
+which occur in people who are not able to lay up and give complete
+rest to the affected part. The next most effective measure in these
+cases is the judicious and proper use of shielding. In applying a
+shield to a case of this nature it should always be remembered that
+the parts affected are usually swollen to a considerable extent around
+the tissues immediately overlying the sac itself. For this reason a
+shield such as would be employed for the protection of an heloma in a
+like situation, is not practical. This is more particularly the case
+where the bursitis is located on one of the interphalangeal joints of
+the toes. In this location an individual shield which is to rest on
+the affected toe alone cannot be applied, for the whole area overlying
+the inflamed sac will be found swollen and leathery and the tissues
+anterior and posterior, as well as those covering the interdigital
+surfaces of the toe, are ordinarily more or less involved in the
+general inflammation. In this instance, then, we must resort to some
+sort of shielding which will take the shoe pressure from the part, and
+yet which will be distributed over the whole digital surface and not on
+the diseased toe alone. A dorso-digital oval or crescent shield (see
+chapter “Shields and Shielding”) answers the purpose and is entirely
+effective in most instances.
+
+Probably the most practical method of removing all pressure from the
+inflamed areas is to have a circular portion of leather immediately
+overlying the part removed from the shoe and another softer piece
+adhered over the opening. The appearance of this will be inconspicuous
+and the small pouch thus formed allows the patient to wear a shoe,
+affording comfort, which, however, exerts no pressure upon the lesion.
+It is wise to remove a piece of leather considerably larger than the
+circumference of the affected part, otherwise the edges of the aperture
+cut in the shoe may become depressed and press upon and irritate the
+already inflamed areas.
+
+=Strapping.= Enlarging upon the theory of rest, inasmuch as complete
+absence of movement aids materially in reducing the local irritation,
+strapping is a practical means of immobilization.
+
+This procedure, although used in these situations, is not so practical
+in bursitis occurring over the first and fifth metatarsophalangeal
+joints, or over the interphalangeal joints, as it is in other locations
+upon the foot.
+
+Adhesive strapping is applied in such manner and at such tension as
+to accomplish almost complete immobilization, and for this reason it
+will be readily seen that this method cannot be used in cases where the
+added pressure will produce additional irritation. Several lengths of
+adhesive plaster are placed over the part and adhered tightly to the
+surrounding integument so that very little or no movement is allowed in
+the affected part.
+
+Strapping, to prevent movement, is particularly effective when the
+bursitis has occurred in the os calcis region between that bone and the
+tendo Achillis (retrocalcaneal bursitis). The foot is placed in plantar
+flexion and a long strip of 1¹⁄₂ or 2 inch plaster is anchored at the
+centre of the upper part of the calf and is then carried down over the
+heel on the plantar surface of the foot. This strip is then reinforced
+by transverse straps applied over the heel at the insertion of the
+tendon.
+
+Aside from these general methods of procedure thus discussed, the
+podiatrist must resort, in a majority of cases, to local treatment
+which will hasten the ultimate resolution of the inflammatory process.
+These local methods of treatment are conveniently divided into six
+groups:
+
+  1. Hydrotherapeutic measures.
+  2. Moist and wet dressings.
+  3. Unguent dressings.
+  4. Counter-irritation.
+  5. Massage.
+  6. Electricity.
+
+=Hydrotherapy.= Hydrotherapeutic measures may be resorted to in the
+treatment of bursal inflammations and either thermal extreme may be
+used with equal results. As one person will react to one extreme more
+readily than to the other, the choice of heat or cold usually depends
+upon the individual case.
+
+=Hot Applications= are probably most practical in these instances in
+the form of compresses. Several thicknesses of gauze, saturated in
+water, as hot as can be borne, are applied over the affected areas, the
+hot water being replenished as soon as the compress commences to cool.
+Hot applications act as mild poultices and their action is similar to
+them in a limited and modified form. They tend to hasten resolution
+of the inflammatory process by accelerating absorption. It is unwise,
+however, to continue hot applications for too long a period; it is
+found preferable to have the patient apply hot compresses for periods
+of one hour duration two or three times a day, allowing the part
+complete rest in the intervals.
+
+Hot compresses, applied continuously for some hours, are apt to bring
+about an over-stimulation in the parts to such an extent as to produce
+a slough. To be effective, it must be remembered that the compress
+must be kept hot for the entire period of application. This may be
+accomplished by immersion in hot water, by moistening intermittently,
+or by keeping the compress covered with some heat-confining covering.
+In the latter instance, oiled silk is in all probability the most
+practical agent, but even the use of an impervious covering does not
+relieve the patient of the necessity of remoistening the compress with
+hot water, at frequent intervals.
+
+[Illustration: INFECTED BURSITIS]
+
+=Cold Compresses=, as here advised, are either applications of cold
+water on a compress of gauze or some similar material, kept constantly
+wet, the use of ice bags or packs, or a cold water drip. The surfaces
+of the foot, particularly if the bursitis be on the toes, are so
+small, however, that as a general rule, ice bags or packs are not
+practical. The cold produces anemia of the parts by contracting
+the calibre of the blood vessels, and forcing the blood from the
+capillaries. They also tend to anesthetize the nervous sensibility
+and are in that way also pain reducing. There is one bad feature,
+however, in the use of cold as a hydrotherapeutic agent. The resulting
+reaction, which is generally bound to occur, gives the patient
+considerable annoyance and is apt in time to increase the infiltration
+and distension in the part. Again, should the patient have any tendency
+toward chilblains, the moist cold is almost always sure to develop the
+tendency into a reality.
+
+=The Poultice= is the older and now obsolete method of applying moist
+heat to a part. The stimulative action of this form of application is
+at times so severe as to cause deleterious effects upon the diseased
+tissues. A cataplasma should never be used where a distinct loss of
+tissue is in evidence, in the presence of pus, or where the vitality
+of the parts is considered to be subnormal, either from the age or
+condition of the patient, or because of the diseased condition of the
+part.
+
+The most generally used materials in this connection are flax-seed, and
+slippery elm, and the most practical manner for preparing a poultice
+for use in podiatry is to make several small bags (about two or three
+inches square) from cheesecloth or some like material. These are filled
+half full with the meal and are dropped into a vessel containing
+boiling water. The bags and their contents are allowed to boil for
+eight or ten minutes and are then applied to the part as hot as can
+be borne. This method does away with the rather “messy” procedure of
+laying a cloth on the part and then applying the warm mass by means of
+a spatula, spoon or like implement; also the poultice, so made, may be
+used again and again. The usual method of procedure in using poultices,
+when recommended, is to have the patient apply them continuously for
+about an hour during some part of the day. It is found much more
+effective to have moist heat applied for a longer period at one time
+than to apply three poultices a day, one in the morning, one at noon,
+and the last at night. The patient removes one bag as soon as it starts
+to cool and replaces it with another taken hot from the boiling water.
+This form of treatment, of course, tends at first to increase the
+overproduction of synovial fluid, and proper drainage must at all times
+be preserved so that this excess may be carried off.
+
+=Baking.= With the development of the modern baking apparatus,
+this method of applying heat to a part has come into use in cases
+of subacute or chronic bursal inflammations. The heat applied by
+this means is dry, in contradistinction to that obtained from hot
+applications of water and from poultices. As the synovial bursae are of
+similar structure to the true synovial membranes of the joint cavities
+and capsules, they are subjected to similar ailments. It stands to
+reason, therefore, that if baking is beneficial in several forms of
+arthritis, it is also beneficial in some forms of synovial bursitis.
+Some podiatrists have baking apparatuses installed in their offices;
+where this is not the case it is recommended that, when such treatment
+is thought advisable, the patient be sent to some hospital or institute
+where this treatment can be administered. Baking serves as a hyperemic
+agent (to bring an abnormal supply of blood to the part) and in this
+way to aid in the more rapid absorption of the exudates in the affected
+region.
+
+=Moist and Wet Dressings.= In conditions of acute bursitis, an
+efficient means of reducing the inflammatory symptoms is found in
+the use of wet dressings. Moist dressings (those with mackintosh
+protection) should not be used in these cases when the skin is broken,
+when there is any suspicion of a discharge, or where infection is
+present.
+
+The agents which may be used with such wet dressings are mercury
+bichloride, liq. aluminum acetate, saturated solution of boric acid and
+alcohol, equal parts, and lead and opium wash.
+
+=Mercury Bichloride= may be used as a wet dressing in all cases of
+acute bursitis, but more particularly where infection is present. It
+should never be used with mackintosh covering, for even without the
+confinement thus afforded, its action serves to macerate the skin to
+a great extent. The solution may be used either hot or cold and in no
+instance stronger than ¹⁄₄₀₀₀. This strength solution should only be
+resorted to in cases where the infection is acute and has progressed
+to some extent, weaker solutions, ¹⁄₅₀₀₀ or ¹⁄₁₀₀₀₀, being found
+efficient in a majority of cases. Mercury bichloride, on account of its
+toxic properties, should not be used after the infective process has
+been reduced, and there are many arguments in favor of an efficient
+substitute for it even in the initial instance. However, no solution
+which is practical for use in these cases can be depended upon for
+beneficent results as surely as corrosive sublimate. In chronic bursal
+inflammations, corrosive sublimate is contra-indicated.
+
+=Liq. Aluminum Acetate= can be used in place of bichloride of mercury
+in many cases of acute bursitis. The solution is decidedly astringent,
+and while this action is to be desired at times, nevertheless it
+has been found detrimental in the treatment of some cases of acute
+bursitis, because when it penetrates through the sinus into the bursal
+sac it has been found to create a decided irritation upon these deeper
+tissues. Liq. aluminum acetate, therefore, is shunned by many in the
+treatment of these cases, but aside from this one detrimental feature,
+the action of the acetate is efficient and is productive of good
+results. The drug may be used plain, or diluted with sterile water to
+reduce its irritant, astringent qualities. A dressing of liq. aluminum
+acetate, like bichloride, should never be confined in a mackintosh
+covering, as it will macerate the skin, quickly and thoroughly.
+This solution is particularly effective in subacute cases where no
+infection is present when its astringent action goes far to reduce the
+infiltration in the parts. It should be applied cold.
+
+=Boric Acid-Alcohol Solution= may be used in all cases of acute or
+subacute bursal inflammations. It is efficient in septic cases and
+its quality of rapid evaporation aids materially in reducing the
+inflammatory symptoms, independent of the therapeutic action of the
+component drugs. This solution, on account of its rapid evaporation,
+must be renewed more often than either of the foregoing, but while this
+demands more attention on the part of the patient, it is immeasurably
+better for the general condition of the disease. The one disadvantage
+in having the patients attend to the moistening of the dressing is
+that often they will fail to carry out instructions properly; but a
+condition of this nature, properly attended, will respond as quickly
+to the boric-alcohol application as to aluminum acetate or to mercury
+bichloride, and with none of the irritant or toxic tendencies of both
+of these. This solution is applied cold.
+
+=Lead and Opium Wash= may be used in the treatment of bursal
+inflammations, usually in the subacute or chronic stages. In cases
+where the integument is broken, avoid the use of this medication on
+account of the irritant qualities of the lead it contains. Prolonged
+applications are apt to develop a dermatitis, and if the skin is
+broken, local lead poisoning will not only be more pronounced, but
+will be manifest in a shorter space of time. Lead and opium wash, hot,
+is an advantageous application in the treatment of chronic bursal
+inflammations, the heated applications being continued for about thirty
+minutes at a time, at intervals of two or three hours. It should always
+be remembered in using this wash that it exhibits marked irritant
+qualities upon prolonged application.
+
+The choice of a moist dressing to be used in subacute or chronic cases,
+especially the latter, should be carefully made. Boric acid, saturated
+solution, is an efficient and safe drug to use under rubber, fish skin,
+or oiled silk covering but, as before mentioned, mercury bichloride and
+liq. aluminum acetate are contra-indicated in this connection.
+
+=Unguent Dressings.= Ointment dressings are used in this instance
+under the same rules and considerations which govern their application
+in all other conditions. No ointment should be applied on any inflamed
+bursa where there is a discharge of any nature. The operator must never
+forget that the base of all ointments is either oily or fatty and a
+serous discharge, coming from any surface, cannot be absorbed by the
+fabric used as a dressing if even a thin unguent film is interposed.
+
+Certain classes of drugs, however, which are known to be beneficial in
+certain stages in the treatment of bursitis, can be readily applied
+in unguent form and for this reason the question of using them may be
+profitably discussed here. The action demanded of drugs to be used in
+the treatment of bursal inflammations are antiphlogistic, analgesic and
+antiseptic. The latter action is particularly demanded in cases where
+surfaces denuded of epidermis are found. Some stimulant action is at
+times desired and drugs which have properties of this nature may also
+be included in this armamentarium. The following named ointments may be
+used, therefore, with beneficial results in certain stages of bursal
+inflammations: ichthyol, sulphur, menthol, balsam of Peru, scarlet red
+and salicylic acid.
+
+=Unguentum Ichthyoli=, 3% to 10%, is used in all cases where an
+emollient action is desired. The stimulating action of the drug in
+this form is negative, but it can be relied upon to reduce acute
+inflammatory symptoms. Ichthyol may be combined best with either
+lanolin or vaseline as a base; the former is preferred inasmuch as it
+does not become rancid when exposed to a variety of conditions as does
+the latter. Lanolin being a wool fat product is supposed to have a
+beneficent action upon certain pathologic conditions of the skin, and
+so it is used as the base of many ointments.
+
+=Unguentum Sulphuris=, 10%, may be used in many conditions of subacute
+or chronic bursitis. Its antiseptic action makes it a desirable
+choice for use when the integument is broken or when a distinct
+antiseptic action, in addition to the general action of sulphur as an
+antiphlogistic, is sought.
+
+=Unguentum Balsamum Peruvianum= is used in these instances, principally
+when some loss of tissue in the part is noticeable and where
+stimulation is required to accelerate granulation. Peruvian balsam is
+sometimes combined with ichthyol (5% of each) in ointment form. In this
+combination the ointment has marked stimulative and antiphlogistic
+qualities. Balsam of Peru is used in strengths of from 3% to 10% in a
+vaseline base.
+
+=Scarlet Red= is a highly efficient stimulative ointment. It is used
+alone, with zinc oxide or with borated vaseline, and should never
+be applied in too thick a coating. The parts should first be made
+thoroughly aseptic and dried, and then scarlet red applied on gauze in
+a thin even coat. Care should be taken that the application of scarlet
+red does not cause over-stimulation to the parts, and thus prove
+detrimental to the general condition of the lesion.
+
+=Unguentum Acidi Salicylici=, 2% to 5%, may be used to good advantage
+where the parts overlying the thickened sac are found to be somewhat
+calloused. One application of an ointment of this strength will serve
+to disintegrate this overlying thickening, thus making the parts
+flexible and soft. A stronger ointment than this should never be used
+in these cases, as salicylic acid is a strong epidermic disintegrant
+and will cause decided irritation if used in greater than 5% strength.
+In such cases salicylic acid may also be combined with collodion in
+the same percentage, 5 grains of ext. cannabis indica being added as
+an anodyne. Unguentum salicylic should never be used when the skin is
+broken or the tissues show any tendency to thinness. All ointments used
+in the treatment of bursitis are applied and kept in place by the use
+of a cocoon dressing. If a shield is to be used, it is first applied;
+the ointment is then placed in the shield aperture and the cotton and
+collodion dressing is made to cover the whole. The ointment should
+be renewed at frequent intervals in order that the dressing may not
+become hardened, and thus become an irritant.
+
+=Counter-Irritation.= Counter-irritation means literally an
+irritation which is developed to act against a previous irritation.
+It would seem, theoretically, that in cases of bursitis, this form
+of treatment is particularly advantageous. A bursal inflammation is
+a fairly deep-seated condition which should readily respond to a
+counter-irritation developed on the surface overlying the trouble.
+Counter-irritant agents should be used only in subacute and chronic
+cases, more particularly in the latter; for it is found that this form
+of treatment applied to an acute bursal inflammation tends to intensify
+rather than reduce the symptoms.
+
+In treating such cases we have a number of counter-irritants which may
+be used with consistently good results: iodine, capsicum, turpentine
+and mustard, are the most important and most commonly used.
+
+Iodine is today, in all probability, the most generally used agent to
+induce counter-irritation in podiatry. Its present popularity as a
+germicide, however, has over-shadowed its action as a counter-irritant.
+
+To obtain the maximum counter-irritant action from tincture iodine (U.
+S. P. 7%) it should be applied in a heavy coat at frequent intervals
+until such time as the inflammatory symptoms have entirely subsided.
+The continued use of iodine after this has been accomplished should be
+avoided as the tincture is irritant and mildly corrosive, and numbers
+of patients will be found whose skin will not stand its activities.
+Churchill’s tincture of iodine (about 16%) has been advocated for
+general use as a counter-irritant, but its action in many cases will be
+found too irritant for ordinary use.
+
+The theory of counter-irritation, simplified, is that a drug applied
+at a spot more or less distant from an inflamed area will cause an
+irritation in this new locality and thus aid the original condition,
+inasmuch as it will draw away the excess blood in the original part and
+allow the vessels to contract to normal calibre and the circulation
+there to become normal. Realizing this, it is readily understood why
+tincture of iodine should not be used as a counter-irritant in acute
+cases. With a discharging sinus to contend with, applying iodine over
+its opening at the periphery might be the cause of a severe irritation
+in that location which would further increase the tissue loss and thus
+prove a detriment to the general condition.
+
+=Capsicum= is generally applied in these conditions in the form of
+a plaster. It should never be used in acute cases as its greatest
+efficacy is apparent in those cases with chronic characteristics.
+Capsicum plaster is applied and renewed as necessary, until the
+symptoms of the deep inflammation have subsided. Shields are usually
+employed to remove the pressure while a chronic case is under
+treatment, and this removal of all irritation which the shoe might
+produce aids materially in the relief and cure of these conditions.
+
+=Turpentine= may be massaged into the parts for the purpose of
+counter-irritation although its action is at times severe; it should
+never be used where the skin is broken or where a discharge is present.
+It is not so desirable an application as either of the foregoing for it
+is found impractical to give proper massage to the comparatively small
+areas which are affected in bursal inflammations.
+
+=Mustard= has been recommended for use in cases of chronic bursitis,
+either in the form of a moderate local application or in a general
+foot bath. It is decidedly energetic in action, and should be used
+with great discretion and care. Every skin will not stand the action
+of mustard and for this reason it is not advocated as a general
+counter-irritant agent. Upon the failure of any of the other drugs
+mentioned under this heading, however, it may be tried, and if properly
+used, may prove conducive to good results.
+
+=Massage.= Massage is at times a potent factor in aiding absorption in
+chronic cases. There is no question but that the stimulation afforded
+by this procedure is efficient and will aid materially in returning the
+tissues to normal.
+
+Some cases of bursitis which occur upon the foot, however, are confined
+to such limited areas that massage is impractical.
+
+Several drugs which are reputed to have great powers of penetration
+are recommended as agents which can be safely massaged into the parts
+and even if the action claimed for them is overestimated, their use at
+least serves to reduce the friction upon the surface tissues.
+
+Many of the so-called “petrogen compounds”--drugs in combination with
+petroleum (mineral oil)--are recommended for use in these cases, and
+are undoubtedly of some benefit. Petrogen iodine, 10%, and petrogen
+camphor, 5%, (Wyeth) are the two most generally used, and have been
+found to be productive of good results.
+
+The compound is applied to the parts and then rubbed, first lightly,
+then gradually increasing the pressure, by the fingers and palm of
+the hand. It is found advantageous to massage the parts at first with
+a circular movement, confining the energy to the areas immediately
+overlying the enlarged sac. After about five minutes, the pressure is
+increased and considerable of the surrounding integument is included in
+the massage. The direction of the finger movements is then changed from
+a rotary one to a series of long strokes under considerable pressure,
+first toward the diseased sac, following as nearly as possible the
+blood supply to the part, and then away from the sac, following the
+outgoing vessels. This serves first, to increase the vascular supply,
+and then to aid in its quick removal, and reduce the congestion in the
+part. With this, the lymph activity is also increased so that it helps
+to absorb the waste products more rapidly.
+
+Massage should be recommended as a daily treatment and should
+be continued until all signs of infiltration have disappeared.
+Perseverance is necessary, for in chronic bursal inflammation, the
+changes are not noticeable nor should they be expected to be rapid.
+
+=Electricity.= Many forms of electrical application are recommended
+in the treatment of chronic bursal inflammations. Among those most
+commonly employed are the high frequency, and the faradic currents.
+Vibration, induced by electric impulses, is also recommended and is
+employed generally by the podiatrist.
+
+=High Frequency Current=, more popularly known or rather misnamed
+“violet ray,” is generally found efficient and is more generally used
+than any other form of electric application. This current serves to
+produce active stimulation in the parts and by this means tends to
+accelerate all functional activities and to hasten absorption. Whether
+the more popular priced and small sized high frequency machines on the
+market today really do create any but a very superficial stimulation,
+is a question, and for this reason a machine of greater power is
+recommended. The parts are treated daily, the glass electrode being
+applied for about eight or ten minutes at a time.
+
+=Faradic Current= is also recommended for daily use being applied by
+means of a moistened sponge electrode. The treatment is from five
+to ten minutes duration. Stimulation is obtained by this treatment
+which, as in the case of the high frequency current, aids the general
+absorption in the affected areas.
+
+=Vibration= used in these cases may be produced by electricity direct,
+or through a modern air compressor, controlled by electricity.
+Vibration is only recommended in chronic cases; it increases the
+functional activities of the part. It should be applied daily.
+
+Bursitis is a stubborn condition in any form, and can only be relieved
+and finally cured by scientific and rational treatment. The operator
+should bear in mind that rest and the absence of shoe irritation will
+do as much or even more for the general improvement of the condition
+than can be accomplished by drugs. Surgical procedure is certainly to
+be recommended in cases where no improvement is shown under palliative
+methods, even though this requires a cessation of activity on the part
+of the patient, and means the transfer of the patient to the care of a
+practitioner of surgery.
+
+
+
+
+CHAPTER XVIII
+
+CHIMATLON
+
+
+Chimatlon, or pernio, is an inflammation of the skin and of the deeper
+structures which is the result of exposure to reduced temperatures. The
+severity of the condition depends upon the length of the exposure as
+well as upon the degree of temperature. If the skin alone is involved
+and there is no loss of tissue, chimatlon mild, or chilblains, is the
+term applied to the lesion; where there is an involvement of the deeper
+structures the condition is called chimatlon severe, or frost bite. In
+many instances it becomes difficult to distinguish between a severe
+chilblain and a mild frost bite. However, for the sake of scientific
+study, in all cases in which the deeper tissues are involved and
+suppurative processes affecting these structures manifest themselves,
+the condition should be considered as chimatlon severe, for these cases
+are usually due to prolonged exposure to low temperatures.
+
+
+CHIMATLON MILD
+
+=Derivation.= Chimatlon, from the Greek, meaning the severity of winter.
+
+=Synonyms.= Chilblains, Dermatitis Congelationes, Erythema Pernio.
+
+=Definition.= Chimatlon mild, or chilblains, is a local inflammation of
+the skin due to exposure to cold and dampness.
+
+=Etiology.= Chilblains are primarily due to exposure to cold in varying
+degrees. When the part is exposed to a decreased temperature, the
+vasomotor nerves become affected and the cutaneous circulation is
+impaired. This interference with the blood flow produces congestion,
+leading to inflammation, which latter is followed by a serous discharge
+or even by the production of pus. Dampness hastens the affection of
+the vasomotor nervous system of the skin, and where this organ is very
+sensitive, in the presence of moisture, only a moderate decrease in
+the temperature is necessary to produce all the symptoms of severe
+chilblains.
+
+The parts of the body most usually affected are the hands and feet;
+the distance of the extremities from the heart is probably the reason
+for this impairment under the other abnormal conditions. Where the
+horny layer of the skin is thin, it receives its nourishment normally,
+regardless of the distance from the heart; but on the hands and feet
+the skin is thicker and is imperfectly nourished and a decrease in
+temperature, in the presence of moisture, results in local inflammation.
+
+Females are more disposed to chimatlon mild than males, and young
+people more than old. Aside from cold as an etiologic factor, there
+is also the predisposition which is equally as important in the
+production of chimatlon mild and should be considered in every case.
+Imperfect circulation in the limbs, due to varicose veins and arterial
+disturbances, caused by a deranged nervous system, are often causes of
+chilblains and must be given consideration.
+
+Any part of the body exposed to the air may become affected,
+particularly the ears and nose. Several cases of chimatlon mild of
+the skin over the throat have been recently reported, due to walking
+against a strong wind, with the throat bared to the weather.
+
+=Symptoms.= The symptoms in the mild form of chimatlon vary with the
+severity of the exposure. In very mild cases the only perceptible
+symptoms are a tingling or slight itch, and the part feels cold and
+clammy to the touch. The most common cases show the parts colored dark
+blue or purple, immediately after exposure and during the reaction.
+The parts are inflamed and there is severe itching coupled with pain.
+After reaction has set in, the color of the lesions varies from a
+scarlet to a purple. There is no sharp line of demarcation between the
+affected and the surrounding area, but there is a gradual blending
+between the discolored and the normal tissues. There is considerable
+congestion, the parts are swollen and after a complete reaction, heat
+manifests itself. These symptoms may soon subside or they may persist
+for many months. In general, they are of a transient nature, but
+the parts remain permanently weakened and congested, and are easily
+affected from the slightest cause.
+
+In the more severe types of chilblains, blebs are formed which, when
+opened, exude serum or even pus. The blebs are commonly found at the
+ends of the toes, and sometimes the entire distal end of the digit is
+covered by one lesion.
+
+No pain is felt immediately after exposure, but as reaction commences,
+shooting pains develop, and if the reaction is severe, these pains
+become almost unbearable. Itching is present to a marked degree, and
+after reaction is complete, dull pains and burning are noticed until
+the affected parts become normal.
+
+=Pathology.= The immediate effect of cold upon the skin is to constrict
+the small blood vessels and to retard the stream within them. Under
+quite severe or prolonged exposure there may ensue a destruction of
+the minute vasomotor nerve terminals in the arterioles, which control
+their constriction and dilation. This nerve function is thereafter
+permanently affected and the muscular coat of the vessels in the parts
+impaired, atrophies from disuse. It is this degree of chimatlon which
+is classified as chimatlon mild, or chilblains. (Destruction of tissue
+beyond this, is classified as chimatlon severe or frost bite).
+
+In winter there is a natural conservation of heat, by the constriction
+of the superficial capillaries; the blood supply to the skin is
+diminished and heat radiation is thus controlled. This reduction in the
+peripheral blood pressure especially affects the feet and other parts
+remote from the heart.
+
+Later on besides this natural deficiency in the blood supply, there
+is in chimatlon mild a deficiency of freely circulating blood, due
+to the blood vessels relaxing. The reverse condition may seem to be
+proven by the heightened color but in reality this redness is due to
+too much blood in the tissues. There is however, congestion; the blood
+entering the tissues has but little motion, the pulse wave is lost in
+the relaxed vessels and the stream is in consequence a sluggish one.
+The reduction in the supply of fresh blood is probably the direct cause
+of the pain; the lack of oxygen brought to the parts and the retention
+of excrementitious chemical substances, act as irritants to the sensory
+nerve terminals. Persons suffering with chilblains have feet which
+are generally cold to the touch in spite of their being surcharged
+with blood. The blood in them is rendered sluggish and the heat is not
+retained long, nor is there a sufficiently rapid supply of fresh blood
+to replace it.
+
+In summer time, when the general peripheral circulation is at its
+maximum, vascular conditions are equalized throughout the entire body
+surface and are congenial to conditions in affected areas.
+
+All the peripheral vessels are dilated and the blood pressure within
+them is increased to facilitate heat radiation and the maintenance
+of a cool body. “The season is congenial to persons who suffer with
+chilblains in winter because the pathologic condition is compensated
+by the physiologic vasodilatation and heightened blood pressure.”
+(Maximilian Stern, M.D.)
+
+[Illustration: CHIMATLON MILD FROM THE JACOBI ATLAS]
+
+=Diagnosis.= Chimatlon mild is a true inflammation of the skin with or
+without bullous formation and serous or purulent exudation. The color
+varies from a light scarlet to a deep purple and the lesions blend
+gradually with the surrounding normal tissue. The part feels cold and
+clammy to the touch, this being a characteristic symptom in spite of
+the heightened red color. The blood present in the parts is sluggish
+so that its temperature is below normal.
+
+Chilblains of the metatarsophalangeal joint of the great and fifth toes
+may be mistaken for bursitis. The chief difference between the two
+conditions is found in the history of the case, which in chilblains
+shows exposure, while in bursitis the lesion is usually accompanied
+by hallux valgus. The usual sites of chimatlon mild of the foot are
+the heel, the tips of the toes, the great and little toe joints and
+the webs between the toes. The pains of chilblains are transient and
+of a shooting variety, and are present with the shoe on or off, while
+those of bursitis are constant and dull, and are present only when the
+shoe is worn. Where inflammatory processes have continued so that the
+deep tissue are involved, the pains are of a throbbing nature in both
+lesions, so that other symptoms must be observed to determine upon a
+proper diagnosis.
+
+      CHIMATLON MILD                           BURSITIS
+  History of exposure                  No history of exposure
+  Hallux valgus not usually present    Hallux valgus usually present
+  Pains of shooting variety            Pains dull and steady
+  Pains present at all times           Pains absent with shoes off
+  Intense itching                      No itching
+
+The lesions of chimatlon are irregular in shape and may involve the
+entire forefoot, including both the dorsal and the plantar surfaces.
+The heel over the tendo Achillis, as well as the skin on the sole and
+lateral surfaces over the os calcis, are common sites of chilblains.
+These lesions are usually deeply colored, the redness gradually
+diminishing as the periphery is reached.
+
+The blebs which have formed, may exude serum or even pus, and these
+lesions may be easily differentiated from the blebs of pompholyx and
+eczema by carefully noting the history of the case, the age of the
+patient and the general appearance of the foot and leg.
+
+=Prognosis.= The ultimate cure of chilblains is uncertain. Cases of a
+mild type often respond immediately, while others persist indefinitely.
+The painful symptoms are readily relieved, but the lesion itself often
+continues until the change of season, when the warmer weather brings
+about a cure. This is due to the changes that occur in the cutaneous
+circulation during warmer weather. Recurrence is the rule in those who
+have poor circulation from anemia or other causes.
+
+=Treatment.= The treatment for chimatlon mild consists in bringing
+about a gradual reaction. This should be commenced immediately after
+exposure, and is accomplished by rubbing the parts with snow or cold
+water. It must be remembered that the reaction must be gradual. If the
+parts exposed are rapidly warmed, the reaction will be equally rapid,
+and serious results may follow. After reaction has been established,
+the treatment varies with the severity of the resulting inflammation.
+
+When the skin has been broken and blebs or bullae are present, the
+lesions must be healed first. For this purpose ointments are most
+desirable. The parts should be thoroughly cleansed with an antiseptic
+such as phenol (1-40) or bichloride of mercury (1-2000), and by
+removing serum or pus present, with hydrogen peroxide. The surface of
+the lesion may then be dressed with any of the following:
+
+  ℞   Ichthyol                 8.00
+      Petrolatum q. s. ad.    32.00
+  M. ft. ung. Sig. Apply over affected parts twice daily.
+
+  ℞   Acid. carbol.            0.60
+      Acid. boric              2.00
+      Petrolatum q. s. ad.    32.00
+  M. ft. ung. Sig. Apply on chilblain once daily.
+
+  ℞   Spirit. terebinthinae    2.00
+      Acid. boric              2.00
+      Petrolatum q. s. ad.    32.00
+  M. ft. ung. Sig. Apply on chilblain once daily.
+
+Wet dressing of Burow’s Solution, diluted with equal parts of distilled
+water, applied for a few days, produces satisfactory results in lesions
+where there is marked inflammation and swelling.
+
+In severe ulcerative processes that do not granulate readily, a strong
+stimulant, such as balsam of Peru or some iodine preparation, should be
+used until the entire area is healed.
+
+After the skin has been healed, or in cases where the skin has not been
+broken, the treatment varies with the severity of the lesion. In very
+mild cases, massage followed by an application of the compound tincture
+of benzoin, which, because it furnishes an occlusive coating and acts
+as a support for the skin, is often sufficient. The liquor alumini
+acetatis (Burow’s Solution) may be used as an astringent wet dressing
+to reduce the swelling and inflammation. The part may also be painted
+with a four per cent. solution of silver nitrate at frequent intervals,
+to be then covered with raw cotton; or nitric acid, diluted with aqua
+cinnamoni, 15 minims to the ounce, may be painted over the unbroken
+skin.
+
+A very satisfactory liniment which has been used extensively to relieve
+the pain and reduce the inflammation in this condition consists of the
+following:
+
+  ℞    Guaiacol               8.
+      Spts. terebinth.       28.
+      Ol. olivae q. s. ad.   64.
+  M. ft. lin. Sig. Rub on affected parts at bedtime.
+
+The itching, which is a marked symptom of chimatlon mild, can readily
+be controlled by the application of camphorated soap liniment. Its
+action is almost instantaneous.
+
+Ichthyol has proven to be a valuable agent in the treatment of
+chilblains; it may be used with collodion, or as an ointment, the
+following being found satisfactory:
+
+  ℞   Ichthyol                8.
+      Lanolin q. s. ad.      32.
+  M. ft. ung. Sig. Spread on gauze or lint and apply.
+
+It must be borne in mind that the apparent cure of an acute lesion
+of chimatlon mild, is not in reality an absolute cure, and thorough
+precautions must be taken to prevent recurrence. Stimulation of the
+cutaneous blood supply and the vasomotor nervous system is essential,
+and for this purpose, massage and the alternate hot and cold foot baths
+are advisable. The latter treatment should be used at least once daily
+and if possible, twice a day. The feet should be kept in hot water for
+thirty seconds and then plunged into cold water and kept there for
+fifteen seconds. This is repeated for an entire ten minute period.
+
+Electricity, in the form of the faradic or the high frequency
+currents, may be used to assist in the stimulation of the action of
+the skin. These treatments should be given for ten minutes, three times
+a day.
+
+The hygiene of the foot is all important, and this should be explained
+at length to the patient. The feet should be protected by wearing
+woolen or cashmere stockings, the latter being preferred, and should
+be used from early in the fall until late in the spring. Hose of this
+kind prevent heat radiation, so necessary for those who suffer from
+chilblains; they also absorb excretory moisture, all of which prevents
+recurrence of the lesions. It is necessary to conserve the body heat
+as much as possible, and warm underclothing, covering the entire body,
+should be worn; the patient should be instructed to take some form
+of general exercise. Footgear should be wide enough to allow freedom
+of the toes and the shoes should be made of either calf skin or vici
+kid. The wearing of silk stockings and patent leather shoes must be
+discouraged if good results are to be expected.
+
+Where the skin is not broken, Dr. Charles T. St. Clair of Bluefield,
+West Virginia, advises as follows: “coal oil (kerosene) applied night
+and morning to old itching frost bites of the feet gives almost
+immediate relief. It should be applied with a cloth and cotton soaked
+in the kerosene and allowed to evaporate, which it will do in a few
+minutes. If the sock is put on and the person goes to bed with the foot
+still wet with the oil, it may burn the skin.”
+
+
+CHIMATLON SEVERE
+
+=Derivation.= Chimatlon, from the Greek, meaning the severity of
+winter; severe, with extremely bad effects on the tissues.
+
+=Synonyms.= Frost bite, pernio, dermatitis calorica.
+
+=Definition.= Chimatlon severe is a local inflammation of the skin
+and deeper structures, produced by exposure to extreme cold, and is a
+result of complete or partial paralysis of the vasomotor nerves.
+
+=Etiology.= The one cause for the severe form of chimatlon is
+prolonged exposure to an extreme degree of cold. The decrease in
+atmospheric temperature lowers the temperature of the parts exposed,
+thereby causing complete or partial paralysis of the vasomotor nerves
+and producing congelation of the blood vessels. When the congelation
+is complete the parts are deprived of their nourishment, and finally
+become devitalized.
+
+=Symptoms.= Immediately after exposure, numbness develops and all
+sensation is gradually lost. The parts are congealed and if there is
+complete freezing, they present a white, blanched appearance. The
+tissues affected may be so completely frozen, that upon thawing, they
+are either found to be absolutely dead, or their vitality so greatly
+impaired that there is very little reaction and gangrene may result in
+a very short time. If the area is not completely frozen, the reaction
+is rapid, the tissues become purple, swollen and very painful. The
+parts may become gangrenous, in which case the line of demarcation and
+separation between the gangrenous and the healthy tissues evidences
+itself. The affected tissue is at first white but gradually becomes
+blue and finally black. The fluids in the tissues rapidly evaporate and
+the odor of decaying flesh is very apparent.
+
+If the parts do not become gangrenous, the symptoms that present
+themselves are those of inflammation. The tissues become swollen and
+assume a deep purple color, which, as the circulation is restored,
+becomes lighter and, after inflammation has subsided, gradually
+disappears. Blebs may form and there may be an exudation of serum or
+even of pus.
+
+=Pathology.= The changes that occur in chimatlon severe are much
+the same of those of the milder type, the former however, causing
+complete destruction of tissue, or the development of gangrene. The
+cold causes a constriction of the blood vessels and the stream within
+them is retarded. The minute nerve terminals in the smaller arteries,
+which control the dilation and constriction, are destroyed and their
+function is lost. The vessels now contract and in extreme cases remain
+so. Where the exposure has not been severe enough to cause complete
+death of the vessels, there is a dilation after the contraction, with a
+very slow movement or even complete stasis of the blood stream.
+
+Gangrene or necrosis will manifest itself in extreme cases almost
+immediately, and often after reaction has commenced, the tissues may be
+cast off. At the line of demarcation between the normal and the dead
+tissues, the changes that accompany inflammation take place.
+
+=Diagnosis.= The diagnosis of frost bite is not very liable to be
+confused with any other condition, in that the history shows exposure
+to an extremely low temperature. The disease known as “Trench Foot,”
+when it first manifested itself, during the world war, was considered
+a form of chimatlon, but since research work has been done along
+the lines of the new disease, it has been found to be quite another
+condition. Trench Foot will be discussed following this chapter.
+
+The color of the part is characteristic. Immediately after exposure,
+the tissues are blanched, and as reaction progresses, the color deepens
+from a light scarlet to a deep red purple or black, depending on the
+length of the exposure and the severity of the condition. As reaction
+advances, the gangrenous tissue is separated from the normal tissue by
+a distinct slough, which, as previously stated, is known as the line of
+demarcation.
+
+The milder cases of frost bite and the severer cases of chilblains are
+often confused, particularly in cases of the former when the loss of
+tissue has been avoided. The confusion, although of no great moment
+(inasmuch as the treatment of both lesions is identical), may be
+avoided by remembering that frost bite develops quickly and that the
+parts have been exposed to a very low temperature, while chilblains
+develop more slowly, are less painful and do not require exposure to a
+very great decrease in temperature for their causation.
+
+=Prognosis.= When the part has been completely frozen and the
+circulation to the parts has ceased, there is no possibility of saving
+the tissues. However, in cases seen immediately after exposure, in
+which proper treatment is commenced at once, it is often possible to
+save large areas that would otherwise be lost. Amputation is the only
+cure in cases where gangrene has developed. The ulcers which result
+after the dead tissue has been removed, respond very slowly, requiring
+from one to four months to heal.
+
+Recurrence is the rule, due to the fact that the vasomotor nerves never
+regain their normal vitality, and persons who have had frost bite will
+develop symptoms from the least imaginable cause.
+
+=Treatment.= In all cases of frost bite, even when the parts seem
+hopelessly frozen, the first treatment should consist of bringing the
+parts back to normal temperature by a gradual reaction. This should
+be carried out as thoroughly as possible, for it often is the means
+of saving large areas of tissue. A case in which the entire forefoot
+is involved may be thus saved so that only one or two toes are lost.
+Such a patient would be able to walk comfortably, whereas if no care
+were taken with the preliminary treatment, the patient might become a
+hopeless foot cripple.
+
+A gradual reaction is brought about by rubbing the parts with snow or
+cold water. The affected parts may be placed in a vessel containing
+cold water, or they may be wrapped in cloths wrung out in cold water.
+The final result depends largely upon the length of time elapsing
+between the exposure and the inauguration of the first treatment.
+
+If the parts are completely frozen, gangrene will soon manifest itself.
+If the affected part is only partly frozen, a gradual reaction can
+be brought about by the above-described means and if the subsequent
+inflammatory reaction is gradual, gangrene may be averted or at least
+limited. Cold water dressings should be continued for some time after
+reaction has occurred, and should be maintained until the certainty
+of the avoidance of gangrene is fixed. The line of demarcation and
+separation will be indicative of this fact.
+
+When all of the gangrenous tissue has separated, the remaining ulcer
+should be treated just as though it had arisen from any cause. In
+cases of gangrene of the toes and feet, complete or partial amputation
+should be practised as soon as the lines of demarcation and separation
+are well established. When gangrene has been avoided in frost bite,
+the treatment consists in stimulating the affected area. Various
+medicaments are useful, among which may be mentioned oil of turpentine,
+balsam of Peru, tincture of iodine, ichthyol and strongly carbolized
+ointments.
+
+If the frost bite is of the bullous, pustular, vesicular or escharotic
+type, soothing agents such as ichthyol, Burow’s solution, etc., should
+be applied to the affected parts.
+
+Wrapping the affected parts in dry salt has been suggested by a western
+chiropodist, who claims to have obtained excellent results by the use
+of this agent.
+
+In cases where gangrene has been averted, the following have proved of
+great value:
+
+  ℞   Acid, carbol.          1.
+      Acid, boric            2.
+      Petrolat, q. s. ad.   32.
+  M. ft. ung. Sig. Apply every morning.
+
+  ℞   Ichthyol               8.
+      Lanolin q. s. ad.     32.
+  M. ft. ung. Sig. Apply on lesions once daily.
+
+  ℞   Ichthyol               8.
+      Aquae q. s. ad.       32.
+  M. Sig. Paint over the affected area.
+
+In frost bite, after the gangrenous tissue has been removed, the
+resulting ulcer may be treated with a stimulant. For this purpose
+balsam of Peru, iodine, ichthyol and other agents have proven
+successful. These ulcers do not respond readily, because of the
+decrease in vitality of the surrounding tissues, and patience is
+essential for a final cure. The patient must be told that the lesion
+will require a long time to heal.
+
+Hernance (Therapeutic Gazette, 1895) draws the following conclusions
+from the study of thirty cases: “1. Ichthyol is the drug that
+gives most relief to pain and is as good a protector as any other
+application. 2. Acetanilid ointment is the best dressing when the
+parts are raw and ulcerated, preventing suppuration and promoting
+granulation. 3. In a certain number of cases one can do nothing but
+keep the parts clean and wait until nature throws off the diseased
+tissue.”
+
+Massage is a very good therapeutic agent for chimatlon severe, and
+should be applied twice a day, if possible. This will help stimulate
+the circulation and tone up the faulty nerve endings. Electricity
+should also be used wherever possible, the high frequency and the
+faradic currents being the best. Applications directly to the affected
+parts for ten minutes, once or twice a day, will aid materially in
+bringing about a rapid cure.
+
+The prevention of the recurrent attacks may be accomplished by
+treatment commenced in the early fall, and including massage, proper
+shoes, cashmere stockings, and other prophylactic measures. This
+treatment is essential, particularly for those who are anemic and
+under-nourished.
+
+
+
+
+CHAPTER XIX
+
+DISEASES OF THE SWEAT GLANDS
+
+
+HYPERIDROSIS
+
+=Derivation.= From the Greek _hyper_, in excess, and _hidros_, sweat.
+
+=Synonyms.= Idrosis; ephidrosis; hydrosis; sudatoria; polyidrosis;
+excessive sweating, sudorrhea.
+
+=Definition.= Hyperidrosis is a functional disorder of the sweat
+glands (usually of the hands and feet) characterized by the excessive
+excretion of sweat. The condition may be limited to certain areas or it
+may be distributed over the entire body.
+
+=Etiology.= When hyperidrosis is general it is caused by faulty
+innervation. The cause in localized forms is doubtless varied from
+that of pure idiosyncrasy to grave systemic disturbances. In instances
+there seems to be an inherited tendency to this disturbance. Excessive
+drinking of water or tea will produce hyperidrosis pedum in some
+people. Localized sweating may follow some debilitating diseases for a
+period of time. Anything that causes a depression of the nervous tone,
+may be an etiologic factor. Neurasthenics often display this symptom.
+Physical or mental excitement will cause profuse sweating in many
+individuals.
+
+=Pathology.= The normal sweat excretion is closely related to the
+nervous system, hence pathologic excretion must have some nervous
+cause. It is most probable that any disease or injury that affects the
+function of the sympathetic nervous system, is the direct cause of
+excessive sweat excretion. Examination of sections of the glands fails
+to show any increase in size or in the epithelium of the gland.
+
+=Symptoms.= Hyperidrosis may occur as a result of a general disease
+such as rheumatism, tuberculosis, malaria, etc., or it may be
+idiopathic and persist for a long period. The latter phase is of most
+interest to the podiatrist. The disease is quite common. The sweating
+may be immediate or profuse, and is always more marked in regions where
+excessive sweating is normal, such as the hands, feet, axillae, etc.
+It is more pronounced in hot weather, but is excessive even in cold
+weather, and is increased by the least exertion. In hot weather it is
+frequently accompanied by miliaria, intertrigo, or acute eczema.
+
+On the feet, hyperidrosis is often disgusting, and may become
+exceedingly troublesome. The excretion is excessive and the feet are
+constantly damp or wet and clammy. The stockings become moist and the
+shoe may become water-soaked. Sweating is most profuse on the soles and
+between the toes. The skin is soggy and macerated and, in severe cases,
+the sole and surrounding areas are reddened, puffy and irritated,
+with ill-defined vesicular or flattened bullous lesions. In ordinary
+hyperidrosis of the feet, the sweat is not offensive immediately after
+it is exuded, but rapidly becomes so, unless the footgear is changed
+frequently. Bromidrosis is often associated with hyperidrosis.
+
+=Prognosis.= As a rule, localized cases are obstinate, but with
+continued treatment, good results will follow. It is often necessary to
+change the treatment from time to time. Relapses are not uncommon.
+
+=Treatment.= The treatment of hyperidrosis is divided into two groups,
+local and general. Excessive general sweating following fevers and
+debilitated conditions of the system should receive general treatment
+at the hands of the physician. When nervous disorders produce sweating
+in limited areas, they also require specially directed general
+treatment. In localized sweating of indefinite cause, under the advice
+of the physician, it is often advisable to administer general tonics,
+and remedies such as ergot, belladonna, gallic acid, etc., may be
+locally applied. Precipitated sulphur, taken internally, one dram
+twice daily, is the resort of many physicians in such cases and the
+treatment has given satisfactory results.
+
+While constitutional treatment should be used in every case of
+hyperidrosis pedum, the external treatment is more positive in result
+and therefore is more essential. This external treatment consists of
+the application of ointments and powders, with frequent washing and the
+use of lotions. Astringent lotions, used for the purpose of hardening
+the skin may be chosen from the following:
+
+  Alum powdered    1 ounce.
+  Water            1 pint.
+
+or
+
+  Zinc sulphate    2 drams.
+  Water            1 pint.
+
+or
+
+  Formalin         3 drams.
+  Alcohol          1 pint.
+
+The feet should be thoroughly cleansed and dried. Lotions applied two
+or three times daily, should be allowed to dry on the foot. This may
+then be followed by a dusting powder of the following:
+
+  Acid salicylic  15 grains.
+  Boric acid       1 ounce.
+
+The local application of belladonna in the form of the diluted
+tincture, the liniment or the ointment, has given excellent results
+in some cases, but great care should be exercised in their use, as
+belladonna may produce toxic effects, through absorption.
+
+Many cases have responded readily to the alternate foot bath (See
+Chapter, _The Care of the Foot_). After the alternate foot bath,
+the feet are thoroughly dried, and in severe cases, the lotion of
+formalin and alcohol may be used, or in ordinary cases, grain alcohol
+is applied. When the lotion has dried, the feet are dusted with the
+following powder:
+
+  ℞ Acid salicylic                      15 grains
+    Alum powdered
+    Lycopodium                aa         1 ounce
+    M. Sig. Dust on feet morning and night.
+
+Diachylon ointment, freshly prepared, is the best remedy among the
+unguents. It is prepared as follows:
+
+  ℞ Lead plaster               1 ounce
+    Oil of lavender flowers   15 grains
+    Olive oil, q.s. ad.        3 ounces
+    M. Sig. Apply on gauze and bandage.
+
+Another ointment which has astringent properties and which has been
+used with some success is:
+
+  ℞ Tannic acid            2 drams
+    Petrolatum             1 ounce
+    M. Sig. Spread on gauze and bandage.
+
+Before these ointments are applied, the parts should be thoroughly
+washed with soap and water, dried, and the ointment spread on gauze
+and held in place with a bandage. The application should be removed
+after twelve hours, the parts rubbed dry with a towel, and the ointment
+reapplied. This should be continued for a week or two, when, if results
+have not followed, other forms of treatment should be used.
+
+The X-rays have a drying influence upon the skin, but if this treatment
+is used, great caution should be exercised, as the rays are likely to
+have a very harmful influence upon the tissues generally.
+
+At the suggestion of a prominent chemist and physician, a series of
+experiments were performed with oxygen gas and vanadium chloride
+solution for the treatment of hyperidrosis, which proved more or less
+successful. The solution of vanadium chloride (1-20,000) was applied
+to the foot, and the oxygen gas was slowly sprayed on the foot, from
+a large gas container. This treatment lasted for ten minutes and was
+applied twice a week. In one particular case, which had resisted the
+ordinary methods of treatment, the use of this remedy was of great
+benefit to the patient. After several weeks, the case showed marked
+improvement, but the inability of the patient to continue treatment
+prevented further trials. In many other ordinary cases of hyperidrosis,
+the results were excellent, while in others there was no marked
+improvement[6]. The use of formalin and alcohol solution in conjunction
+with the oxygen treatment, has proven very effective. The lotion is
+used at night, immediately before retiring.
+
+Stillians, in the Journal of the American Medical Association, states
+that a 25% solution of aluminum chloride in distilled water, dabbed
+gently on the part every second or third day and allowed to dry, will
+cause a rapid amelioration of the excessive sweating; three such
+applications are usually sufficient. If the condition recurs, the
+treatment may be repeated.
+
+Potassium permanganate solution, 5 parts to 1,000, has been found
+efficient as a wash for the feet. More active, and therefore to be used
+with more care, are “chromic acid” solutions, as:
+
+  Chromium trioxide    2.5
+  Water               50.0
+  Sig. Use as a paint once a week.
+
+Less active, but more pleasant than the foregoing, is:
+
+  Tannic acid         5.
+  Alcohol           100.
+  Water, q. s. ad.  200.
+  Sig. Use as a wash twice a day.
+
+The lotions and washes should be used in conjunction with drying
+powders, such as have been already mentioned.
+
+The use of the various solutions of aluminum chloride, or of chromium
+trioxide, may, in some cases, cause a mild dermatitis, perhaps
+with itching. This may be relieved by the application of protective
+dressings to prevent scratching, and the application of ointments, such
+as cold cream containing 12 per cent. boric acid, or a calamine lotion.
+Itching may be relieved by adding 0.5 per cent. phenol to the calamine
+lotion.
+
+
+BROMIDROSIS.
+
+=Derivation.= “_Bromos_,” a stench; and “_hidros_,” sweat.
+
+=Synonym.= Osmidrosis.
+
+=Definition.= Bromidrosis is a functional disorder of the sweat glands,
+characterized by a sweat excretion which has an offensive odor.
+
+=Etiology.= The etiology of bromidrosis is much the same as that of
+hyperidrosis, occurring in those who are anemic, chlorotic and nervous
+and in those who are compelled to stand for long periods. Eating
+certain foods and drugs will give peculiar odors to the perspiration,
+among which are garlic, onions, assafetida, and sulphur. The cause of
+the odor of the sweat in bromidrosis pedum is the decomposition of the
+fatty acids of the sweat, as well as the presence of the bacterium
+fetidum, which is found on the feet, especially between the toes.
+
+=Pathology.= Immediately after the sweat is excreted, it is not
+offensive, but soon becomes so, due to the presence of microorganisms
+and the decomposition of the fatty acids.
+
+=Symptoms.= The sweat has a disagreeable odor and is usually associated
+with hyperidrosis, but not necessarily so, as it may occur in persons
+having a normal sweat excretion. When the excretion is excessive, there
+are the usual symptoms of hyperidrosis, viz., puffiness, tenderness,
+sogginess and possibly blebs or vesicles. The odor is offensive, stale,
+penetrating and peculiar and often is sufficient to make the sufferer
+unfit for society.
+
+=Treatment.= The treatment is essentially the same as for hyperidrosis,
+coupled with absolute cleanliness and frequent change of footgear.
+Shoes should be allowed to stand in the air for at least twenty-four
+hours after having been worn, so that several pairs are required.
+Constitutional treatment is the same as for hyperidrosis as is also the
+external treatment. The feet should be washed in boric acid solution,
+and the powder used freely in the socks and on the feet.
+
+The feet may be painted once every three weeks with a 5 to 10 per cent.
+solution of chromic acid, or they may be washed every other day in one
+per cent. solution of potassium permanganate, and in the interval the
+following powder proves efficacious:
+
+  ℞   Acid salicylic            10 grains
+      Tannoform                  2 drams
+      Zinc oxide
+      Talc                    aa 3 drams
+      M. Sig. Dust on feet morning and night.
+
+
+ANIDROSIS
+
+=Derivation.= _a_, without; and _hidros_, sweat.
+
+=Synonym.= Decrease or absence of sweating.
+
+=Definition.= Anidrosis is a functional disorder of the sweat glands
+characterized by a diminution or suppression of sweat.
+
+=Etiology.= Anidrosis is rare as an idiopathic condition, occurring
+generally in diabetes and fever, also in some skin diseases such as
+ichthyosis and pityriasis rubra pilaris; also in the parts affected
+by anesthetic leprosy, scleroderma and keloids. Localized sweat
+suppression follows injury to the nerves.
+
+=Symptoms.= The skin seems to be abnormally dry, and this dry skin may
+be a form of ichthyosis or may predispose to eczema. When the sole
+of the foot is dry and the skin shows clefts, which contain helomata
+miliare, and has a yellowish color, diabetes may be suspected. There
+may be but slight diminution of sweat excretion, or total absence.
+
+=Treatment.= In congenital cases, nothing is of much avail. In the
+acquired cases, applications of hot water or vapor baths externally,
+and general tonics, the free drinking of water and the use of warm
+clothing, are indicated. Pilocarpin or jaborandi may be given
+internally, but this must be on the prescription of a physician.
+Massage with oil or the application of galvanic or faradic electricity
+have proven of benefit. Hot alkaline baths, preceding the massage with
+oil, are also at times beneficial.
+
+In addition to the above there are a number of rare granular
+perversions which occasionally are seen by the podiatrist and of which
+but brief mention need here be made:
+
+_Chromidrosis._ A condition in which the sweat is colored, usually
+black. When this condition arises from accident, the sweat may be
+colored green. Red sweat, which occasionally occurs in the axillae, is
+due to the action of bacterium prodigiosum.
+
+_Sudamen._ A collection of sweat in the upper layers of the epidermis,
+due to obstruction of the sweat ducts, which gives rise to an eruption
+of numerous pinhead, transparent vesicles. Occurs during the course of
+fevers and is usually of but short duration.
+
+_Uridrosis._ Characterized by the excretion of urine constituents
+through the sweat glands. Usually the result of suppression of urine by
+reason of impaired kidney function, whereupon the sweat glands assist
+in the elimination of the urinary deposits. There is a urinous odor to
+the skin.
+
+_Hematidrosis._ Characterized by hemorrhage from the sweat glands. A
+very rare condition.
+
+_Phosphoridrosis._ In this very unusual disease the sweat glands exude
+a phosphorescent sweat, said to be due to a species of photobacterium
+following the ingestion of phosphorus or of food stuffs containing
+phosphorus.
+
+_Miliaria._ A mild inflammatory affection caused by obstruction of
+the sweat ducts, characterized by the occurrence of small papules and
+vesicles at their mouths.
+
+_Hydrocystoma._ A condition characterized by the formation upon the
+face of firm, pinhead sized vesicles, due to sweat gland obstructions.
+
+_Hydradenitis Suppuration._ An inflammatory disease of the sweat glands
+followed by deep-seated, shot-like nodules, which suppurate and leave
+scars.
+
+_Seborrhea._ A lesion of the fat-producing glands characterized by an
+increased and altered secretion of sebum resulting in an oily or scaly
+condition of the skin.
+
+
+
+
+CHAPTER XX
+
+ULCERS
+
+
+=Definition.= An ulcer is a lesion of a cutaneous or mucous surface,
+caused by a molecular disintegration of the superficial parts, usually
+attended by more or less suppuration. A wound, or superficial loss of
+tissue due to traumatism, is not primarily an ulcer, but may become
+such if the healing process is arrested or the wound becomes infected
+with pyogenic microorganisms.
+
+The following ulcers frequently come under the observation of the
+podiatrist:
+
+=Simple Ulcer=, a local non-constitutional lesion attended with no
+marked pain or inflammation.
+
+=Indolent or Callous Ulcer=, a chronic lesion, with hard, elevated
+edges and few or no granulations and showing no tendency to heal.
+
+=Varicose Ulcer=, localized destruction of the skin over a varicose
+vein, usually of the leg, due to mechanical pressure, to nutritive
+disturbances, or to bacterial action.
+
+=Perforating Ulcer of the Foot=, malum perforans pedis, a round, deep,
+trophic lesion of the sole of the foot, following disease or injury (in
+any part of its course from the centre to the periphery) of the nerve
+supplying the parts.
+
+=Syphilitic Ulcer=, due to syphilis in late secondary or in tertiary
+stages.
+
+Before describing the characteristics of the various forms of lesions
+just mentioned, together with their differential diagnosis, treatment,
+etc., it is deemed advantageous to briefly discuss the general etiology
+and pathology of all ulcers.
+
+=Etiology.= One or several factors may be concerned in the etiology of
+ulcers, which are grouped under: (a) predisposing causes; (b) exciting
+causes. The first group includes local as well as general causes.
+
+=Predisposing Causes.= Age can hardly be considered as a very important
+factor, except that old age is accompanied by retrogressive tissue
+changes, hardening of the arteries, impaired circulation, etc., and one
+would therefore expect the statistics to show a greater proportion of
+ulcers during the later years of life.
+
+As regards sex, ulcer is more common among men than women in the ratio
+of about three to one. Alcoholism, syphilis, and traumatism may in
+some measure explain why ulcers are more common in men than women.
+Occupation seems to have little to do with the etiology beyond the fact
+that it may predispose to various forms of infection, and it is due to
+this element that we have the most important factors in the causation
+of ulceration. Varicose ulcer is always associated with varicose veins
+in the lower extremity, and these may be described as veins whose
+valves are incompetent. The most obvious cause of the breaking down
+of the valves is hard work, that is the lifting or carrying of heavy
+loads, as in the case of laborers, freight handlers, and longshoremen.
+The great strain occasioned by work of this kind lays a heavy load
+upon the veins of the legs. Whether the valves become useless through
+stretching of the vein walls, or are directly broken, is immaterial.
+The occupations which involve standing for long periods without moving
+the legs are, in a lesser degree, a source of valvular incompetence,
+and this is not from excessive back pressure but from stasis due to
+lack of muscular movement. Among women, the venous engorgement of the
+legs, so often seen in pregnancy, may, after the birth of several
+children, result in varicosity.
+
+Many of the constitutional diseases such as gout, anemia, diabetes,
+syphilis, and tuberculosis, which lower the vitality of the tissues,
+and other conditions, such as valvular disease of the heart, general
+obesity, and arterial hardening which prevent proper circulation,
+predispose to the formation of ulcers when there is in addition some
+exciting cause.
+
+Embolism, which cuts off the nutrition of the part, may also act as a
+local cause. Certain vasomotor disturbances, such as occur in frost
+bite and in Raynaud’s disease, may produce small areas of localized
+gangrene which subsequently become the seat of an ulcer.
+
+Interference with the return of venous blood from a part predisposes to
+ulceration. Where phlebitis and periphlebitis occur, especially in the
+smaller venous radicles, small abscesses often form, the adjacent skin
+becomes involved, and an ulcer results; or the rupture of the diseased
+wall of one of the small veins may become infected, and ulcer develops.
+
+Perforating ulcer of the foot is a frequent complication of tabes
+dorsalis. Myelitis, and other pathologic conditions of the nervous
+system may also, either through trophic changes or by reason of
+impaired sensation, bear a distinct relationship to ulcerative
+processes.
+
+=Exciting Causes.= Traumatism is one of the most frequent causes of
+ulcer formation. Its degree may, of course, vary greatly, and whether
+it will produce an ulcer depends upon one or more of the predisposing
+causes already mentioned. Infection by any of the staphylococcus or
+streptococcus group of organisms as well as by the tubercle bacillus
+will produce ulcers; malignant ulceration also occurs.
+
+=Pathology.= The pathology will vary according to the conditions
+causing the ulcer, although in the non-specific forms of ulcer
+the phenomena of congestion, exudative and necrotic inflammation,
+together with reparative inflammation or granulation, will only be
+in evidence. In the development of an ulcer the degenerative process
+predominates; in the healing stage, the reparative. When the ulcer
+develops from without, as when infection enters the skin through an
+abrasion, congestion first occurs. This is rapidly followed by the
+emigration of leucocytes, by a diapedesis of red blood cells which
+rapidly disintegrate, and by an exudation of serum and fibrin. At
+the same time there is a proliferation of the epithelial cells and
+also a proliferation of the connective tissue cells of the corium. The
+tissue next becomes softened by the exudate between the cells. Then,
+as a result of the pressure of the exuded serum, of the crowding by
+the leucocytes, and of the cutting off of the blood supply, and also
+in some measure through the effects of the toxins furnished by the
+bacteria, there occurs necrosis of the cells, which are thrown off
+from the surface with the products of exudation, until there is formed
+an ulcer with its base consisting of spheroidal and a few epithelioid
+cells developed from the connective tissue cells by proliferation.
+
+When an ulcer in its complete stage of development is examined,
+the surface is found to be covered with a layer formed by the
+overproduction of new round cells, together with the exudate of fibrin,
+serum, and the cellular elements of the blood. When the discharge from
+the ulcer is profuse, this may be constantly washed away. When the
+ulcer is sluggish, it may be in a condition of coagulation necrosis. In
+this latter condition a croupous material covers the base of the ulcer,
+and below this is a more or less distinct layer, largely composed of
+cellular elements, with very little cellular substance, the cells being
+spheroidal and epithelioid in character and mingled with polynuclear
+leucocytes. As we go deeper, the amount of intercellular substance
+increases, and a number of transparent fibres and fusiform cells are
+found. In this layer of granulation tissue are also the newly formed
+blood vessels, the most superficial branches being vertical to the
+surface, and developing by a process of budding from the endothelial
+cells of the capillaries deeper down. This layer is paler in color than
+the layer made up of the cellular elements, but may contain pigment
+from the disintegration of the red blood cells. It gradually merges
+into a layer of cicatricial connective tissue which lies beneath the
+ulcer.
+
+A section of a chronic ulcer would show an enlargement and
+prolongation of the papillæ, with a marked proliferation of
+the epithelial cells covering them. This is most pronounced in
+the condition known as callous ulcer, where the edges may, by
+proliferation, be considerably raised about the level of the
+surrounding skin, and often overhang the base of an ulcer. Under proper
+treatment the reparative process proceeds faster than the degeneration
+of the cells and the ulcer begins to heal by granulation. Small sprouts
+or buds of protoplasm protrude from the capillaries below or in the
+base of the ulcer, developing from the cells in their walls. These
+are hollowed out by the blood pressure and form new blood vessels
+which anastomose with others. Nuclei form in the protoplasm and thus
+endothelial cells develop. At the same time small spheroidal cells,
+developing from the connective tissue cells, become grouped around
+the blood vessels. These are closely crowded together at first, being
+separated by only a small amount of fluid intercellular substance. Some
+of the round cells then become larger and fusiform or branched. The
+larger cells are known as epithelioid cells. Some of the fusiform and
+branched cells, called fibroblasts, develop the new delicate fibrillar
+intercellular substance, while others form the connective tissue cells.
+Gradually the fibrous intercellular substance increases in amount,
+while the cells become fewer and flattened, and cicatricial tissue
+is formed. The contraction of this cicatricial tissue constitutes an
+important element in the healing of an ulcer.
+
+During the process of granulation, more of the round cells are produced
+than are necessary. These die and are thrown off in the discharge.
+Healthy granulations should be small, even, and of a reddish pink
+color. Where the growth of the blood vessels proceeds more rapidly than
+the development of the cells and the formation of connective tissue,
+there is produced a soft, pale, flabby condition known as exuberant
+granulations, or proud flesh. On the other hand, both the cells and the
+blood vessels may develop very slowly, forming indolent or sluggish
+granulations. In order that the ulcer may heal it must eventually
+become covered with epithelium, and this can develop only from the
+epithelium at the edges of the ulcer. Under favorable conditions,
+when the granulations reach the level of the surrounding skin, the
+epithelium begins to spread in a thin bluish white line from the edges
+out over the surface, until the latter is entirely covered, when the
+ulcer is healed.
+
+=Simple Ulcers.= By far the greatest number of ulcers coming under the
+observation and within the province of the podiatrist are of the simple
+variety. Heavy calloused areas which are neglected are apt to become so
+irritant as to cause the softer tissues underneath to break down and
+ulcerate, and a similar condition very often occurs in connection with
+helomata, particularly heloma molle.
+
+Constitutional diseases, either trophic or specific, may be
+predisposing causes of these conditions but the exciting cause is
+surely traumatism.
+
+Simple ulcerations are most generally found upon the plantar surfaces
+of the feet, under the heads of the first or fifth metatarsal bones. As
+has been previously mentioned, however, the interdigital surfaces are
+also prone to these conditions. In this latter location the amount of
+perspiration excreted in the locality undoubtedly has much to do with
+the lowering of the vitality of the skin covering the part, and renders
+it susceptible to disintegrative processes.
+
+=Treatment.= All the overlying callous must be immediately removed
+so that the parts may be properly cleansed and so that drainage may
+be maintained. This may be done with a sharp sterile scalpel, but
+sufficient care should be exercised so that no hemorrhage is caused.
+After the hardened tissue has been cut away, all necrosed tissue
+adhering to the floor and edges of the ulcer should be removed. A spray
+of alcohol, 60%, may then be employed to obtain thorough asepsis and
+after the parts are thoroughly dried, a dressing is applied in keeping
+with the conditions present.
+
+=Wet Dressing.= If infection is present, or if the parts be
+considerably inflamed, due simply to the traumatic irritation, a
+wet dressing of mercury bichloride, ¹⁄₄₀₀₀, liq. aluminum acetate,
+or alcohol and boric acid, equal parts, should be employed for a
+sufficient time to reduce all infective or other inflammatory symptoms.
+Bichloride of mercury should not be used for a prolonged period of time
+in these cases, for its corrosive action will prevent new granulations
+and thus retard healing. The aluminum acetate and alcohol, boric acid
+combination may be used without fear of toxic irritation. If simple
+inflammation is present in the parts, Goulard’s extract may be employed
+to reduce the acute symptoms, but care must be exercised and the parts
+watched so that no lead dermatitis shall develop from the drug.
+
+It is unwise under any condition to prolong the use of wet dressings
+beyond a time when they are thought to be necessary. The constant
+moisture is not conducive to prolific or to healthy granulation and
+for this reason these applications are best discontinued as soon as
+possible.
+
+=Boroglycerine=, a combination of boric acid and glycerine, applied to
+a simple ulceration, particularly one of the indolent type, is found to
+stimulate granulation and thus aid materially in the healing process.
+It is applied on sterile gauze and allowed to remain unchanged for from
+twenty-four to forty-eight hours.
+
+=Dry Dressings.= Dry dressings, either of plain aseptic gauze or
+of dusting powders, are found effective in the treatment of simple
+ulcerations. The choice of the dusting agent is, of course, dependent
+upon the conditions present, but it should combine astringent and
+antiseptic properties.
+
+=Thymol Iodide=, while not astringent, is a general favorite for most
+simple ulcerations. Contrary to the action of most powders, this
+combination of iodine and thymol induces a discharge rather than
+prevents it. This is due to the action of its constituent thymol and
+is desirable in dry ulcerations where more or less coagulation is
+present. This powder, known best by its trade name, aristol, has an
+energetic, antiseptic action due to the liberation of iodine and is
+used practically to the exclusion of all other iodine powders. It
+is principally used as an iodoform substitute, having none of the
+disagreeable odor of this drug.
+
+=Bismuth Subgallate=, a combination of gallic acid and bismuth, is an
+efficient powder for use in these conditions. Its action is markedly
+astringent and it can be depended upon for antiseptic action as well.
+
+=Bismuth Subnitrate= is also an astringent and antiseptic powder which
+may be substituted for the other bismuth salt in these conditions. The
+molecules of this powder are very fine and there is a tendency for it
+to cake so that when used, the dressing should be changed at regular
+and short intervals; the parts should be thoroughly cleansed of the
+dried powder from previous application before the new dressing is
+applied.
+
+=Zinc Powders=, such as the oxide and the stearate, are also applicable
+in cases of simple ulcer. Zinc oxide may be combined with various other
+powders and numerous such combinations are now in the market. Zinc
+stearate is used alone and can be depended upon for a mild astringent
+action, although not comparable with either bismuth subgallate or
+subnitrate.
+
+=Ointment Dressings.= The use of ointments is contra-indicated in the
+presence of a discharging surface and for this reason drugs in fatty or
+oily bases are not generally used in all stages of ulcer regeneration.
+Several ointments may be used, however, either for antiseptic or
+stimulative action after the acute discharge, if present, has subsided
+or if no great amount or exudation is present.
+
+=Ung. Hydrargyri Ammoniati=, white precipitate of mercury, will be
+found useful where antiseptic action is desired.
+
+=Ung. Acidi Borici=, an antiseptic ointment, is also used in this
+connection.
+
+=Ung. Acidi Tannici=, twenty parts of tannic acid, twenty parts
+glycerine, sixty parts cerate, is an astringent ointment efficient in
+these cases.
+
+=Ung. Eucalypti= is used as an antiseptic and stimulant application for
+indolent ulcers.
+
+=Ung. Zinci Oxidi= is a soothing and mildly astringent ointment which
+can be used advantageously.
+
+=Ung. Balsam of Peru=, a 3% to 10% ointment of Peruvian balsam in
+vaseline or lanolin, is both antiseptic and stimulant.
+
+=Scarlet Red=, an ointment prepared from medicinal scarlet red
+(Biebrich), may be used in strengths from 1% to 8% as a stimulant and
+healing application.
+
+In the use of all ointments it is advisable to place only a thin film
+of the mass over the parts. Avoid the tendency to use a large quantity
+of any ointment.
+
+A shield may, at times, be used in connection with the application
+of the dry or of the ointment dressing. These appliances, however,
+particularly if made from a thick material, tend to arrest the
+circulation to the localized area, and, as free blood flow is to be
+desired at all times, the shield should be omitted in cases in which an
+ointment dressing is being used, unless it is sure that circulation is
+not being thereby impeded.
+
+Squares of sterile gauze held in place by adhesive strips or by a
+soft cocoon dressing, are practical means of retaining a powder or an
+ointment to the part. In choosing the latter form of dressing, never
+use a great amount of collodion in binding down the cotton fibre. If
+applied too freely, it is absorbed by the cotton and is apt to come in
+contact with the ulcerated surface itself. The dressing, if applied
+over a discharging area, should be absorbent, and this possibility is
+nullified when it is hardened by collodion.
+
+
+INDOLENT OR CALLOUS ULCER.
+
+This form of ulcer occurs principally on the leg, but occasionally is
+found on the foot and ankle. Callous ulcers vary in size from a five
+cent piece to the entire circumference of the part attacked.
+
+The surface is usually smooth and glistening and of a dirty yellow
+color, with perhaps a few badly formed granulations. The edges are hard
+and sharply cut and elevated considerably above the surface, while the
+surrounding skin may be inflamed over the margin and is either covered
+with sodden cuticle or is congested. The skin surrounding the part
+is often deeply pigmented from chronic congestion, the pigmentation
+starting in separate papillæ as maculae, which gradually coalesce. The
+discharge is purulent or serous and may be so abundant and irritating
+as to cause eczema of the skin. The base is adherent to the underlying
+tissues and this constitutes one of the main difficulties in healing,
+as contraction is thus prevented. If the ulcer is situated above a
+bone, such as the tibia, chronic periostitis may result. Such ulcers
+are sometimes very painful from pressure on cutaneous nerves, or from a
+localized cellulitis associated perhaps with inflammation of veins and
+lymphatics. Thrombosis not infrequently occurs in both sets of vessels,
+leading to chronic edema of the feet.
+
+=Etiology.= _General Causes_: (a) Various devitalizing fevers and
+diseases such as typhoid, scorbutus, diphtheria, chronic nephritis,
+etc. (b) Mineral poisoning, such as is produced by phosphorus. (c)
+Anemia and debilitating conditions brought on by starvation, improper
+food, poor hygiene, overwork, lack of sleep, etc.
+
+_Local Causes_: (a) Old scar tissue, the contraction of which has cut
+off the circulation. (b) Continuous pressure, from splints, lying in
+bed, etc. (c) Local destruction of the tissues such as is produced by
+extremes of heat and cold. (d) Local irritation or injury of tissues
+from violence. (e) Various diseases of the skin, for example, pemphigus.
+
+=Symptoms.= These ulcers are most commonly found on the inner side of
+the lower third of the leg. They show great variety in size, shape and
+appearance, of base, edges, and surrounding area, and in accordance
+with these differences, many different names are applied to them. They
+may be round, very irregular, or funnel-shaped, as in perforating
+ulcer of the foot. When the granulations are large, irregular, and
+bleed easily, they are spoken of as exuberant or fungating; when
+pale, soft and flabby, as weak or edematous; when small and growing
+slowly, as indolent. Sometimes the base is covered with a grayish or
+yellowish-white necrotic layer formed of fibrin and necrotic cellular
+elements. When this is removed, no granulations appear, but instead it
+presents a smooth, shining base resembling mucous membrane. This form
+is known as the croupous ulcer. The edges also vary greatly. They may
+be irregular or sharply cut, moderately thickened, or very much so,
+due to chronic congestion and edema, with enlargement of the papillæ
+and proliferation of the epithelial cells. When this is a prominent
+feature, the name callous ulcer is applied. The edges may be adherent
+to the deeper structures, thus preventing contraction and healing; they
+may be rounded, elevated, undermined, or overhanging.
+
+The discharge from an ulcer is usually slight in amount, serous in
+character, and contains very few pus cells. The surrounding area may
+be swollen, red, congested, pigmented, edematous, eczematous, or the
+ulcer may be surrounded by smaller sores, by vesicles, or by masses
+of varicose veins. As a rule, there is an absence of severe pain
+accompanying leg ulcers, unless there is an exposure or involvement of
+some nerve filaments; but frequently, after the patient has been on his
+feet for a long time, there is a dull, aching pain in the part, due to
+chronic congestion which causes tension in and about the ulcer.
+
+=Differential Diagnosis.= The diagnosis of a chronic indolent or
+callous ulcer can be easily made by the character of the granulations
+and by the location of the ulcer itself. The history points usually to
+an injury or infection and the situation of the sore is at the site
+of the previous injury or infection. The base is shallow, inflamed
+and often of a grayish-yellow color, with no thickening or elevation
+of its edges. The surrounding area is usually round and inflamed. A
+varicose ulcer is differentiated by the history of varicose veins or
+phlebitis, by its occurrence at the lower third of the leg and by the
+undermined thickened and irregular-shaped edges. A syphilitic ulcer is
+diagnosed by the history of lues; by its usual occurrence at the upper
+third of the leg; by a dirty sloughing and deep base; by punched out,
+thin, dense, firm and undermined red edges; and by scars of a dusky red
+color. A tuberculous ulcer, by the history of previous glandular bone
+or lung disease; soft, pale, edematous granulations; thin undermined
+edges; involvement of glands and other signs of tubercular sinuses,
+bone disease, etc. A perforating ulcer, by the history of the case; the
+appearance of the ulcer upon the sole of the foot or in the vicinity of
+the heel; the presence of a sinus leading to necrosed bone; the pale,
+flabby granulations; all these signs should make the diagnosis easy.
+
+[Illustration: CHRONIC ULCER OF THE FOOT
+
+(BEFORE OPERATION)]
+
+=Treatment.= This naturally depends upon the stage at which the
+ulcer is seen and the conditions present. If there is considerable
+inflammation, accompanied by marked cellulitis and pain, wet dressings
+are indicated. Two distinct therapeutic actions may be derived
+from the wet compress, depending upon whether or not an impervious
+covering is employed. These actions are antiphlogistic and hyperemic,
+and these in turn may be either antiseptic or astringent. The wet
+dressing, without a covering, is cleansing and heat reducing,
+because of evaporation. There should be frequent replenishment of
+the solution where there is considerable discharge, or where it is
+desirable to reduce inflammation. A wet dressing with an impervious
+covering is contra-indicated in the presence of pus, the warmth and
+moisture of such a dressing, being congenial to the growth and to
+the multiplication of bacteria. For the relief of pain and for the
+reduction of inflammation, wet dressings are the most effective form of
+treatment because (1) they are aseptic; (2) they permit free drainage;
+(3) no new granulations are disturbed in changing the dressing.
+
+A great many different solutions are used and among these are: (1)
+sterile water; (2) ordinary saline solution (a teaspoonful of salt
+to a pint of water); (3) saturated solution of boric acid (prepared
+by dissolving a teaspoonful of boric acid in a pint of water); (4)
+Thiersch’s solution (prepared by dissolving 15 grains of salicylic acid
+and 90 grains of boric acid in a pint of water); (5) Burow’s solution
+(prepared by dissolving 675 grains of alum and 270 grains of lead
+acetate in a pint of water); (6) solution of bichloride of mercury
+(varying in strength from 1 to 3,000 to 1 to 10,000); (7) lead and
+opium wash (U. S. P.); (8) Dakin’s solution (hypochlorite of soda).
+
+After the reduction of the inflammation, the next step is the cleansing
+and sterilization of the ulcer. Before healthy granulations can
+form, the removal of sloughs and the cleansing of the base must be
+accomplished as thoroughly as possible. Many means toward this end may
+be effective. A one-half to two per cent. creolin or lysol emulsion
+is very useful for those dirty ulcers from which a profuse, foul
+discharge escapes. A one per cent. solution of formalin is of great
+value for smaller ulcers, especially those due to tuberculous disease.
+The destruction and removal of sloughs may be hastened by cauterization
+with the solid stick of nitrate of silver. The use of certain ferments,
+such as brewer’s yeast, papoid, or protonuclein, may help to clean up
+a chronic ulcer. The most frequent means employed for the cleansing
+and sterilization of the ulcer, previous to the application of some
+stimulating dressing, is washing the part with tincture of green soap
+and water. Peroxide of hydrogen can next be used, then sulphuric
+ether, and finally ninety-five per cent. alcohol. Where there is an
+accompanying eczematous condition, the scales can best be removed with
+benzine.
+
+[Illustration: CHRONIC ULCER OF THE FOOT
+
+(AFTER OPERATION)]
+
+Having reduced the inflammation and succeeded in cleansing the ulcer,
+the next thing to consider is the means by which granulations may be
+stimulated. This may be accomplished by applications in the form of
+powders, solutions, ointments and grafts.
+
+Dusting powders are employed either as antiseptics or as astringents
+or for both purposes. Their use in this instance is limited, and they
+are employed only where the secretion is scanty. Among the various
+powders used are: aristol, dermatol, boric acid, orthoform, calomel,
+protonuclein, alum, zinc oxide, etc. Thymol iodide, or aristol, is
+a superior antiseptic powder and enjoys the advantage over iodoform
+of being inodorous. Iodoform should be used only in tuberculous
+conditions; calomel only in syphilitic cases. Dermatol, or bismuth
+subgallate, combines the astringent and mildly antiseptic qualities of
+bismuth and gallic acid. Boric acid is mildly antiseptic. Zinc oxide
+and alum are both astringent. Scarlet red, five per cent., with boric
+acid, ninety-five per cent., is indicated when the granulations are
+sluggish.
+
+Among the various solutions used are silver nitrate in various
+strengths, zinc and copper sulphate, ichthyol, balsam of Peru, and
+calamine. Silver nitrate, zinc and copper sulphates are employed for
+their astringent action. Balsam of Peru, fifty per cent., with castor
+oil, fifty per cent., is used for its stimulating action.
+
+Ointments are used in the treatment of ulcers either to stimulate the
+granulations or to soften thick epidermis. Ointments should never be
+employed where there is a profuse discharge. Many different kinds of
+ointments are used, prominent among them being: balsam of Peru, in a
+ten per cent. strength for the stimulation of the granulations; boric
+acid and ichthyol, in the same strength; Lassar’s paste (which consists
+of salicylic acid, one dram; starch and zinc oxide, each one ounce,
+and vaseline to make four ounces). This latter ointment is especially
+indicated when there is an eczema present. An ointment which has given
+good results is scarlet red, 1% to 5%. Scarlet red (Biebrich) was
+originally prepared as a dye for wool and silk, and is so named because
+of the fact that it was first manufactured in the town of Biebrich.
+Its application to granulating surfaces induces healing, not by the
+formation of scar tissue, but in every case by producing a high grade
+of normal skin which very soon becomes freely movable on the underlying
+tissue. The return of sensation in the healed area takes place from
+the periphery inward, instead of upward from the underlying tissue.
+Usually the dressing should be left undisturbed for from twenty-four to
+forty-eight hours, then reapplied, as indications warrant. In removing
+the dressing, if it be adherent to the granulations, peroxide of
+hydrogen should be used to loosen it. The skin about the granulating
+surface is best cleansed by benzine, as this removes all traces of
+scarlet red better than any other solution. The following formulas are
+recommended:
+
+Scarlet red (medicinal Biebrich) fifteen grains; ungt. acidi borici, q.
+s. ad three ounces (one per cent.).
+
+Scarlet red (medicinal Biebrich), forty-five grains; ungt. zinci oxidi,
+q. s. ad three ounces (three per cent.).
+
+Scarlet red (medicinal Biebrich), seventy-five grains; balsam of Peru,
+seventy-five minims; petrolati, q. s. ad three ounces (five per cent.).
+
+The first is indicated where scarlet red is desired over a large area
+and for a long time; the second, where an astringent action is required
+because the granulations are profuse; the third, where the granulations
+are sluggish and require stimulation.
+
+
+VARICOSE ULCER.
+
+=Etiology.= To chronic ulcers of the leg, associated with varicose
+veins, especially of the smaller venous radicles, the name varicose
+ulcer has been given. The usual development of this variety of ulcer
+is as follows: persons who suffer from varices of the leg usually
+complain, for some time before the external manifestation of the
+disease, of a dull, aching pain in the limb, with a sense of weight,
+fullness and fatigue. In a more advanced state of the disease the
+ankles swell after a day’s hard work, and the feet are constantly
+cold; an embarrassed state of circulation is denoted by these symptoms
+and the deep-seated veins begin to swell. After a time, which varies
+with the idiosyncrasy and occupation of the patient, small, soft,
+blue tumors are seen at different points of the leg, most of them
+disappearing on pressure, but returning when it is removed, or when
+the patient stands up. Each little tumor is caused by a vein, dilated
+at the point at which it is joined by an intramuscular branch. Around
+many of these tumors a number of minor vessels of a dark purple color
+are clustered; these are the small superficial veins which enter the
+dilating vein and in which the passage of the blood is retarded. An
+increasing area of veins gradually becomes involved and a number
+of irregular, knotty, consolidated tumors are developed, grouping
+themselves around the point at which the dilatation first began. The
+external and internal saphenous veins are those primarily affected,
+but long tracts of tortuous veins may extend up the leg and thigh.
+Dangerous and even fatal hemorrhage may ensue from the bursting of a
+varix through the skin. The vessels may become filled with clots and
+permanently obstructed, and ulceration with thrombosis or phlebitis
+may be the sequel. The capillaries become engorged with blood, and
+hence the assimilation changes are retarded and sometimes altogether
+checked. Gradually the entire circulation of the part is arrested. The
+vitality of the superficial structures becomes permanently impaired;
+consequently they are unable to resist the effects of slight injuries
+and repair fails to take place after a portion has been destroyed, and
+an open sore or ulcer is established.
+
+=Symptoms.= The varicose ulcer is usually single, oval, round or
+irregular in outline, and is most often seen on the lower third of
+the leg near the internal or external malleolus. The edges are thick,
+everted, and swollen. The swelling is largely due to edema and is found
+to pit on pressure. The floor is generally covered with rather large
+granulations which bleed freely when touched. In a varicose ulcer the
+destruction of tissue often begins at the margin of a congested area
+and advances toward the centre. The size varies from the small ulcers,
+less than one-half inch in diameter, formed by the breaking down of an
+area of periphlebitis around a small vein, to those several inches in
+diameter. Several ulcers may be present on one limb. The granulations,
+as a rule, are weak and flabby. The discharge is thin, serous, mixed
+with débris, and may be blood-stained. The skin surrounding a varicose
+ulcer is often of a brownish blue color, due to a deposit of pigment.
+The recognition of varicose ulcers is usually easy; but the mere
+presence of enlarged veins, it should be noted, is not pathognomonic,
+because they may exist along with ulcers of other origin--the luetic,
+trophic, etc. The most frequent complication is phlebitis; cellulitis
+is also seen. This latter may sometimes be so severe as to necessitate
+operation. Complications such as necrosis of bone, involvement and
+ankylosis of the ankle joint, together with atrophy and contracture
+of muscles and adhesions of tendons (perhaps giving rise to various
+deformities of the feet, such as flat foot or even club-foot) are
+extreme and unusual complications.
+
+Where the varicose ulcers have persisted for a long time and refuse
+to heal, it is always advisable to apply the Wassermann test in order
+to exclude the possibility of syphilis. In doubtful cases it is also
+advisable to test by the Noguchi luetin skin reaction.
+
+[Illustration: VARICOSE ULCER]
+
+=Treatment.= In these cases of varicose ulcers it is impossible to
+effect a cure until the chronic congestion of the limb is relieved
+and the blood supply of the part approaches normal. Often all that is
+necessary is a gauze, muslin, rubber or flannel bandage.
+
+A bandage, when applied with moderate, even pressure, has for its
+purpose the relief of congestion. In a great many cases rubber has an
+irritating effect upon the skin, and that kind of a bandage should
+therefore be cautiously used. When the granulations are almost on a
+level with the skin, and also where there is considerable thickening
+of the edges of the ulcer, the best means of keeping up an even
+pressure and causing absorption of the thickened margins, as well as of
+hastening epithelial growth, is to apply zinc oxide adhesive plaster
+in strips, one-half to one inch in width. These strips should overlap
+to the extent of about one-third of their width, should extend about
+three-fourths of the way around the limb, and should be evenly and
+smoothly applied. They should be started about one inch below the ulcer
+and should run from two to three inches above it.
+
+In order to effect a permanent cure, varicose veins must be operated
+upon, and a number of operations have been devised, as follows: the
+ligation of the internal saphenous, as advised by Trendelenburg; the
+multiple percutaneous ligations of Schede; the total extirpation of the
+internal saphenous, as recommended by Mayo; the dissection after the
+method of Madelung; and the spiral of Rindfleisch.
+
+=Perforating Ulcer of the Foot.= This type of ulcer usually occurs
+where pressure and irritation are greatest and is therefore commonly
+found on the plantar surface of the foot under the heads of the first
+and fifth metatarsal bones, and on the under surface of the great toe.
+Occasionally, however, they develop on the dorsal surfaces or ends of
+the toes, in cases such as hammer toe.
+
+=Etiology.= There are various theories relative to the causation of
+lesions of this nature. One claims injury to be the sole cause; another
+attributes it to arteriosclerosis and capillary thrombosis; still
+another charges it to chronic peripheral neuritis and alteration in
+the nerve terminals. One writer states that traumatism is an important
+factor in their development, conceding, however, that various systemic
+conditions must necessarily enter into the etiology, among them,
+locomotor ataxia and injuries to the spinal cord, diabetes and injuries
+to the peripheral nerves. This latter, known as the “mixed theory,”
+is the one most generally accredited and is in all probability most
+correct.
+
+This type of ulcer is found more frequently in males than in females
+and it occurs almost exclusively in adult life (between 40 and 60
+years). Occupation is a predisposing factor, and work demanding long
+periods of standing or walking unquestionably has much to do with the
+development of a perforating ulcer, all other conditions being equal.
+
+[Illustration: POST-OPERATIVE DIABETIC ULCER]
+
+=Characteristics.= The ulcer is usually found to be irregularly
+circular in shape, with a tendency to progressive development,
+involving the deeper soft tissues, finally attacking the periosteum
+and the bone itself, causing necrosis. The superficial edges of the
+ulceration are heavily calloused and the lesion shows little or no
+tendency to heal. One of the most marked characteristics is the entire
+loss of sensation. Many cases have been observed where the patient
+feels no pain, even when the lesion is deeply probed.
+
+=Symptoms.= At times, particularly in diabetic patients, a purulent
+blister is the initial lesion, but in most instances these lesions
+develop under a heavy callous, the centre of which breaks down into
+an indolent superficial ulceration, discharging a thin, discolored,
+odorous pus, but never in great quantities.
+
+The fact that changes in the peripheral nerve supply usually take place
+in the development of perforating ulcer probably accounts for the
+absence of pain, as above mentioned, and also explains the progressive
+degeneration which takes place, allowing the ulcerative process to
+progress into the deeper tissues.
+
+=Treatment.= The systemic disturbances which may be present are
+important factors to be considered in the treatment of perforating
+ulcer, but local applications may be made and local conditions must
+be considered. If the ulcer be upon the plantar surfaces of the foot,
+walking and standing, which would bring continued pressure, must be
+avoided. Shoes must be well fitted and must not irritate the parts,
+and cleanliness must be obtained and maintained. All callous must be
+removed from the edges of the ulcer and proper drainage is of great
+importance. All necrosed tissue must necessarily be removed and any
+burrowing sinuses should be thoroughly opened. Artificial hyperemia,
+massage and electricity are found to be of benefit in improving the
+general circulation in the foot and leg.
+
+In the local treatment of the ulceration itself, prolonged application
+of strong germicidal solutions is to be avoided at all times. Cleansing
+with warm normal salt solution is recommended as a non-toxic and
+stimulant application.
+
+Dressings may be of plain aseptic or iodoform gauze packed lightly into
+the ulcer. These lesions are discouraging to treat, inasmuch as even
+after complete healing, relapses usually occur which leave the parts as
+bad or worse than the original lesion.
+
+Stimulant applications may be employed locally, with some success in
+connection with internal medications for the systemic disturbance
+present. Balsam of Peru or scarlet red (1% to 3%) are advocated in this
+connection.
+
+The prognosis in cases of perforating ulcer is bad, inasmuch as the
+progress of the lesion sooner or later involves sufficient tissue in
+the degenerative process to necessitate surgical interference--perhaps
+amputation of the foot. As has been previously mentioned, even when
+fully healed, relapse almost always occurs.
+
+=The Syphilitic Ulcer.= The syphilitic ulcers do not properly come
+within the province of the podiatrist for treatment, but he should be
+able to recognize them. They may develop from pustules or begin as
+original lesions in the tertiary stages of the disease. Developing in
+this latter instance from gummata, they are immediately deep ulcers.
+
+The worst superficial ulcers of syphilis may develop early in the
+course of the general disease.
+
+[Illustration: SYPHILITIC ULCER OF THE LEG]
+
+=Symptoms.= These ulcers vary in size from a quarter to a silver dollar
+and occur on the upper third of the leg, occasionally on the upper
+part of the middle third. During the early stages of the lesion it is
+surrounded by an inflamed area of skin at the ulcer and presents an
+even, “punched out” edge. Being a new growth, developed in the corium,
+the edges are usually more firm and dense than in other forms of
+ulcer. The floor of the lesion is of a dusky red or coppery color,
+and has a characteristic slough of a greenish color. The discharge is
+frequently bloody and is filled with broken-down tissue.
+
+If on account of the presence of enlarged veins, it is difficult to
+distinguish a syphilitic from a varicose or other type of ulcer, a
+positive Wassermann test will confirm the diagnosis.
+
+Being merely a local manifestation of a general infection, the systemic
+disturbance must be treated by a licensed physician. It is generally
+found that a lesion of this type, once healed, remains so.
+
+=Treatment.= Treatment for syphilitic ulcers comprehends the use of
+mercurials as local applications. Mercury bichloride ¹⁄₁₀₀₀₀ may
+be employed with beneficent results in most cases where a profuse
+discharge is present. Where there is little or no discharge, calomel
+powder dusted into the ulcer will give good results.
+
+As in most cases where a syphilitic lesion has developed locally on the
+leg, the patient is or has been under a physician’s care, practically
+none of these cases come to the podiatrist for his treatment alone.
+Many times, however, he is called in by the physician to do local
+dressings under his direction, and it has even happened that the
+podiatrist has been the first to recognize the significance of the
+local lesion.
+
+
+
+
+CHAPTER XXI
+
+CUTANEOUS MANIFESTATIONS OF SUPER-ACIDITY
+
+
+A surcharging of the blood with an abnormal amount of acidity leads
+generally to conditions which come under the domain of the physician.
+So-called rheumatism, gout and kindred ailments of all forms and
+varieties are every-day occurrences, and, being symptoms of systemic
+disturbances, should be treated by internal administration.
+
+The podiatrist, however, in his daily treatment of foot troubles is
+called upon to treat locally certain forms of skin disturbances due to
+hyper-acidity which manifest themselves upon the surfaces of the foot.
+
+Uric acid eczema is the general term employed to designate these
+annoying conditions and is synonymous with the older and now obsolete
+terms, lithemia and uric-acidema.
+
+=Definition.= Uric acid eczema is a skin eruption due to a surcharge of
+uric acid in the blood and a precipitation of this acid in a certain
+part, so that the acid elements or urates are carried by the blood
+stream to the skin and there set up a dermatitis.
+
+=Characteristics.= These manifestations may be found in all varieties
+and degrees from a mere dryness and hardness of the skin, in which
+the normal flexibility is gone, and in connection with which there is
+usually intense itching and burning, to the formation of deep fissures
+(usually found in the toe webs) and small ulcerative processes which
+may manifest themselves in any part of the foot and often present a
+stubborn resistance to all endeavors at healing. These symptoms may
+occur singly or, as in the most instances, in combination.
+
+These conditions are usually met with in the spring of the year and no
+doubt are brought about by a series of changes in habits and diet which
+occur at this time.
+
+=Etiology.= During the winter months the average person takes but
+little physical exercise as compared to his activities during the
+warmer weather. The foot, being at the base of a column of blood which
+must be forced back to the heart, against gravity, is coming constantly
+in contact with cold surfaces. This, together with a lack of exercise,
+tends to stagnate the blood circulation in the pedal extremities.
+Coupled with these two conditions, during the winter months, people
+are inclined to over-eat and over-drink, the waste materials from
+which excesses are but improperly eliminated, due also, to a great
+extent, to insufficient exercise. Here, then, we have a stagnation
+of the blood current in the pedal extremities, a surcharging of the
+blood in the feet with certain urates, and a precipitation of these
+solid constituents, due to the cold surfaces with which those members
+constantly come in contact.
+
+This condition is present in the spring of the year when fresh
+vegetables and fruits begin to come into the market. A great many of
+these edibles, particularly strawberries and tomatoes, are markedly
+acid and when ingested tend to exaggerate the conditions in the blood
+already present. The result is generally a cutaneous eruption which may
+appear on any part of the body and which frequently occurs in the feet.
+(See chapter on Fissures and Burns.)
+
+=Fissures.= Probably the most common condition met with from this cause
+is the cracking or fissuring of the toe web. This may be accompanied by
+itching and burning in varying degrees, but these latter complications
+are not always present. The skin between the digits is found to be
+blanched and macerated and often the superficial epidermic layers
+will become slightly thickened and exfoliated. The fissures occur in
+the web and are due to the skin losing its normal flexibility so that
+the tissues, as they expand in walking or in drying the parts with
+a heavy, rough towel, are not sufficiently extensible, and so they
+crack or fissure. These cracks may be merely superficial splits through
+the epidermic layers or they may become deep and ugly fissures which
+penetrate well into the corium. When they reach this latter stage, the
+parts are found to be exceedingly tender and the irritation to the
+tissues is severe. These fissures are prone to infective processes as
+their deep recesses present an excellent lodgment for invading bacteria.
+
+The fissured area is usually confined to the web, but may be found
+extending around under the toe on either side or upon the plantar
+surface of the foot. When these conditions are of long standing, the
+edges of the fissure will be found to be thickened and calloused; it is
+found necessary to remove this growth before normal granulations may be
+expected.
+
+=Treatment.= In cases where only pruritis is present and no distinct
+lesion manifests itself, tr. benzoes compositas will be found an
+efficient agent in reducing the itching and in aiding the general
+irritation to subside. In superficial fissures, tr. benzoin compound
+may also be used in many cases with good results. The parts should
+first be thoroughly cleansed with alcohol, 60%, dried, any loosened
+or exfoliated epidermis to be removed before the benzoin is applied.
+More or less smarting is to be expected from the application of the
+tincture, but as this is very transient, no great amount of pain is
+suffered by the patient. The tincture is applied by means of a sterile,
+cotton wound applicator, and is painted well down into the fissure
+itself, and over considerable of the surrounding integument. This
+tincture is very sticky and should be allowed to dry thoroughly before
+the hosiery is replaced. As compound tincture of benzoin forms a thin
+film or coating upon thoroughly drying, no gauze or cotton need be
+placed over the painted areas. This application may be renewed daily,
+the coating from the previous application being removed by alcohol and
+the parts cleansed and dried before the second application is made.
+
+Mild vegetable astringents may also be employed in such cases.
+Principal among these are gallic and tannic acid. These drugs may
+be used in solution, ointment or dusting powder form and seem to
+be efficient in all. Dusting powders are usually preferred and the
+two most popular are bismuth subgallate (dermatol), a combination
+of bismuth and gallic acid, and tannoform, a powder containing 5 to
+10% of tannic acid. These are applied after the parts have been made
+aseptic and thoroughly dried. Bismuth subnitrate may also be used with
+good results in this condition, as may thymol iodide (aristol). The
+latter has very little astringent action and, therefore, except for its
+antiseptic properties, cannot compare with the other powders mentioned.
+Pure ichthyol may also be used in the treatment of superficial
+fissures. The drug is dropped into the lesion and covered with gauze or
+cotton, as are the dusting powders. Another drug recommended in these
+cases is sodium bicarbonate. This agent is alkaline in its reaction
+and, coming in contact with the perspiration (acid) in these parts,
+serves to neutralize this excretion and so aids in returning the
+tissues to normal.
+
+There are many other preparations, any of which may be used in the
+treatment of fissured toe webs. Among these are ichthyol ointments, 5
+to 10%; balsam of Peru, scarlet red, and a 5% ointment of ammoniated
+mercury. Reports of cases treated by the above varying drugs show good
+results.
+
+When the fissures are deep, and the discharge from their surfaces
+is considerable, slightly different measures must be adopted to
+hasten granulation. The edges of deep fissures are almost always
+found to be calloused and thickened and this condition, of course,
+must be eradicated before further treatment is administered. This is
+accomplished with a knife or shallow curette and the operation is
+usually painless to the patient and creates no hemorrhage. After the
+removal of this tissue, if the fissure be deep, silver nitrate, 5%
+solution, will be found efficient as an astringent to contract the
+parts and reduce exudation. After this application, a bland ointment
+is smeared over the area for the purpose of keeping the tissues soft,
+and this is covered by a sheet of gauze or cotton to hold it in place.
+Applications of the silver solution are made at frequent intervals
+until the desired result is obtained, when it may be discontinued and
+some dusting powder resorted to, to complete the healing process.
+Should proud flesh have developed in a lesion of this nature, through
+neglect, stronger solutions of silver nitrate or the fused stick must
+be resorted to for reduction of the superfluous granulations, followed
+by a wet dressing of liq. alum. acetate to aid in the reduction of the
+accompanying inflammatory symptoms. Lanolin and cocoanut oil have both
+been found efficient to massage into the parts in order to keep them
+soft and to prevent continued dryness and fissuring.
+
+=Blebs.= Aside from the fissuring of the interdigital webs,
+super-acidity manifests itself upon the skin of the foot, and the whole
+body for that matter, in the formation of yellow or brownish blebs or
+vesicles. They are found to be a more or less circumscribed eruption
+and are met most frequently in the foot on the plantar surface in the
+hollow of the longitudinal arch. They range in size from a pinhead to a
+pea and, in most instances, are but slightly elevated above the surface
+of the surrounding epidermis. This is in all probability due to the
+involvement of the superficial parts of the true skin.
+
+These lesions are usually uniform with a tendency to coalesce, and
+cases have been noted where patches of these eruptions covered a
+considerable area, in one instance, from the under surface of the foot,
+over its inner side, to the internal malleolus. Vesicular developments
+of this nature seldom occur singly but are often found in several
+groups on different parts of the integument, each group consisting of
+two, three or four distinct blebs.
+
+Pruritis may or may not be present in connection with this dermatitis.
+When itching is present it is usually intense and the patient often
+breaks and tears the skin in an effort to relieve the irritation.
+
+The areas of normal tissue adjacent to the eruptions may be found
+involved in a slight inflammatory process, although this is not common.
+These inflammatory symptoms usually subside rapidly under treatment.
+
+=Treatment.= It is usually found advisable, if possible, to allow these
+blebs to remain intact, making no effort to puncture them but simply
+applying a dressing which will promote and hasten their absorption.
+Cases have been noticed where these lesions have been opened and have
+developed into angry, deep ulcerations which showed a marked tendency
+toward indolent granulation accompanied by profuse discharge.
+
+However, when a bleb for any reason must be opened, it is best
+accomplished by use of a sharp pointed, sterile knife. The fluid
+contents are found to be a thin, syrupy, translucent, discolored serum,
+without any great odor, although resembling ichorous pus to some
+degree. There is a distinct loss of tissue as the ulcerations are often
+found to involve the upper parts of the derma. Upon evacuation of the
+fluid contents, the parts should be thoroughly sprayed with alcohol,
+60%, and a moist, unguent or dusting powder dressing, as the operator
+desires, applied.
+
+The solutions which may be used as moist applications are liq. aluminum
+acetate, or boric acid (saturated solution). Powerful germicides, such
+as mercury bichloride, are not necessary unless an infective process be
+present, and when used needlessly, they simply prevent or break down
+new granulations.
+
+The dusting powders found useful in this connection are aristol (thymol
+iodide) and dermatol (bismuth subgallate). The parts should first be
+thoroughly dried before the powder is dusted on. If the discharge is
+found negative and the pruritis still persists, an ointment of ichthyol
+and sulphur, such as follows will prove efficient in reducing the
+itching and in stimulating healthy granulations:
+
+  Ichthyol     1.
+  Sulphur      1.
+  Menthol      1.
+  Vaseline    32.
+
+This unguent is best held in place by a cocoon dressing and should be
+renewed until granulation is complete. Other unguents which may be used
+in this connection are sulphur, 10% (lanolin or vaseline base), balsam
+of Peru, 5%, and unguentine (a proprietary but useful combination of
+ichthyol, balsam of Peru and zinc oxide). These, however, do not tend
+to relieve the intense pruritis which usually accompanies these lesions
+as efficiently as the first mentioned combination.
+
+
+URIC ACID AND THE NAILS
+
+The toe nails also manifest conditions of super-acidity. They may be
+affected as to color or texture, and sometimes in advanced or neglected
+cases, as to size and shape.
+
+=Discoloration.= The nails, due to functional derangements in the
+matrix, become loosened and discolored from the presence of an abnormal
+amount of uric acid. They may be whitish, yellowish or brown, and in
+some cases are found almost entirely black, as if bruised. The nails
+in these instances are usually entirely loosened, or at least in part,
+from the bed, and sometimes fall off, practically of their own accord.
+
+=Treatment.= Nothing much can be done locally for these conditions,
+and the main concern of the podiatrist is to see that the edges of the
+loosened nail are not allowed to irritate the softer tissues adjacent.
+This is best accomplished by packing cotton or gauze under these edges
+so that the nail, if movable, will rub upon this packing and not upon
+the skin. It may be found advisable to first clean out (from under and
+around the nail) any excrementitious matter which is always present to
+a greater or lesser degree. However, too much “digging” about these
+parts should never be indulged in, as the operator is liable not only
+to cause a lesion, but to loosen the nail to such a degree that its
+removal is imperative. If possible, this is to be generally avoided,
+for it has been found advantageous to allow the older nail to remain
+in place as long as possible in order to protect the new-forming
+nail beneath. Alcohol, 60%, sprayed over the part after removing the
+disintegrated material, will serve as a cleansing agent and will insure
+asepsis to the parts.
+
+=Texture Changes.= Under the influence of uric acid precipitation in
+the pedal extremities, the texture of the nail is often found changed
+to a marked degree. The nail becomes exceedingly hard, dry and brittle
+so that it powders, chips off and breaks away under any sort of
+pressure. The nails are often found ridged, and in some instances these
+longitudinal ridges have become decided and permanent cracks in the
+nail body.
+
+=Treatment.= In clipping nails of this nature, care should be taken
+that too much does not chip off or break away from the pressure of the
+clipper blades. It will be found advisable to cut but a small portion
+of the nail at a time, and that very carefully. The waste material
+found around or under the nail body should be carefully removed and, if
+necessary, the nail itself should be thinned out by the use of a rotary
+file. The parts should be thoroughly cleansed, and the grooves and free
+edge should be packed with gauze or cotton to prevent the nail from
+moving during the movements of the toe and thereby developing trouble.
+
+=Changes in Size and Shape.= The so-called “club” nail is found in
+many cases where the patient is a sufferer from a uric acid diathesis.
+This does not occur as frequently in cases of acute dermatitis as in
+cases of chronic rheumatism and gout. These are cases where there
+is functional derangement of the matrix which causes the nail’s
+longitudinal growth to be arrested, followed by an increased vertical
+development.
+
+The nail is generally found to be about one-half its normal length and
+may be from one-sixteenth to one inch or more in thickness. Cases have
+occurred where the nail in appearance and structure closely resembled a
+cow’s horn.
+
+Club nails of this variety do not, as a rule, cause a great amount of
+discomfort and then only when they develop to such thickness as to
+receive and transmit direct pressure from the shoe.
+
+=Treatment.= Club nails are not curable and the treatment is merely
+cosmetic. It consists in grinding and filing the nail down to what
+would be its normal thickness, or as nearly that as possible. This,
+of course, is best accomplished by means of a rotary file. As much of
+the nail is clipped away as is possible, when the rotary file with
+a coarse-grained “barrel” bur is used. Considerable pressure should
+be brought to bear unless the patient complains of heat due to the
+friction. When the greater portion of the nail is thus removed a
+“finishing” bur is substituted and the roughened surfaces are smoothed
+off. The clippers should then again be used to give the nail a fairly
+normal shape and the parts under the nail are to be then cleansed out
+as much as is advisable.
+
+In using a rough cutting bur the operator must exercise great care that
+the skin covering the posterior or the lateral folds is not broken. If
+the handpiece of the file is grasped firmly in the palm of the hand and
+directed by the index finger while the thumb is rested on the toe and
+the bur is directed to it (the thumb), the operator will always have
+complete control of the instrument, and this danger is minimized. It
+will be found advisable, after cleaning under and around the nail, to
+spray the parts with some antiseptic solution or to paint the parts
+with tincture of iodine. This is done to insure complete asepsis.
+Should the skin be broken during the filing or cleaning, the parts
+should be first made thoroughly aseptic and a dressing to prevent
+contamination should be applied.
+
+=Prognosis.= It must always be remembered that these lesions are merely
+local manifestations of a systemic derangement and although the
+painful or annoying characteristics may be alleviated or cured, the
+cause of the trouble must be reached, through internal channels.
+
+Diet is the principal means of removing this surcharged acid condition
+of the blood and, although some medicines or waters may be and are
+ordered by the physician as eliminants, proper care as to dietetics
+is essential to the patient’s well-being. Systemic treatment by the
+physician, combined with local applications by the podiatrist, are
+usually conducive to beneficent and lasting results. In cases of
+manifestations of a uric acid diathesis in the nails, nothing much can
+be done except through the channels just described; and in cases of
+club nails due to a like etiology, nothing can be done to cure them.
+Removal of the nail does not, as is sometimes supposed, effect a cure,
+and in many instances serves but to make the new nail even worse than
+its predecessor.
+
+
+
+
+CHAPTER XXII
+
+VOCATIONAL FOOT DISORDERS
+
+
+Among the numerous diseases of the foot, there is a class of lesions
+produced by strain and misuse, in consequence of the occupation of the
+individual. Many occupations cause those who are engaged in them to
+stand or walk for long periods of time on hard and unelastic ground,
+and others subject the foot or a part of it to such unusual work that
+the entire foot, or a part of it, ceases to functionate normally.
+
+=Weakfoot.= The general term “weakfoot” is used to indicate all types
+of disability caused by improper functioning of the foot. It is
+particularly applied to that condition of the foot in which the muscles
+and ligaments on its inner side have become weakened by overuse or by
+improper use, and it is, as a vocational foot disorder, common among
+barbers, waiters, letter-carriers, policemen and servants. It manifests
+itself by pain in the foot, particularly in the heel and on the inner
+side, and sometimes by pain in the calves of the legs, in the knees and
+lower part of the spine.
+
+At rest, the foot has a normal appearance, but, under weightbearing, it
+assumes an attitude of deformity varying in degree with the extent of
+the overwork to which it has been subjected. The chief characteristics
+of weakfoot are: abduction of the forefoot, an inward rotation of
+the upper part of the heelbone and a flattening, or obliteration, of
+the longitudinal arch under weightbearing, only. When seen in its
+incipiency, an anatomically correct shoe, together with suitable
+exercises, can be made to arrest the progress and effect a cure of
+weakfoot; but when found in the advanced stages it takes from several
+months to several years of conscientious work on the part of the
+practitioner and the patient to get results. In such cases, massage,
+adhesive plaster strapping, corrective braces and shoes, exercises
+and sometimes immobilization in an overcorrected attitude by means of
+plaster of Paris dressings, have to be employed in order again to get a
+normally functionating foot.
+
+=Flatfoot.= This is a condition in which the longitudinal arch is
+depressed and does not regain its normal position when relieved from
+pressure. The forefoot is abducted, the head of the astragalus rotates
+downward and inward, and the os calcis rotates inward from above and
+outward from below. It is the successor to the weakfoot and differs
+from it only in that it exhibits also at rest, the abnormal attitude
+that a weakfoot assumes under weightbearing only. In flat foot this
+attitude is static, in weakfoot it is only temporary. The person
+afflicted with it walks with a shuffling gait, due to the accommodative
+changes that have taken place in the muscles and ligaments of the foot.
+
+=The Subjective Symptoms= are similar to those in weakfoot and quite
+often are not as pronounced as in weakfoot, due probably to the fact
+that in this condition a further stretching and strain of the ligaments
+is impossible as the limit has already been reached.
+
+=The Treatment= is similar to weakfoot, but must be augmented by means
+to overcome the accommodative changes in the foot and leg. The same
+class of patients suffer from this condition as are sufferers from
+vocational weakfoot.
+
+=Chauffeur’s Foot.= As the term indicates, this condition is found in
+people who professionally, or otherwise, drive an automobile for many
+hours each day. It is an affection, usually of the right foot and leg,
+due to the excessive use of those members while “feeding the car.”
+
+The constant pressure of the “ball” of the foot on the accelerator
+causes pain in that part of the foot, followed by a numbness of the
+entire foot. The foot feels as if it were dead and when moved, later
+on, feels as if a thousand needles were penetrating it. Cramps in the
+calf muscles are usually associated with the symptoms in the foot.
+
+=Treatment.= Massage of the foot and leg together with flexion
+exercises of the foot and toes.
+
+=Policeman’s Heel.= When a person is compelled to stand upon hard
+pavements for a long period of time, great strain is put upon the
+tissues over the os calcis or heel. The calcaneo bursa becomes inflamed
+and gives rise to pains in that region. This inflammation may affect
+the periosteum, causing periostitis and finally a spur may develop
+on the under surface of the heel bone, which will become a source of
+constant pain.
+
+=The Treatment= consists of rest to the part, and of transferring the
+weight to a place other than the painful area, by means of a felt pad
+or a brace. If a spur has developed, surgical intervention will be
+necessary.
+
+=Dancer’s Foot.= This is a foot lesion first described by Miss Bryde
+Campbell, of New York City, who termed it the “Modern Dancer’s Foot,”
+because she found it to occur almost invariably in women who were in
+the habit of dancing excessively in a modern high-heeled slipper. It
+is a painful enlargement of the tissues under the head of the first
+metatarsal bone and is found, as a rule, in the left foot only. The
+under and inner side around the head of the first metatarsal bone
+becomes painful to the touch, and under weightbearing. It is best
+described as a periarthritis although it is often complicated by a
+bursitis.
+
+=Treatment.= Measures to relieve the painful part from weightbearing.
+(Felt pads, braces, etc.) Rest and means to reduce the existing
+inflammation.
+
+=Golfer’s Foot.= The attitude assumed in playing golf, especially when
+driving the ball from the tee, often gives rise to a painful condition
+called “Golfer’s foot.” This pain is felt on the dorsum of the foot
+over the course of the extensor brevis digitorum muscle. The extreme
+extension of the foot, while striking at the ball, is the direct cause
+of the pain. Massage and rest have proven of benefit in Golfer’s Foot.
+
+    (Full details of all orthopedic lesions have been but
+    superficially treated in these pages by reason of the fact
+    that “Podiatry Orthopedics,” a volume now in the course of
+    preparation and the next of this series (Otto F. Schuster and
+    Alvah H. Stafford, authors), will provide exhaustive material
+    bearing upon all phases of foot orthopedics).
+
+
+
+
+CHAPTER XXIII
+
+LOCOMOTION AS AN AID IN DIAGNOSIS
+
+
+One need not be a very experienced physician to know that there is a
+group of diseases, mostly of the nervous system, which at a certain
+point of their evolution, stamp the sufferer with a characteristic mode
+of locomotion. To observe such a modification of the normal walk is
+often sufficient to make a correct diagnosis.
+
+It is strange, however, how little attention this important subject
+has received from the medical profession. In fact, other than the work
+of the brothers Weber, who established the physiology and mechanism
+of human locomotion, of Neugebauer and of Gilles de la Tourette, who
+developed the ichnogram method of gait study, scarcely anything of
+importance has been done along these lines for the last quarter of
+a century. The study of the mode of locomotion in various diseases
+and ailments remains, therefore, a fertile field of research for the
+podiatrist.
+
+=Elements of Locomotion.= The act of locomotion or the _power_ of
+progression is not a simple one. Various co-related movements combine
+to form what we ordinarily term the _walk_. The three chief elements
+are: (1) _Posture_, (2) _Station_, and (3) _Gait_. These three factors
+may be influenced by local or general diseases, either separately or
+together.
+
+=Posture.= Posture is the term applied to the position of the body
+in space and is not of much interest to the podiatrist except as
+corroborative of the two other elements of locomotion. It has, however,
+its value in diagnosis and the new practitioner of podiatry will do
+well to learn to observe the position of the body at various angles
+and in various diseases. One should learn early, for instance, that
+_immobility_ is not always due to paralysis. It may be due to _pain_,
+as in rheumatism or to a disinclination to move as in scurvy, rickets
+or any condition causing dyspnea. The _restlessness_ in fevers and in
+large hemorrhages, as well as the _throwing about_ in renal, gallstone
+or intestinal colics, is known to all. Equally characteristic are
+the _agitation_ and irregular movements in chorea and hysteria;
+the _gun-hammer posture_ in cerebrospinal meningitis, and the
+_opisthotonos_ in tetanus and strychnine poisoning.
+
+=Station.= Station is the _power_ of standing more or less firmly
+on one’s feet. It includes _attitude_ which is the _manner_ of
+standing, i.e., the relation of the rest of the body to the erect
+position. The carriage of the head and shoulders should be noted; the
+shape of the entire body whether bending _forward_, as in “stooped
+shoulders” (faulty attitude habit) and in paralysis agitans, or bending
+_backward_, as in ascites and abdominal tumors, should be closely
+studied and differentiated from the actual lordosis which is seen
+in spinal diseases, in advanced pregnancy, in pseudo-hypertrophic
+paralysis and in cretinism. The strictest attention should be paid to
+the attitude of the lower limbs, their individual shapes and their
+relation to each other when the erect position is assumed. The degree
+of firmness with which the individual stands should always be taken
+into consideration before a final diagnosis is made. _Swaying_ is the
+term applied to any departure from the ideally rigid erect attitude and
+perpendicular station. The normal individual, with eyes open and heels
+close together, sways about one inch forward and three-quarters of an
+inch from side to side. In functional and static ataxias, the swaying
+may become so extreme as to produce absolute incapacity to stand.
+
+=Gait.= This term means the specific _manner_ of walking. It is a
+narrower term than locomotion which is the _power_ of walking. It
+is, however, the chief factor in the act of progression and in the
+majority of cases it is characteristic enough to stamp itself indelibly
+on the normal as well as on the diseased individual. While in character
+reading, gait expression may not be as popular as face expression, it
+is often more reliable and in certain diseases it is simply invaluable
+as an aid in diagnosis.
+
+
+METHODS OF DIAGNOSIS
+
+
+=A.--The Observation Method.= This is the usual method of ascertaining
+the gait of an individual. It is practised by the average physician and
+podiatrist and consists in observing the patient while he or she walks
+up and down the room, taking notice of the peculiarities of gait which
+may develop. The patient may be allowed to roam freely about the room
+or should be directed to follow a carpet seam or a crack in the floor
+at right angles to a previous line of vision. This may be varied by
+opening or closing the eyes, stretching out the arms, with legs wide
+apart, or keeping them close together. Brisk walking should alternate
+with a slower gait and the effect of stopping abruptly and turning
+sharply at command should be closely observed.
+
+It is best to have the patient uncovered from the hips down. In women,
+the nightgown or chemise can be pulled tightly between the thighs and
+fastened anteriorly with a safety pin.
+
+=Caution.= Due allowance should be made for nervousness and a careful
+watch must be maintained against a serious fall.
+
+[Illustration: Fig. 1
+
+ICHNOGRAM OF A NORMAL GAIT]
+
+=B.--The Ichnogram Method= consists in studying the impressions left by
+_both_ soles (previously colored) when walking on paper for a distance
+of about twenty-five feet. Ichnograms (from the Greek--_ichnos_--trace,
+and _gramma_--to write) as a method of gait diagnosis are more exact
+than the method of observation and should supplement it. Besides, they
+inform us, at the same time, of the state of the plantar arch as each
+_pelmatogram_ (the impression of a single foot) shows more or less
+clearly a posterior oval which changes but little, and an anterior oval
+as well as toe marks which undergo characteristic contour changes,
+depending on the state of the ligaments, of the tarsal and metatarsal
+bones and phalanges, and the relation of these structures to the
+musculature and innervation of the foot.
+
+Comparatively little has been accomplished along this line of endeavor,
+although it offers a vast and fruitful field for podiatric research.
+In fact this branch of podiatry deserves a special treatise, and it
+will be discussed in fuller detail in our forthcoming book on Podiatry
+Orthopedics.
+
+[Illustration: Fig. 2
+
+A. PELMATOGRAM OF A NORMAL FEMALE FOOT
+
+B. MODIFIED PELMATOGRAM SHOWING WEIGHT BEARING POINTS]
+
+[Illustration: Fig. 3
+
+PELMATOGRAM OF A MALE, SHOWING FLAT FOOT]
+
+=Classification of Gaits.= Strictly speaking there are only three types
+of gait: (1) the _paretic_, (2) the _ataxic_ and (3) the _choreic_.
+In some diseases there may be a combination of the three, while in
+others one type of gait predominates during the early stage and another
+during the later developments. At times, one comes across a gait that
+combines characteristics of the three types and hence is difficult of
+classification.
+
+=I.--Paretic Gait.= _Paresis_ means a lessening of the normal motility
+of a muscle, while the term _paralysis_ denotes entire absence of motor
+power. We may have, therefore, two or three distinct paretic gaits
+according to whether the muscle is slightly or severely weakened or
+entirely paralyzed:
+
+  A.--The mild paretic gait.
+  B.--The moderate or flaccid paretic gait.
+  C.--The severe or spastic paretic gait.
+
+=A.--The Mild Paretic Gait= is caused by muscular weakness due to a
+large number of etiologic factors. It results in slowing of locomotion,
+the steps being shortened on account of an exaggerated flexion at the
+knee joint. The following are examples of mild paretic gaits:
+
+(1) _The Pompous Gait._ The upper part of the body leans backward,
+the back is hollowed, the abdomen is protuberant, the feet are widely
+separated and appear to move with deliberation and dignity, giving the
+impression of conscious importance--hence the name. This gait may be
+seen in obesity, pregnancy, ascites, large abdominal tumors, cretinism
+and rickets.
+
+(2) _The Hobbling Gait._ The pelvis tilts towards the sound side,
+while the trunk leans over to the affected side, causing more or
+less pronounced _limping_. This gait is seen in people afflicted
+with corns, rheumatism, gout, sciatica, plantar neuralgia, Morton’s
+neuralgia, metatarsalgia, hip or knee joint disease or injury (recent
+or old), sacro-iliac disease, sprains, inflammatory diseases of the
+lower extremity, chimatlon, short leg, paralysis of one leg, abdominal
+aneurism, and subacute and chronic appendicitis.
+
+(3) _Intermittent Limping_ (disbasia angiosclerotica or intermittent
+claudication) may be classified here and is a curious limping gait
+which develops in arteriosclerosis of the lower extremities. There
+are pain and fatigue on walking, which disappear after a short rest,
+to reappear again soon after walking is resumed. The pulse is weak or
+absent below the knee.
+
+(4) _The Waddling or Goose Gait._ The pelvis and head of femur are
+jerked forward at each step, knee advanced and extended only after
+foot is flat upon the ground. There is more lordosis and swinging
+of the body from side to side at each step, than in the pompous
+gait. It resembles the gait of a goose. The patient cannot stand on
+tiptoe. It is seen in: congenital dislocation of both hip joints and
+in pseudo-hypertrophic muscular paralysis, a hereditary disease seen
+mostly in boys under ten years of age, and characterized by inability
+to get up from the floor.
+
+(5) _The Wobbly Gait._ Resembles the above and is due to atrophy or
+paralysis of the three glutei muscles and prevents the patient from
+climbing. This inability to climb is also seen in those exhibiting the
+waddling gait.
+
+(6) _The Tottering Gait._ Seen in those who have taken large doses
+of bromides for long periods; also in hydrocephalus, in Korsakoff’s
+disease (psychosis polyneuritica) and in idiopathic muscular atrophy.
+
+(7) _The Shuffling Gait_ is the gait seen in normal old age or senility
+and is associated with slowly progressive loss of strength and
+mentality. It is also seen in general paresis and is the “normal” gait
+of the long-term prison inmate. The patient gives the impression of
+being too lazy to lift his feet and instead pushes them along with his
+legs.
+
+(8) _The “Charlie Chaplin” Gait_ has been erroneously described as
+an ataxic gait. It is rather a combination of the “funny part” of
+several gaits in which the waddling, shuffling, tottering paretic gaits
+predominate and to which some elements of the spastic paretic, as well
+as the ataxic gaits, have been added. The inspiration must have come
+originally to the celebrated movie star from some waddling cripple whom
+he proceeded to imitate and later burlesqued.
+
+=B.--The Moderate or Flaccid Paretic Gait.= In this form of the paretic
+gait there is commonly a paresis of a certain group of muscles, usually
+the extensors of the foot or the peronei, causing “toe drop” and
+apparent lengthening of the affected extremity. It corresponds to the
+“wrist drop” of the upper extremity. To compensate for the lengthening
+of the limb, overflexion at the hip or knee, or at both joints, takes
+place. The limb is flaccid or flabby.
+
+The foot is lifted high up with each step in order to raise it clear
+off the ground and avoid tripping. As the foot is brought down, heel
+first, this gait may sometimes be confused with tabes and is therefore
+sometimes referred to as the pseudo-tabetic gait. It is, however,
+easily differentiated from the true tabetic gait by its characteristic
+“high action” or “high stepping” quality which made Charcot compare it
+to the gait of a horse and hence called it:
+
+(1) _The Steppage Gait_, mostly seen in the chronic intoxications
+producing neuritis. It resembles the gait of a man walking through
+thick grass or brushwood and stepping over constantly recurring but
+non-existent obstacles. The typical steppage gait is seen in arsenical
+neuritis with ankle drop, also in alcoholic neuritis, polyneuritis
+potatorum (ataxia of drunkards) and in lead neuritis (lead palsy,
+plumbism, saturnism), in which first the peroneal muscles are affected,
+later the extensor communis digitorum and finally the extensor
+proprius hallucis. Phosphorus, copper and grain (ergotism) poisoning
+may give rise to a neuritis in the lower extremities and produce the
+characteristic steppage gait. Tuberculosis, malaria, diabetes and
+diphtheria (motor form) may sometimes produce this gait. It may also
+develop as a sequel of sunstroke (thermic fever, insolation) and in
+fact following any disease which will cause peripheral neuritis of the
+anterior tibial nerve.
+
+(2) _The Prancing Gait_ is an exaggeration of the preceding gait.
+It is seen in epidemic anterior poliomyelitis (infantile paralysis)
+when the disease affects the anterior horn cells of the lumbar cord,
+causing atrophy of the extensor muscles of the foot, resulting in
+“foot drop.” It is also seen in acute ascending paralysis (Landry’s
+disease), which is probably a form of poliomyelitis, and in progressive
+hereditary muscular atrophy of the leg (Charcot-Marie-Tooth type) where
+the muscles of the leg, not the foot, are primarily affected, i.e.,
+first the peronei become atrophied, later the extensors of the toes
+and finally the calcaneal muscles. Finally the prancing may be seen in
+connection with certain tumors of the cord, unilateral hip disease,
+dislocation or injury and in multiple neuritis and beriberi (epidemic
+multiple neuritis).
+
+=C.--The Spastic or Severe Paretic Gait.= The spastic gait is due to
+the hypertonicity of the weakened muscles, the resulting stiffness
+causing a slowing of locomotion and diminished excursion of the
+affected limb. The hypertonicity is produced either by direct
+stimulation of the motor cells in the anterior horn of the spinal cord,
+as in traumatic myelitis, or by impulses coming down from the cerebral
+cortex. The limb is spastic or rigid, due to the tonic spasm. When the
+tonic spasm is of long standing, it is termed a _contracture_. The
+lower extremity moves as a whole, the toes clinging to the ground,
+scraping it and very often “catching.” Contrary to the moderate paretic
+gait, this group presents difficulty in flexion which is partly
+overcome by the elevation of the pelvis on the side of the swinging leg.
+
+(1) _The Mowing or Hemiplegic Gait._ This is the prototype of
+all spastic gaits and is encountered in its simplest form in all
+hemiplegias, i.e., in paralysis of one side of the body, which may
+be caused by cerebral hemorrhage, embolism, thrombosis, syphilis,
+brain tumor, multiple sclerosis of a cerebral hemisphere, meningeal
+hemorrhage or suppuration, Raynaud’s disease, general paresis of the
+insane; sometimes it may be due to hysteria (functional hemiplegia)
+or to uremia (transient hemiplegia). No matter what the cause of the
+hemiplegia, there is always the typical mowing gait. This mowing
+movement is due to the fact that the spastic limb swings lateralward,
+describing an arc of a circle (outward), and strikes the ground in a
+flail-like manner. Technically speaking, circumduction takes place by
+tilting of the pelvis and the swinging of the foot outward and around
+to the front. The patient afflicted with hemiplegia makes the same
+movement with his limb as does the reaper with the hand in which he
+holds the scythe. _Exception_: the only paralytic gait in which there
+is no mowing movement occurs in hysterical (functional) paraplegia,
+which is very rare. In this condition the leg is dragged forward
+instead of outward.
+
+_Important shoe sign in paraplegia._ The sole of the shoe is worn down
+on the inner side.
+
+(2) _The Small-step Gait_ (la marche à petits pas). This gait is seen
+in cerebral softening following an apoplectic stroke, especially in
+pseudo-bulbar paralysis; the steps are very short and the feet are
+lifted from the ground with difficulty, the patient seeming to count
+his steps.
+
+(3) _The Cross-legged Gait._ This gait is due to a spasm of the
+adductors of the thigh causing the knees to rub against each other,
+resulting in cross-legged progression, the lower limbs having a
+tendency to cross during locomotion. It is seen in both Little’s
+congenital and Erb’s syphilitic form of lateral spinal sclerosis. In
+the syphilitic form, a dragging and shuffling gait is often associated
+with the cross-legged type.
+
+(4) _The Ill-defined Spastic Gaits._ Ill-defined spastic gaits are seen
+in tetany (paroxysmal tonic spasm) from any cause, and in amyotrophic
+lateral sclerosis, which is the spastic form of progressive muscular
+atrophy (Charcot’s disease). This involution disease, due probably to
+developmental defects of the lateral pyramidal tracts, has the combined
+symptoms of spastic spinal paralysis, anterior poliomyelitis and bulbar
+palsy, hence the difficulty in classifying it. Myelitis (inflammation
+of the spinal cord) may be due to trauma, alcoholism, syphilis,
+vertebral caries (compression myelitis), tumors, aneurism, hemorrhages
+into the cord, etc., and will exhibit various gaits according to
+the stage and severity of the disease. It may begin with a mild
+paretic gait passing through several stages of the spastic gait or to
+complete paraplegia (paralysis of both lower extremities). In complete
+paraplegia there is of course no gait, as the patient cannot walk,
+there being a loss of the power of locomotion but not of progression (a
+patient so afflicted may still move from place to place on his hands).
+
+(5) _The Dragging Gait._ In hemiplegia one foot only is dragged.
+Dragging of both feet is seen in multiple neuritis, hereditary peroneal
+atrophy, spasmodic spinal paralysis and spinal and syphilitic spinal
+paralyses.
+
+(6) _The Dromedary Gait_, so called on account of its resemblance to
+the gait of a camel, is seen in children suffering with progressive
+torsion spasm (Flatau-Sterling disease).
+
+Finally, spastic paretic gaits are often observed in pellagra (maidism,
+Italian leprosy, Alpine scurvy) and in lathyrism (lupinosis), where
+the slow toxic spinal sclerosis finally leads to spastic paraplegia
+and loss of the power of locomotion; also in caisson disease (divers’
+paralysis).
+
+=II.--The Ataxic Gait.= The ataxic gait may be either:
+
+  A--The Static ataxic gait, or
+  B--The Functional ataxic gait
+
+and these are termed either (1) spinal or (2) cerebellar, according to
+the location of the lesion.
+
+=A.--The Static Spinal Ataxic Gait= is the most easily recognized gait,
+and once seen, is never forgotten. There is an exaggeration of all the
+movements of locomotion. The hips are overflexed and rotated laterally,
+the foot is raised suddenly and too high, the toes are lifted and the
+whole limb is thrown suddenly forward with unnecessary vehemence and is
+then brought down heel first or flat-footed, with a stamping sound. The
+feet are kept wide apart and while in the air they move in an undecided
+manner, as if the patient was doubtful where to put them. The eyes of
+the afflicted person are glued to the ground or fixed to the limbs so
+as to supplement the lack of muscular and articular sensation by the
+sense of sight.
+
+In the cerebellar type of this gait the movement excursion is not as
+extensive as in the spinal type. A sudden turning movement or an abrupt
+sitting posture is difficult or impossible to assume in this type of
+locomotion.
+
+In order to test static ataxia, the patient is made to stand heels
+and toes together, whereupon marked swaying takes place. The swaying
+is increased when the eyes are closed and the patient looks like a
+“chicken on a clothes line.” If there is more than one inch forward
+swaying and more than three-quarters of an inch lateral swaying, the
+patient is considered ataxic.
+
+In the disease known as tabes dorsalis, or locomotor ataxia of
+syphilis, the swaying may be so pronounced as to produce absolute
+incapability to stand or to walk.
+
+=B.--The Cerebellar (functional) Ataxic Gaits.= These gaits are
+produced by a disturbance of the equilibrium accompanied by vertigo
+resulting in a very irregular swaying from side to side, resembling the
+gait of an intoxicated person.
+
+The patient makes short steps, keeps his feet wide apart, staggers,
+rolls, sways to and fro and reaches a set point by zigzagging toward
+it. The swaying is relieved when support is given under the armpits.
+
+(1) _The Titubating Gait_ is a form of functional cerebellar ataxic
+gait seen in the following affections: Friedreich’s (disease) ataxia;
+hereditary cerebellar ataxia; dementia paralytica; ataxic paraplegia;
+labyrinthine disease and to some extent in vertigo; syringomyelia; and
+in some cases of general paresis, and various chronic intoxications
+like lead or arsenic or alcohol poisoning affecting the cerebrospinal
+system.
+
+(2) _The Reeling or Staggering Gait_ is seen in acute alcoholic
+intoxication and Mésnière’s disease (disease of the middle cerebellar
+lobe).
+
+=III.--The Choreic Gait.= The choreic gait, sometimes called _tremor_
+gait, spasmodic or hysterical gait, is very variable in quality
+depending on the cause of the tremor. It consists of a series of
+quivering or trembling movements of varying intensity, but nearly all
+due to clonic spasm and disappearing during sleep or passive motion.
+This distinguishes it from the spastic or paraplegic gait in which
+the spasm is tonic in quality, lasting from one minute to one month.
+The clonic spasm, on the other hand, consists in rapidly alternating
+contractions and relaxations of the muscle.
+
+(1) _The Stumbling Gait_ is seen in chorea (St. Vitus’ dance) and
+Huntington’s (hereditary) chorea, in Friedreich’s paramyoclonus
+multiplex (which is not to be confounded with Friedreich’s ataxia),
+in Unverricht’s progressive myoclonus, and in multiple sclerosis
+of the spinal cord. The gait resembles that of a schoolboy, who
+clownishly stumbles or trips over his heel to attract attention.
+Technically it consists of spasmodic adduction, extension and outward
+rotation of the legs which soon renders locomotion impossible. When
+these abrupt twitchings and jerking movements, which are involuntary
+and purposeless, affect only one-half of the body, we speak of the
+condition as hemichorea. The patient appears restless, unsettled and
+fidgety.
+
+(2) _The Festination Gait_ is typical of the disease known as
+paralysis agitans (Parkinson’s disease, shaking palsy) and is an
+advanced choreic gait in which there may be observed the curious
+phenomena of propulsion and retropulsion, i.e., the impossibility of
+stopping, once the patient is pushed either forward or backward. In
+some instances, when pulled suddenly backward, the patient will take
+a few backward steps with increasing rapidity, also the body remains
+in the characteristic posture of paralysis agitans; namely, in the
+forward-leaning attitude. In festination “the body tries to overtake
+its centre of gravity” (Trousseau).
+
+(3) _The Saltatory Gait_ (“The jumpers”), is a very rare condition
+occurring the instant the weight of the body is put upon the feet. It
+consists in strong and rapid contractions of the muscles of the thigh
+and leg causing the patient to jump up violently. It is probably a
+hysterical spasm.
+
+(4) _The Myotonia Gait_ occurs in Thomsen’s disease and consists of
+tonic, _painless_ spasms whenever a certain group of muscles begin
+to functionate. The steps are first checked and delayed; but this
+gradually wears off. This curious condition returns again when the same
+group of muscles are called into action. Owing to the tonic spasms,
+this gait might have been properly classified as a spastic paretic
+gait, were it not for the fleeting and irregular character of the
+spasticity.
+
+(5) _The Hysteria Gait_, known also as astasia-abasia, is notable by
+the ease with which it may simulate any and all of the gaits described
+above, the spastic as well as the flaccid types of paralyses,--even
+the cross-legged gait, ending in complete inability to stand or walk.
+It differs from all of them, however, in the ability of the patient to
+perform all the nervous functions of the limb when lying in bed. The
+hysterical gait may also end in:
+
+_Catalepsy_ which is a state of muscular rigidity enabling a limb to
+maintain a posture in opposition to gravity for one hour or more (waxy
+flexibility). This curious phenomenon of retaining the leg or any other
+part of the body in a fixed attitude (given to it by the operator)
+is sometimes seen in catatonia, general paresis, brain tumors and,
+(rarely) in meningitis.
+
+    (The above chapter was especially prepared for “Practical
+    Podiatry” by Paul Luttinger, M.D., Professor of Bacteriology in
+    The First Institute of Podiatry. It is the first compilation of
+    its kind ever published and should prove a valuable aid to both
+    practitioners of medicine and of podiatry--_Editor_).
+
+
+
+
+CHAPTER XXIV
+
+MISCELLANEOUS FOOT LESIONS
+
+
+TRENCH FOOT
+
+A foot lesion has arisen during the present war, which, because of the
+fact that it appears on the feet of those who have been subjected to
+long sieges of service in the trenches, has been called “Trench Foot.”
+
+The condition has been and is being investigated by many medical men
+of note, and although the literature available has been rather meagre,
+several facts have been established and some of the data has been
+classified.
+
+This chapter has been compiled from various papers upon the subject
+written by those who are now serving their respective countries in
+France, and who have had experience in dealing with the lesion.
+Articles by the following writers have been used, and all of the
+statements contained therein have been verified: B. Sherwood Dunn,
+M.D., of Paris, in _The Medical Record_; “Anonymous,” in the same
+publication; H. Oswald Smith, in _The Lennox_, a journal devoted to
+dentistry, and several articles in the _Journal of the American Medical
+Association_.
+
+Trench foot is a lesion found in the lower extremity and is a result of
+exposure to cold and dampness in the trenches. It has been likened to
+frost bite, but cases reported during the summer months show that the
+parallel is not justified. There are several stages to the disease, and
+they are classified by Smith into four groups: (1) Neuritic--producing
+acute pain and preventing the patient from walking or sleeping. There
+is no swelling or discoloration of the foot. (2) Edematous--without
+discoloration, but acute pain is present, produced by the pressure
+on the nerve endings. (3) Edematous--with blisters and varying
+discoloration of the skin, short of gangrene. (4) Gangrenous--partial
+or circumscribed, with edema and blisters and reddening of the skin
+involving the lower leg.
+
+=Etiology.= The lesion is found chiefly among men of from twenty to
+thirty years of age who have been in continuous service in the trenches
+for a minimum of three days. That it is truly the result of trench life
+is proven by the fact that men in the artillery, who do not see trench
+service, are not thus afflicted.
+
+The constriction of the foot in ill-fitting shoes and stockings with
+lack of cleanliness are also etiologic factors. Cold is not accepted
+as the cause of trench foot, as the trouble occurs in weather above
+freezing and some cases have developed in the summer time. Neuritis,
+produced by humidity, is the cause of the lancinating pain.
+
+Raymond and Parisot have stated that the disease is caused by
+bacterial invasion. They have isolated the microbe, from the mud of
+the trenches, and have reproduced in animals the various symptoms
+manifested in trench foot. The microbe was found in the purulent layer
+of the vesicles and the injection of these germs into the epidermis
+of the rabbit and guinea pig caused the same lesion as is found in
+man. They have reached the conclusion that the disease is similar to
+mycetoma, the fungus foot of Madura and misnamed by English surgeons
+“tuberculosis foot.”
+
+The disease is prevalent among those standing in the soft, slushy mud
+or in the muddy water of the trench. The skin of the feet becomes soft
+and macerated, and while in such condition offers easy ingress for the
+microorganism, especially along the nail grooves or through abrasions
+caused by shoe friction.
+
+A committee of United States army surgeons in France, headed by Major
+R. P. Strong, are making extensive tests in order to ascertain the
+cause of _trench fever_. Their unfinished report (they are still
+investigating) shows as follows: (a) the organism causing trench
+fever is present in the plasma of the blood; (b) the organism is not
+filtrable; (c) the disease is transmitted naturally by the body louse
+(pediculis corporis); (d) this method is apparently the important and
+common means of the transmission of the disease[7].
+
+=Symptomatology.= The symptoms of trench foot are always the same. The
+ball of the great and second toe are swollen and edematous, the skin
+is distended and glossy and there are occasional blisters or vesicles.
+The edema may extend to the remaining toes and to the ball of the
+foot, and, from being white, may become rose-colored or even red and
+violet. In grave cases the liquid in the vesicles changes from citron
+color to a hemorrhagic hue, the skin becomes blue-black, then livid
+and gangrenous. Some of these vesicles may dry and the scab fall off,
+leaving no scar; the base of the vesicle may change in color from brown
+to black, and this change may extend beyond the borders and cover the
+entire area affected by the edema. This change is the forerunner of
+gangrene; the vesicle becomes a crust; when it falls off it leaves a
+putrid base which may gradually eat into the tendons and articulations
+and periosteum. It is not infrequent to have the first crust followed
+by a second and third, and when the disease has progressed to this
+stage, no medication seems to avail and the member has to be amputated
+at a healthy point beyond the parts affected.
+
+There is little if any fever accompanying the lighter forms, but a
+temperature of 104 degrees F. may attend the graver forms, with general
+disturbances of the nerve trunks. Albuminuria is not infrequent.
+
+The patient complains of lancinating pains which interrupt sleep and
+cause difficult locomotion. Walking is accomplished on the heels, with
+the toes elevated. The pain is excited at several points, chiefly by
+pressure on the heads of the metatarsals. In the lighter forms, the
+patient complains of numbness (but only in the affected members) which
+at times extends to a condition of anesthesia. The mildest form is
+characterized simply by pain and paresthesia.
+
+The trouble appears, as a rule, after the patient has spent his
+assigned period in the trenches and manifests itself when he has
+retired to the sector for repose and removes his shoes for the first
+time in several days.
+
+In the very worst cases there is gangrene accompanied by all of the
+dangers of infection, by destruction of tissue and loss of limbs.
+There is a tendency to contracture of the foot, usually described as a
+turning under of the foot.
+
+=Prognosis.= Trench foot has a duration of from two to three weeks, in
+the lighter forms, and from six weeks to three months in the severe
+cases. The simpler lesions respond well to treatment, and in the type
+in which vesicles have formed, these latter dry and fall off, leaving
+no scar. A cure is effected in about one month. In more advanced types,
+in which extensive ulceration is present, the toes alone are lost and
+the rest of the tissues are saved under proper treatment. When general
+septicemia develops, and according to statistics of two thousand cases
+treated from October, 1916, to January, 1917, there have been only two
+such cases, the patients have immediately succumbed.
+
+Complications are frequent accompaniments of the malady--abscess,
+neuritis, lymphangitis, etc. Tetanus has been observed with sufficient
+frequency to cause all patients to be injected with antitetanic serum
+upon admission for treatment.
+
+=Treatment.= The prophylactic measures that have been adopted since
+trench foot has been more thoroughly understood, have eliminated it
+to a great extent, and the disability that it caused at that time is
+gradually being controlled. The perfection of general sanitary methods
+and the construction of better trenches have helped to diminish the
+incidence of the condition as well as to reduce disease and disability
+in general. The smaller sectors and the greater reserve of men,
+allowing for more frequent change, have of themselves, without the
+actual preventive methods instituted, reduced both the severity and
+the occurrence of trench foot. Where previously the men had to stay in
+the trenches for long periods, at present there is a change every few
+days.
+
+As a general preventive measure against the lesion, it was found that
+the wearing of looser boots, perhaps a size too large, was of great
+help. This measure prevents the restriction of the circulation, which
+is so large a factor in the causation of trench foot. The general
+circulation of the body can be maintained by warmth and by appropriate
+movements and exercises. Socks must be changed very frequently and must
+be kept dry. Torn socks are especially liable to constrict the blood
+vessels and to produce injury to the foot. Foot rags, well paraffined,
+have been tried, with more or less success, to obviate the difficulty
+of keeping socks whole. If these foot rags are well applied, they are
+found to be far more comfortable than socks. Puttees must be loosely
+applied. Boots must be thoroughly greased before being put on. Rubber
+boots have been extensively used and are looked upon with favor.
+Thorough greasing of the feet was tried at the beginning, but was found
+to be offensive to the men, and consequently was not conscientiously
+carried out.
+
+The newest and apparently most successful method of preventing trench
+foot is by means of the so-called “trench-foot washhouses.” Immediately
+before returning to the trenches the men go to these washhouses for
+treatment. Here they have their feet soaked in warm, not hot, water
+and washed with a special soap composed of soft potash soap 1000
+parts, powdered camphor 25 parts and borate of soda 100 parts. The
+feet are then carefully dried and treated by the regimental surgeon
+or podiatrist, and are finally dusted with a mixture of powdered
+camphor, talc and borate of soda. In the trenches, the soldiers must
+be served with hot food in order to maintain warmth and keep up the
+general circulation. No amount of attention to the feet of the soldier
+can be too painstaking as regards cleanliness, shoeing and physical
+condition. To escape disability as the result of actual war violence
+and to acquire it as the result of preventable sanitary conditions,
+would be indefensible.
+
+The treatment of the lesion itself, depends upon the severity and the
+extent of the condition.
+
+1. =Simple Edematous Form.= In the beginning, the erroneous diagnosis,
+and the subsequent treatment directed along the lines of frost bite,
+and the taking of potassium iodide, salversan-methylene blue, and the
+application of tincture of iodine and copper sulphate, did more harm
+than good in some cases, and the results, at best, were irregular. The
+statistics of Raymond and Parisot, who have treated more than 2000
+cases in a short time, are the best compiled, and as their results have
+been excellent they are here given.
+
+At the earliest moment possible the feet of the patient should be
+thoroughly soaked in warm water and washed with liberal quantities of
+the soap, previously mentioned, and composed of soft soap, camphor and
+sodium borate. The cleansing should be thorough, but with care not to
+break the skin or to open any existing vesicles. The skin must be dried
+carefully with a soft towel and the following applied: cover a layer of
+absorbent cotton of the thickness of the hand with gauze; soak this in
+a solution of camphor, 1.1; borate of soda, 15, boiled water, 1000, and
+apply while still thoroughly wet (being careful to cover the ends of
+the toes) to all the edematous surface as far up the leg as it extends.
+Cover the whole with oiled silk or rubber sheeting, and fit by adhesive
+strips. If a roller bandage is used, it must be applied loosely. The
+dressing should be damp when changed the following day.
+
+Renew this dressing daily, until the edema disappears, which should
+be from the second to the sixth day; after this, continue the same
+dressing for two or three days without the impermeable covering;
+following this, camphorated oil is to be applied without rubbing.
+
+When the disease proves obstinate and is accompanied by persistent
+pain, some relief is afforded by bathing the feet at the time of the
+daily dressing in warm water, using the same liquid soap as at first.
+
+2. =Vesicular Form.= The small vesicles, not larger than a ten cent
+piece, should be left undisturbed and will dry up without scar with the
+above-described treatment. When they are extensive, and especially when
+the contents are hemorrhagic, they should be completely denuded and the
+gelatinous base should be carefully removed by aid of a sterile tampon,
+and then these denuded surfaces should be covered with compresses
+soaked in a solution of camphor, 30, ether, 1000. These compresses and
+the whole affected surface are covered by the fomentation previously
+described, and should be changed daily.
+
+When the edema subsides, omit the fomentations and continue the
+application of camphorated ether solution, and as the denuded surfaces
+show improvement, dust them with camphor powder or with boric acid
+powder.
+
+3. =The Formation of Crusts.= The foregoing treatment will ordinarily
+prevent the formation of crusts or scabs; when these do form, steps
+must be at once taken for their removal without undue force or surgical
+aid, as they cover the most virulent germ collections, which are liable
+to produce a general infection if permitted to contaminate freshly cut
+surfaces. On the other hand, if permitted to remain, the germs thus
+protected have a tendency to burrow profoundly, involving the tendons
+and articulations.
+
+The crusts must be softened and carefully removed from their borders
+daily, little by little, by aid of the forceps, the operator being
+careful to cause no bleeding. To soften the crusts, the following
+are recommended: (1) liberal dressings soaked in camphorated ether
+and covered with oiled silk or rubber sheeting; (2) collodial silver
+dressings; (3) camphorated oil and borated vaseline. As the crusts are
+gradually removed each day, the uncovered surfaces should be treated
+with the camphorated ether.
+
+Not infrequently the crusts will re-form, in which event it is well
+to treat them with pomade of Reclus, made as follows: vaseline, 200;
+boric acid, 3; iodoform, 1; antipyrine, 5; salol, 3; carbolic acid
+(crystals), 1; bichloride of mercury, 0.1.
+
+4. =Extensive Invasion.= Where the processes have progressed and
+involve a considerable amount of tissue, evidenced by a congested,
+violet-red surface, but with little or no erosion or vesicles, we
+recognize the presence of the malady in its worst form, and prompt
+measures must be taken to save the member. In these cases the germs
+have penetrated beyond the surfaces, and in order that they can be
+subjected to contact treatment and destroyed, we must reach the hidden
+centres of their activity.
+
+After surgical preparation of the surfaces, they are incised by a sharp
+pointed bistoury in the long axis of the foot and down to the level
+of the infection, indicated by a purulent layer of fetid edema. If a
+collection of pus is found, a free and extensive incision is made and
+the tissues thus exposed are thoroughly washed out with an antiseptic
+solution, by aid of a syringe. The thermocautery should not be applied,
+as the results of its use in such cases have been very bad.
+
+When the infected parts are opened they are treated with the previously
+mentioned camphorated ether, or with collodial silver dressings or,
+in the presence of purulent infiltration, with collodial gold, which
+can be varied by the following: eucalyptol, balsam of Peru, guaiacol,
+gomenol, camphor, of each 10, in ether, 1,000. Under the influence of
+these dressings, the hardened infiltrated surfaces soften and can be
+removed little by little by the aid of the forceps, in measure as the
+sloughing continues, until the destroyed and contaminated tissues are
+eliminated.
+
+In so far as possible, surgical intervention should be avoided; where
+the bone is attacked, it is better to permit it to be eliminated
+by the progressive destructive action of the disease. Tentative or
+conservative operations upon the bone have been followed by extensive
+destructive osteitis. If an amputation becomes necessary, it should be
+made at a healthy point beyond the infected area.
+
+5. =Reparation Stage.= When the necrosis has been arrested and the
+granulations show that the affected parts are disinfected, the usual
+emollient applications can be employed to aid the repair; but here, a
+treatment brought into use by Rathery and Bauzil is recommended. This
+forms an impermeable covering easily applied and changed, and possesses
+self-evident advantages. It is composed of naptholate of soda, 2;
+essence of thyme, essence of origanum, essence of geranium, of each 3;
+vaseline 1,000; paraffin (45°-50°), 5,000. Melt and thoroughly mix by
+aid of heat and put aside in pots holding 125 grams each; sterilize for
+twenty minutes at 120°.
+
+At the time of the daily change of dressings, place the number of
+pots necessary in a bath of boiling water to melt the wax, cover
+the affected parts with a single layer of sterile gauze and paint
+thoroughly with the melted wax. This dressing hardens as fast as it is
+applied. Apply a second and third layer in the same manner, to form a
+perfectly occlusive dressing. Cover with cotton and bandage. Dressing
+comes off easily and completely without pain, and gives remarkable
+results in healing and repair and renewal of the skin to the parts.
+
+6. =General Treatment.= In the cases complicated by septicemia,
+subcutaneous injections of camphorated oil in doses of from 5 to 15
+c.c. per day, or intramuscular injections of collodial camphor in doses
+of 2 c.c. per day, are advisable.
+
+7. =Complications.= The most frequent is tetanus. Every patient should
+at once be injected with antitetanic serum, and this should be repeated
+every eight days during the period of ulceration and sloughing. It is
+even prudent to augment the second injection in those gravely afflicted
+(20 c.c. of the Pasteur Institute serum, or 3000 units of the American).
+
+Gaseous gangrene is infrequent with the treatment here indicated. If
+present, it can be treated in the usual way.
+
+Smith has employed subcutaneous injections of oxygen in cases of this
+condition which have been neuritic, or edematous without discoloration,
+edematous with blisters, gangrenous, partial or circumscribed. The
+technic of the oxygen treatment is as follows: a Woulfe bottle is
+required, with two glass tubes bent at an angle and inserted into a
+tightly-fitting cork. To the end of one glass tube is fitted three
+yards of red rubber tubing connected with the usual oxygen cylinder; to
+the end of the other glass tube is fitted two yards of a finer rubber
+tube, and the distal end of the tube has fitted on it a salvarsan
+needle. The bottle contains a saturated solution of sodium carbonate.
+The needle should be sterilized in boiling oil for each individual
+case. The operator, having sterilized his hands, uses iodine on the
+proposed sites of the puncture. The needle is inserted into the
+subcutaneous tissue at a point midway between the heel and the external
+malleolus. The oxygen is allowed to enter slowly until the foot is
+filled up. The needle is then withdrawn and inserted midway between
+the internal malleolus and the heel. If the toes are black and cold
+the needle is inserted in the mid line at the base of the toes. It is
+important that the oxygen should be injected slowly. If the part is
+almost gangrenous, injection into the deeper tissues is of advantage.
+
+The treatment is based on the conclusion that trench foot is akin to
+Raynaud’s disease. The edema produces stasis in the veins of the foot,
+impeding or stopping circulation, and the venous blood, if oxygenated,
+will help to keep the tissues alive until the serum can be drained
+away, while the oxygen helps to drive out the serum, slowly but
+steadily, through the puncture holes. Mere puncturing has been found
+useless in relieving the edema. The oxygen balloons the subcutaneous
+tissue, thus relieving pressure on the blood vessels and lymphatics.
+When the oxygen is absorbed and the serum drained away, circulation is
+quickly restored to the limb.
+
+There is marked relief to pain at once, and under the eye of the
+observer certain changes can be seen taking place. The reddish blue
+appearance changes to pink; the redness which often extends up the leg
+disappears, and where blackened areas exist, a white line makes its
+appearance and any living tissue is noticeable by its pink color. The
+white line indicates what would ultimately be the line of demarcation
+of gangrene, and it is noted that healthy granulations start from
+this white line after injections of oxygen. The destruction of parts
+is greatly lessened, and is often confined to the tips of the toes.
+Areas of black blood on the dorsum of the foot rapidly undergo change,
+becoming grayish white and pink, and more nearly resembling healthy
+tissue. In many of the severe cases, recovery of the whole foot has
+taken place, and in some the loss of but a single digit has had to be
+recorded.
+
+A minor but important point is the treatment of all blisters. They
+should be drained by sterilized thread passed through by means of a
+straight surgical needle and the ends cut short. The dead skin should
+be left in situ as a protective, unless pus is present.
+
+The oxygen causes an increase in the pulse of the posterior tibial
+artery. There is no rise in temperature, pain is relieved, and sleep
+promoted. Lint, wrung out in 1 per cent. solution of picric acid, is
+applied to the parts and renewed every day. No cotton wool should be
+employed or disastrous results will ensue. The lint and bedclothes next
+day will be found saturated with serum, sometimes clear, and sometimes
+blood-stained. The skin will have a peculiar wrinkled appearance,
+pointing to the previous state of edema. The foot is warm even at the
+toes, and movement will have returned. At the end of the second day
+tingling sensations arise. In cases which are semi-gangrenous and
+where the edema still persists, a second injection may be given. One
+injection is usually found to be sufficient, but picric acid should be
+used once or twice a day to keep the part dry and sweet. The effect of
+the oxygen on the deep layers of the true skin is notable; a rich red
+velvet color persists for several days.
+
+Smith advocates conservative treatment in all cases of trench foot
+unless gas gangrene or grave toxemia be present. Repair is slow but
+sure and many hopeless looking cases have recovered with useful limbs
+and minor loss of structure. The cost of the oxygen treatment is small,
+and oxygen is usually available. There is no risk to the patient if
+this treatment be intelligently used, but healthy tissue, as far as
+possible, should be utilized for injection purposes. The length of time
+for repair and recovery of the part is long in the semi-gangrenous and
+in the gangrenous cases. The granulation tissue is often indolent with
+the epithelial margin heaped up, and here, again, oxygen has been found
+to stimulate epithelial growth, a hypodermic needle being utilized in
+place of the salvarsan needle.
+
+The conclusion drawn is, that if the edema can be relieved by
+withdrawing the serum, the circulation can be re-established, and
+during this withdrawal the tissues are supplied with oxygen to keep
+them nourished.
+
+
+GROUND ITCH OR UNCINARIAL DERMATITIS
+
+Prof. Paul Luttinger in addressing the students of his class at The
+First Institute of Podiatry gave the following outline of this disease:
+“this condition is known as water itch, water pox, water sores, sore
+feet of coolies, panighao, mazamorro (Porto Rico), tunnel-digger’s sore
+foot. It is an erythematous or papulo-vesicular irritation of the feet,
+due to infection with the larvae of the hookworm. These latter gain
+entrance through the skin of the lower extremities and cause the very
+grave tropical disease known as uncinariasis (hookworm), or tropical
+chlorosis.
+
+“The eruption, which is very itchy, appears first as reddish spots
+between the toes and on the dorsum of the foot. These spots become
+macules and later vesiculate. In some cases blebs may be formed which,
+upon rupturing become raw, oozing surfaces accompanied by considerable
+local swelling. Pustulation and ulceration may result if these surfaces
+become infected with pus producing microorganisms.”
+
+=Treatment.= Under proper treatment, this condition will subside within
+a few weeks; otherwise it may take months or until the systemic disease
+develops. Sometimes gangrene of the part may result. Cleanliness,
+combined with mild antiseptic lotions, is all that is necessary to cure
+the disease in its early phase. A three per cent. alcoholic solution
+of salicylic acid has been highly recommended by Barlow, who opens the
+blebs and applies pledgets of cotton dipped in this solution twice
+daily for five minutes.
+
+The proper disposal of excreta in rural communities and the avoidance
+of going barefoot in the warm and rainy season, are the best methods of
+prevention.
+
+
+GAS INFECTION AND GAS GANGRENE
+
+Gas infection is a very common condition found in the wounded in the
+present war. It is controlled successfully if it is seen and treated
+early in its course, but when it has progressively developed it causes
+a most dangerous condition called gas gangrene.
+
+=Etiology.= The infecting agent is called the bacillus of Welch, the
+bacillus aërogenes capsulatus or the bacillus perfringens. The bacillus
+is of the anærobic type, and being lodged in deep wounds with ragged
+tissues, recesses and pockets, and completely obstructed by fragments
+of broken-down tissues, all of which prevents the air from reaching
+them, they multiply rapidly with the formation of gas followed by a
+great destruction of tissue.
+
+The bacillus of Welch grows rapidly and it is on that account that
+immediate and radical action is essential if loss of life is to be
+prevented. Kenneth Taylor has obtained a pure culture in a very short
+time as follows: a series of six or more culture tubes are inoculated,
+each tube from its predecessor, at intervals of only half an hour.
+Even in this short period bubbles of gas became evident in the
+successive tubes. By the time the sixth or the seventh tube is reached,
+one may obtain a pure culture, so far has the gas bacillus outgrown the
+other germs.
+
+=Symptoms.= The rapidity of the development of the bacteria is
+responsible for early symptoms of the infection, and Bowlby has
+observed well-marked infection with the formation of gas within five
+hours, and death of an entire limb has occurred from gas gangrene in
+sixteen hours.
+
+The course of the disease varies somewhat, being at first, a _local_
+condition; bubbles of gas appear in the discharges from the wound, and
+crackling from gas may be felt in the tissues immediately surrounding.
+Prompt and radical treatment will prevent further development and will
+restrict the lesion to a limited area. Certain muscles will be lost and
+with them the corresponding motions, leaving the patient crippled to
+that extent, but beyond this, recovery will follow.
+
+A more serious and fatal form, is the _diffuse_ or rapidly spreading
+process. The skin is discolored, the limb is extremely swollen and
+edematous, gas penetrates the cellular tissues and advances rapidly, so
+pressing upon the muscles as to render them useless, and obstructing
+vessels and nerves; the pulse is small and rapid, the extremities are
+cold; vomiting and hiccough may occur. The patient is profoundly toxic
+but he may not feel very ill. If improvement cannot be secured by
+thorough exposure of all pockets and excision, death ensues, the gas
+spreading rapidly upward to the abdomen, chest, and then to the neck,
+causing distressing pressure and finally loss of life.
+
+In other cases the whole limb is involved suddenly, beginning within
+a few days of the initial injury. A wound which is doing fairly well
+at night may reveal a condition of gangrene--swollen, tense, and
+discolored in the morning; the patient, already in collapse, succumbs
+before the gas itself has apparently spread far enough to cause death.
+
+=Treatment.= The paramount importance of the earliest possible
+treatment during the first stage of rapidly spreading infection,
+before the production of gas in any serious quantity has occurred, is
+self-evident. Every hour counts against the patient.
+
+Taylor points out clearly what is to be done:
+
+1. Destruction of the bacillus.
+
+2. Removal of the tissues especially favoring its growth, which are the
+necrotic muscles.
+
+3. Measures to prevent the destruction of the muscles as a result of
+mechanical pressure.
+
+For the destruction of the bacilli, Taylor recommends a one per cent.
+solution of chlorhydrate of quinine. Others have found Dakin’s fluid
+effective.
+
+All foreign bodies (clothing, etc.) in the wound, must be removed as
+they will keep up the anærobic infection; _all_ dead tissue must be
+removed, the wounds kept open, and frequent antiseptic dressings used.
+Dakin’s fluid or Taylor’s quinine chlorhydrate, when properly used in
+connection with the above absolutely necessary means, will enable the
+surgeon to conquer the infection at the start if he sees the patient as
+early as possible--certainly within the first twenty-four hours.
+
+The muscles should be opened by numerous longitudinal incisions,
+incisions of the muscular sheaths, and the excision of all necrosed
+tissue. Sometimes single muscles or a group of muscles may need to be
+excised. The dead muscle can be distinguished from the living by its
+dirty brick-red color, in contrast to the normal purple-brown. The
+dead muscles also lose their contractility. The focus of infection,
+if known, should be excised. The wound should be dressed with the
+chosen antiseptic solution. The incisions should be kept open by light
+gauze compresses, wet with this solution. No circular bandages which
+can exert the least compression, and so hinder the escape of the gas,
+are allowable. Nothing should obstruct the free escape of the gas.
+Everything should be done to promote it.
+
+If gas gangrene occurs or has already set in, the same free incision
+should be made, unless this has already been done.
+
+Bacteriologic diagnosis in the early stage is most important. Soon the
+discoloration of the skin, blebs, and crepitation make the diagnosis
+positive, but crepitation often appears late rather than early. The
+X-rays may disclose the bubbles of gas in the tissues. On incision,
+if the muscular tissue is bloodless, pale, dry, of a brick-red color,
+gangrene already exists. The best judgment then will be required to
+decide whether free excision of this gangrenous tissue, with suitable
+subsequent dressing, or immediate amputation should be done. If the
+limb is amputated, it should be by the so-called “guillotine” method,
+i.e., without flaps. The wound should be dressed with the end of the
+stump entirely uncovered until the infection has been conquered. Then
+the skin may be drawn down by lacing or by weights, and sutured as soon
+as feasible. The bone may have to be shortened.
+
+=Antitoxin Treatment.= One of the most important contributions to
+surgery as a result of the war has recently appeared in the form of
+a paper by Carrol G. Bull and Miss Ida Pritchett, of the Rockefeller
+Institute. This paper describes a lengthy series of experiments with
+the bacilli Welchii, which were cultured from wounds caused by the war.
+A very powerful, soluble toxin, produced by the bacilli has been found,
+which has killed animals almost instantly. The most important result of
+the experiments is that they give promise of an antitoxin which may be
+as potent in the prevention of gas gangrene and gas infection as other
+antitoxins have been effective in their respective spheres. Among these
+are antitetanic, antityphoid and other antitoxins.
+
+    (The above material has largely been taken from “The Treatment
+    of War Wounds,” by Dr. W. W. Keen, and from “Surgical Nursing
+    in War,” by Dr. Elizabeth R. Bundy).
+
+
+SYPHILIS
+
+Although syphilis is a disease that is usually considered as of a
+systemic nature and manifests itself in every part of the body, the
+skin is a very common place for its appearance (syphiloderma), and the
+foot is often involved. It then becomes the function of the podiatrist
+to diagnose the lesion, and as this necessitates a knowledge of the
+general characteristics of the disease, the following should prove of
+interest:
+
+=Derivation.= From the Greek _sus_ and _philos_, “a companion of swine.”
+
+=Synonyms.= Syphilis cutanea, lues, syphilis of the skin.
+
+=Definition.= Syphilis is a chronic, specific, contagious, sometimes
+hereditary disease, caused by a germ, the spirochaeta pallida,
+involving the skin and nervous system, but capable of affecting any
+organ or tissue. Inoculation occurs usually at some part of the
+genitalia, the first evidence of the disease being the initial lesion
+or “chancre,” but inoculation may occur at any other part of the body
+forming the so-called “extra-genital chancre.”
+
+=Etiology.= Syphilis may be hereditary, i.e., transmitted by the
+parent. In the majority of adults it is acquired directly from an
+existing chancre or other lesion, the spirochaeta pallida being
+conveyed directly from one to another. Extra-genital chancres are
+caused by kissing, by towels, by drinking cups, or by infected
+instruments, bites, etc. The extra-genital chancre may occur on the
+mucous membrane or at the site of any skin abrasion. It is essential
+that infected persons be informed of the danger of transmitting it to
+others. The contagious period exists to the end of the second year and
+any secretion, from the possible presence of mucous patches, may be
+infective.
+
+=Pathology.= Syphilitic deposits are new growths and consist of round
+cell infiltration, especially about the vessels, generally endothelial
+proliferation, and in the tubercular and some other lesions, a
+variable number of giant cells. The initial changes are noted in the
+upper part of the corium. The rete, the corium, and, in the deeper
+lesions, the subcutaneous tissues, are involved, the retrogressive
+steps being by involution, through fatty degeneration and absorption,
+or by necrosis and ulceration.
+
+All the various syphilitic lesions are structurally the same, amounting
+to an endarteritis of a special kind, slowly obliterating and tending
+to the production of hypertrophy of the tissues about it. The coppery
+ham-color in syphilitic lesions is due to blood coloring matter from
+the extravasated red blood corpuscles and to the sluggish nature of the
+inflammation. These exudation processes are found for months after the
+process has healed clinically.
+
+=Diagnosis.= Syphilis usually runs a mild course, but occasionally
+it is malignant. In some instances its cutaneous symptoms resemble
+other skin lesions, and it is on that account that diagnosis is often
+difficult. The general points to be observed are the distribution,
+color, form, course and duration.
+
+=Distribution.= The secondary lesions are more or less general and
+symmetric in distribution. The lesions vary in duration and may show
+a preference for certain locations, such as the upper part of the
+forehead, anus, palms and soles. The late secondary lesions, and
+particularly those of the tertiary period, are usually confined to one
+region, are grouped, and are not bilateral in distribution.
+
+=Color.= Syphilodermata are dull coppery-red or ham-color. Exposure to
+cold air often makes the eruptions on the body more distinct. Color
+alone cannot be depended upon to make certain a diagnosis.
+
+=Form.= The earliest lesions are round or oval, showing no tendency to
+grouping. In the late secondary, and in the tertiary stages, grouping
+occurs and the lesions may be serpiginous and circinate. This is an
+important point in diagnosis.
+
+Early ulcers are superficial and the scars are insignificant. Later
+ulcers are deeper, and the scars, often pigmented, are sometimes
+diagnostic.
+
+There are many and various forms of syphilis, all of which have
+characteristic symptoms, but for the podiatrist, who usually sees the
+later lesions, and who cannot make an examination of the entire body,
+it will be necessary to recognize those that appear on the foot only.
+
+The nails are occasionally involved in syphilis. Onychia and
+paronychia are found in the active secondary stage of the disease.
+The inflammation starts in the matrix or in the nail folds, followed
+by nutritive disturbances, and subsequent thickening, friability and
+opacity, furrows and depressions. The nail is lifted up, as a rule,
+and if there is much ulceration, the nail falls off. Such lost nails
+are generally replaced by new nails which are ill-formed at first, or
+they may remain deformed permanently. The skin surrounding the nail
+is swollen and infiltrated. In infants, the ends of the toes become
+club-like (syphilitic dactylitis). This condition is rarely seen in
+adults. The pain is not severe unless accompanied by further pyogenic
+infection or by mechanical disturbance.
+
+[Illustration: PLANTAR SYPHILID]
+
+=Plantar Syphilid.= The plantar surface of the foot is a common site
+for dry syphilids. The palm of the hand, and the sole of the foot
+are the most common locations for the papulosquamous lesions of the
+late secondary stages of the disease. The lesions are not so elevated
+and their edges are not so well defined, papules looking more like
+macules; infiltration, however, is distinct. The shape may be irregular
+and the usual ham-color does not appear on the surface on account of
+the scaliness or dry heaped-up epidermis. There is usually a central
+brownish, gray, callous-like thickening, surrounded by a partly visible
+band of brownish-red, underlying, papular infiltration. The color
+is disclosed by removal of the scale. Surrounding the lesion is an
+encircling edge of partially detached epidermis with its loose, ragged
+edge directed toward the centre. This semi-detached edge is of extreme
+value in the diagnosis of plantar syphilids.
+
+The plantar lesions come on slowly and spread gradually. They are
+usually limited to one sole, but may be found on both feet. There is
+no itching, but they may be painful if fissures are present. If the
+plantar lesions are a part of a generalized eruption of the second
+stage of the disease, they yield readily to treatment, but if they
+are a recurrence of a generalized eruption, they are more obstinate.
+Occurring as a late manifestation, they may be extremely rebellious.
+
+Papulosquamous syphilis is the most common lesion of syphilis found on
+the foot, and is most apt to be confused with eczema. The latter often
+occurs on the soles of the feet; the following table will show the
+differential diagnostic points:
+
+  PAPULOSQUAMOUS
+  SYPHILODERM                              ECZEMA
+
+  1. History of syphilis.             1. History of previous outbreaks.
+
+  2. Concomitant signs present.       2. No associated signs.
+
+  3. Favorite seats, palms and        3. Favorite seats, flexor surfaces.
+     soles.
+
+  4. Itching usually absent.          4. Itching present.
+
+  5. Edge of lesion surrounded        5. Scales completely detached.
+     by detached scales.
+
+  6. Scales scanty and dirty-grayish. 6. Scales abundant, and granular.
+
+  7. Infiltrated, dull red papules    7. Flat, reddish patches beneath
+     beneath the scales.                 the scales.
+
+Eczema can also be differentiated by the more inflammatory aspect,
+the involvement of the toes and toe-ends, by its appearance on the
+dorsum of the foot as well as on the plantar surface, by the itching,
+and by the presence of inflammatory exudation. There is no attempt at
+configuration in eczema, while this is characteristic of syphilis. In
+addition, some of the elemental lesions of eczema will usually be found
+around one of a doubtful nature.
+
+=Blood Tests.= Testing the blood is practised to a great extent for
+determining the presence of syphilis, but this method of diagnosis is
+not absolute. The Wassermann complement fixation test and the later
+modification by Noguchi are of value when they are positive. A negative
+reaction is no absolute proof of the absence of the disease. They are
+positive during the active secondary stages, but in the first week or
+two they are usually negative. In the late stages, when the bacteria
+may be encapsulated in a lesion, the reaction may be negative. This
+may be made positive by the administration of potassium iodide, which
+causes the germs to enter the blood or lymph stream. One should be
+able to make a diagnosis without the aid of the blood tests in cases of
+syphilis in which there are skin lesions.
+
+The luetin test, a vaccine test, is of most value in the late stage of
+the disease.
+
+=Course and Duration.= Secondary lesions appear rapidly and are fully
+developed at the end of two weeks, and in time disappear spontaneously.
+Palmar and plantar lesions are apt to be more persistent. There is
+little tendency to spontaneous disappearance of the tertiary eruption.
+
+=Treatment.= The treatment of syphilis is entirely out of the domain
+of the podiatrist, and when such a case is discovered, it should be
+turned over to the dermatologist or to the general medical practitioner
+at once. Plantar syphilids should be treated with soap and warm
+water so as to remove the scales and thickened epidermis, and this
+may be followed by an application of salicylic acid ointment, 5 to
+10%. Thereafter ointment containing mercury, the white precipitate
+(ammoniated mercury) preferred, should be used twice a day.
+
+Constitutional treatment is absolutely essential if the disease is to
+be cured, and this should be vigorous during the first few months after
+inoculation. The general health must be maintained and nutritious,
+plain diet, rest, moderate exercise and abstinence from alcohol
+and tobacco must be urged upon the patient. With all of the above
+precautions, accompanied by the proper use of remedies, recovery is
+usually prompt and the symptoms are limited.
+
+Mercury is the one drug that is used almost exclusively. It is
+very dependable, and should be employed freely, up to the limit of
+tolerance, during the active stages of the disease. In the tertiary
+stage, potassium or sodium iodide, in addition to the mercury, is
+administered. These drugs are used in various forms and in various
+doses, all of which are of no interest to the practitioner of podiatry.
+
+Recently many practitioners of medicine have been using a complex
+compound of arsenic, viz., arsphenamine, (salvarsan). This drug is
+injected into the muscles or the veins. Although many have taken up
+the use of salvarsan and like chemicals, most practitioners still rely
+upon mercury. The newer preparations are used more as adjuvants than
+as specifics. Lesions of the mucous membranes disappear rapidly under
+treatments with these drugs.
+
+Formerly it was difficult to tell when a case of syphilis had been
+cured; however, with the advent of the various blood tests, this has
+become a less doubtful matter. When the various reactions of these
+tests are negative in uncomplicated cases, toward the end of the second
+year, it is safe to say that the disease is cured.
+
+    (The above is largely compiled from the lectures of Dr. Andrew
+    H. Montgomery, Prof. of Dermatology at The First Institute of
+    Podiatry).
+
+
+FOCAL INFECTION
+
+Focal infection is the name given to a pathologic condition in the
+human body, which manifests itself in a part remote from the original
+focus of infection, or from the original lesion.
+
+Up to a few years ago, focal infections were not recognized by even the
+most advanced members of the medical profession, and many thousands of
+people have suffered and died, due to the fact that lesions of this
+type remained undiagnosed.
+
+Thanks to the efforts of Dr. M. L. Rhein, of New York City, and Prof.
+Gies, of Columbia University, who drew the attention of the scientific
+world to the intimate relationship between tooth infections and
+indefinite ailments in the body, including those of the feet, a large
+quantity of material has been accumulated on this subject, which throws
+an interesting light upon it.
+
+It has now been firmly established that the teeth, the tonsils, the
+adenoids, the male and female urethra, the uterus and the gall bladder,
+in fact, any part of the body which serves as a portal of entrance
+to any infection, may become the reservoir of a chronic pathologic
+condition, and cause disease in any other part of the body. So the
+teeth, harboring certain microorganisms, have been shown to be directly
+responsible for heart, stomach and kidney lesions, as well as arthritis
+and other joint and bone diseases.
+
+=Mode of Infection.= The bacteria responsible for focal infections
+thrive best upon dead or necrotic tissue. These bacteria, when they
+locate in a place where such necrotic tissue is available, such as a
+tooth in which some of the dead pulp remains, or in a diseased tonsil
+or urethra, develop so that they throw off toxins or poisons without
+causing any visible signs of inflammation. These toxins circulate in
+the blood stream, and locate in various parts of the body, especially
+in those which offer the least resistance to the invasion.
+
+=Relationship Between the Foot and Focal Infection.= The most common
+lesion of the foot due to focal infection, is arthritis or inflammation
+of the joints. This is due to infection of the teeth, tonsils, nose
+or adenoids with the common microorganisms such as the staphylococci,
+streptococci, influenza bacilli, etc., that infest the cavity of
+the mouth. It may also be due to an infection of the valves of the
+heart with the streptococcus viridans, or of the gall bladder with
+typhoid bacilli, or of the genital organs with the gonococcus. In some
+instances, arthritis of the foot may be traced to an auto-intoxication
+of the intestinal tract or of the bladder by the colon bacillus.
+
+Osteomyelitis, or inflammation of the bone marrow, periostitis or
+inflammation of the bone covering, and less often, osteitis or
+inflammation of the bone proper, may be caused by the typhoid bacillus
+or its toxin, which originally manifests itself in the intestinal
+tract. These diseases may develop during an acute attack of typhoid,
+but usually appear after the acute symptoms have subsided.
+
+=Gonorrheal Heel= is a well defined type of focal infection due
+to original invasion of the urethral tract by the gonococcus. The
+microorganism, or its toxin, reaches the inferior surface of the os
+calcis, at the point where the flexor brevis digitorum muscle arises,
+lodges there and causes a chronic inflammation of the periosteum and
+the bursa. The process is a mild and slow one, and gradually the
+periosteum is absorbed. With their covering removed, the bone cells
+increase in number, causing the formation of a spur or exostosis.
+Walking upon this growth causes the characteristic pain referred to as
+“painful heel.”
+
+=Painful Feet in Women.= Dr. Henry Frauenthal, of New York City, has
+recorded a large number of cases of painful heel in women, in which the
+foot manifests no signs that would warrant such pains. Investigation
+has shown that these women were suffering with leucorrhea. Such cases
+often come to the podiatrist’s office, where they may be mistreated for
+flat and weak foot by means of mechanical appliances which do no good
+and often cause additional pain. Discreet questioning will reveal the
+fact that the patient is a sufferer from leucorrhea, and she should be
+sent to a physician for treatment.
+
+=Treatment.= Focal infections of all types require treatment at the
+initial source of infection and therefore are out of the domain of the
+podiatrist. These cases should be referred to the physician or dentist,
+as the circumstances warrant. Attempts at local treatment will prove
+futile, and bring the podiatrist into bad repute. His duty ceases when
+he has recognized such an infection and sends his patient to the proper
+person for professional care.
+
+It is a well known fact that the removal of an infected tooth or of a
+diseased tonsil has often given immediate relief to one suffering from
+foot pains, due to focal infection. It is equally well known that heel
+pains, due to gonorrheal causes, have disappeared contemporaneously
+with the cure of an old venereal lesion. So fully satisfied are the
+authorities in charge of the Clinics of The First Institute of Podiatry
+of the utility of such a procedure, that means are now being devised
+whereby there shall be in nightly attendance, physicians and dentists,
+to whom are to be referred all cases of foot pains, in which, by
+exclusion, a diagnosis has been reached that focal infection may be the
+cause of the same.
+
+
+MORTON’S TOE AND METATARSALGIA
+
+Morton’s toe and metatarsalgia are conditions, so common in the
+practice of the podiatrist that it is deemed best to discuss them
+briefly in this volume, although they will be treated most exhaustively
+in “Podiatry Orthopedics,” the next volume of this series.
+
+=Morton’s Toe or Morton’s Neuralgia.= When the foot is kept in a narrow
+shoe, the strain placed upon the forefoot is so great, that the fifth
+metatarsal bone is forced upward and the fourth one downward, and the
+latter bone is made to act as the pillar of the arch. In consequence,
+a severe pain is produced, caused by pressure upon one of the plantar
+nerves, between the head of the bone and the skin. This condition
+is called Morton’s toe, or Morton’s neuralgia, after Morton, of
+Philadelphia, who was the first to call attention to it.
+
+=Treatment.= The pain induced by Morton’s toe, as stated, is caused by
+direct pinching of a branch of the external plantar nerve, and it is
+therefore necessary to relieve the pressure on the head of the bone
+which causes this condition. This is accomplished by the application
+of a felt pad about one inch long, three-fourths of an inch wide and
+three-eighths of an inch thick, properly skived and fastened by some
+adhesive substance, reinforced with adhesive plaster strips, well
+behind the head of the affected bone. This will raise the head of the
+bone so that pressure on the nerve will cease, thus relieving the pain.
+It is essential to remember that the pad must be placed behind the head
+of the bone, for if it is put too far forward, increased suffering
+will result. If the case is one in which it becomes necessary to use
+a pressure of this kind for any length of time, the felt should be
+discarded, and a plate of metal or some other stable substance should
+be substituted, with an elevation at the point at which the pressure is
+desired.
+
+In addition to the device for raising the arch to its normal position,
+exercises and massage should be prescribed. The exercises should be
+those which will strengthen the flexor muscles of the toes. Attempting
+to pick up a pencil or other cylindrical object with the toes, if
+practised daily for ten or fifteen minutes will ultimately prove
+effective. Massage, to help develop these muscles and to stretch the
+shortened extensors, will also be of benefit. The patient should be
+instructed to wear shoes that are wide enough to allow for the normal
+spreading of the anterior part of the foot in walking. The waist of the
+shoe, the portion behind the ball of the foot, should be snug.
+
+=Metatarsalgia.= The name applied to this lesion is, literally, a pain
+in the metatarsal region, but is particularly relevant to the condition
+in which there is a painful depression of the heads of the second,
+third and fourth metatarsal bones, the bones that make up the anterior
+arch. This condition is readily recognized by the fact that the heads
+of the bones are in a straight line instead of forming a concave arc,
+when the foot is at rest. Upon weight bearing, the normal anterior arch
+is obliterated.
+
+=Treatment.= Metatarsalgia is treated much the same as Morton’s toe,
+except that the pad is made large enough to support the three middle
+metatarsal bones. The pad should be so shaped that it conforms to the
+contour of the normal arch. Metal or other devices may be worn, if
+properly fitted, in cases where the pressure is desired for a period
+of time. Exercises and massage should be used in these cases as well
+as in Morton’s toe, especially the former, for stretching the extensor
+muscles.
+
+A tight bandage around the foot just behind the heads of the metatarsal
+bones will often give relief in metatarsalgia and Morton’s toe; it acts
+beneficially by preventing the heads of the bones from being forced
+below their normal level. Adhesive plaster and rubber bands may also
+be used for this purpose.
+
+The shoe should have a very low heel and a broad toe, so that only
+a little weight is borne at the metatarsophalangeal joints, thus
+affording the extensor muscles of the toes a chance to stretch. This
+type of shoe will cause the patient to experience a feeling of falling
+backwards, particularly in the case of a woman who has been accustomed
+to wearing high heels; but this feeling and the strain that is caused
+on the calf muscles, will soon pass off.
+
+
+
+
+CHAPTER XXV
+
+X-RAYS IN PODIATRY
+
+
+Roentgenology is the science that deals with the use of the Roentgen,
+or X-rays, in all their applications. The subject is divided into
+three parts, each distinct from the other, and with special required
+study for each part. The first branch of roentgenology is known as
+_roentgenotherapy_ or _actinotherapy_, and comprehends the treatment of
+disease by the use of the X-rays or by other radiant energy.
+
+Roentgenotherapy, to be intelligently applied by the practitioner,
+requires a thorough knowledge of pathology and is strictly within
+the province of the licensed doctor of medicine. The second branch
+variously styled _fluoroscopy_, _skiascopy_, _radioscopy_ or
+_roentgenoscopy_, is utilized for examining the various parts of
+the body by projecting the X-rays through the body and fixating
+the shadows cast on the fluoroscope. This branch of the science of
+light is of great assistance in diagnosis and is used extensively in
+surgery for the location of foreign bodies in the tissues. The third
+division of roentgenology is called _radiography_, _skiagraphy_ or
+_roentgenography_, and consists of the making of X-ray photographs by
+passing the ray through the body in front of a photographic plate.
+This branch is of great importance to the podiatrist because of the
+value it possesses in the diagnosis of foot lesions, involving the bony
+structures; it often clears up a doubt as to the true state of a lesion
+when other means have failed. The soft tissues through which the ray
+passes readily appear in light shadow, while the bones, because they
+are solid, cast a darker shadow on the plate.
+
+Experiments with electricity and with the modifications of the various
+currents of electricity, have been responsible for all of the new
+discoveries and inventions along these lines, and the same may be said
+of the X-rays.
+
+The two divisions of electric current are the direct and the
+alternating, named after the direction in which they flow. The direct
+current moves in one direction and may be likened to the flow of water
+from a faucet, while the alternating current does not maintain a
+steady pressure nor does it flow in the same direction continuously.
+The alternating current, which is commonly used for lighting purposes,
+reverses its direction of flow and pressure 120 times per second. It is
+therefore called 60 cycle current, in that it makes 60 complete cycles
+per second. The alternating current may be likened to the tide, which
+rises and falls every twelve hours. Instead of passing from ebb to
+flood and back again each twelve hours, the alternating current, used
+for illuminating purposes, does so in one-sixtieth of a second.
+
+The alternating current, is of most value to the sciences, because its
+voltage or pressure may be easily changed. Thus it can be raised or
+lowered by passing it through special apparatus. One particular form
+of alternating current has a voltage of from 30,000 to 120,000 and can
+be used for the production of Roentgen rays, if it be transformed into
+a so-called pulsative or unidirectional high tension current. This
+transformation is easily brought about by modern Roentgen ray apparatus.
+
+The discovery of the X-rays was preceded by an improvement in the
+knowledge of alternating currents. Many scientists were experimenting
+and looking for new rays and currents, and after the invention of the
+air pump and the production of glass globes, from which the air was
+removed by means of the pump, Geissler invented the process of sealing
+platinum into glass and produced the Geissler air pump, which is used
+to the present day. This made it possible to seal electric conductors
+into vacuum tubes.
+
+Following this, Faraday and Maxwell developed the electro-magnetic
+theory of light and laid the foundation for a theory of the Roentgen
+ray, which, although later considerably changed, has proven one of the
+most useful adjuvants to the science of physics. The period between
+1840 and the discovery of the X-rays was an active one in electric
+experimenting. Many men were interested in this work, and their
+observations and discoveries were important in the final discovery of
+the rays. In fact, Roentgen’s discovery was fully expected, inasmuch
+as several investigators, including Sir William Crookes and Roentgen
+himself, were convinced that rays existed of which they knew nothing.
+The earlier of the two workers, Crookes, had probably produced X-rays,
+but overlooked them and it fell to Roentgen to become aware of the
+conditions under which they were produced. He called them X-rays or
+unknown rays, but after a time, they were named after him, and are
+known in science as Roentgen rays. Roentgen wrote and published three
+papers on the subject and these have become classics on this topic. All
+of the facts announced by him at that time continue to be accepted,
+because, notwithstanding all the work done along these lines, they have
+never been disproven.
+
+Experiments have been continuous, and gradually the types of generators
+and tubes have changed, always improving. Where at first only simple
+work could be accomplished, the most wonderful things in this art are
+now being done, with probably many more wonderful things still to
+come. The dangers to which the earlier workers were subjected have
+been gradually eliminated, and today with proper care, the danger from
+the X-rays has been reduced to a minor factor. This danger came about
+from lack of knowledge of what occurred in the tube when the ray was
+being generated. There are three rays produced, one of which causes
+destruction of the human tissues, when exposed for a prolonged period
+of time. By preventing the passage of this ray, by the use of lead and
+lead glass, as protective mediums, the danger has been practically
+controlled.
+
+
+X-RAY APPARATUS
+
+The apparatus used in the generation of the X-rays consists of a
+generator, a vacuum tube and an appliance for holding the tube in a
+fixed position, called the tube stand.
+
+=The Generator.= The generators used in X-ray work are of three types,
+the motor generator, the interrupterless type and the coil generator
+with a chemical interrupter.
+
+The function of the Roentgen ray apparatus is to produce high potential
+electric discharges in one and the same direction, or what is known
+as a unidirectional current. Dependent upon the kind of current used
+to start with, distinction can be made between the types of apparatus
+previously mentioned. These types are operated by either direct or
+alternating current.
+
+Direct current apparatus requires an interrupting device for the
+purpose of producing the necessary change of flux of magnetic lines in
+the inductive part of the apparatus. Interrupting devices, which are
+used in connection with such apparatus, are of three kinds: _first_,
+the hammer interrupter; _second_, the mercury interrupter; _third_, the
+electrolytic interrupter. The function of any one of these interrupters
+is to break up the continuous flow of direct current into small
+fragments. Each one of these fragments then produces one impulse of
+high potentiality, which is then directed through the tube.
+
+The alternating current, as its name implies, is already interrupted,
+but the impulses are alternately changing direction, passing first
+in one direction and then in the opposite direction. Hence, if the
+alternating current is used as a primary source of electric energy,
+then the secondary or high potential impulses will also be changing
+their direction alternately. Two methods are used in employing the
+alternating current as a primary source of energy. The first consists
+of the suppression of one phase (that which would pass in the negative
+direction) by means of the so-called rectifier cell. The second
+consists of producing high potential impulses which flow in alternate
+directions, and to then redirect these impulses so that all of those
+passing through the tube are in the one and the same direction.
+
+[Illustration: INTERRUPTERLESS TYPE GENERATOR]
+
+Accordingly, X-ray apparatus can be divided into the three classes
+previously mentioned. The coil, consisting of an induction coil
+activated by direct current, which is broken into small sections by
+the interrupter; or the induction coil which is energized by the
+alternating current of which one phase is suppressed through a liquid
+rectifier cell, and in which the proper interruptions are again
+produced by some interrupting device. The most extensively used type
+of apparatus is known as the “interrupterless machine.” This machine
+operates on either the direct or the alternating current, but, if
+the direct current is used as a primary source, it is transformed
+into an alternating current by means of a rotary converter or motor
+generator set. The alternating current, therefore, either produced or
+already available, passes into the primary coil of a transformer which
+changes it into alternating impulses of high potentiality. In order
+to transform them into impulses, all of which shall pass in the same
+direction, a so-called rectifying system is employed. This consists
+of either a disk or of cross-sticks, which are so arranged that they
+produce contact with both terminals of the transformer in such a way
+that current of the same polarity, the unidirectional current, is
+always delivered to the tube. The name “interrupterless machine” merely
+implies that the devices used for interrupting the primary current have
+been eliminated.
+
+There is one other type of apparatus which is built on the principle of
+an electrically oscillating system. Here again a start is made with the
+alternating current, obtained either from the line or by changing the
+direct current by means of an interrupter. The current is transformed
+through a so-called step-up transformer into one of high potentiality
+which is then still alternating. This current oscillates over a spark
+gap. Parallel to this spark gap a resonator is connected in which
+impulses are produced that correspond to the discharges over the gap
+and which, if applied to a specially built, so-called high frequency
+Roentgen ray tube, will produce X-rays. Since the principle of electric
+oscillations of a high frequency is used in this type of apparatus, it
+is generally called the high frequency Roentgen ray apparatus.
+
+[Illustration: TUNGSTEN TARGET TUBE]
+
+=Roentgen Ray Tubes.= The various types of apparatus previously
+described require special forms of Roentgen ray tubes. For the coils
+by virtue of their relatively small capacity, platinum target tubes
+are generally employed. The capacity of the interrupterless type being
+considerably higher, the use of a material of greater resistance as
+a target is necessitated. For this purpose tungsten is generally
+employed. For the high frequency, or Tesla coils, a tube which embodies
+a rectifying or valve action device is necessary.
+
+The mechanism of the production of Roentgen rays can be described
+in the following way: the cathode, or negative terminal of the
+tube, consists of a hollow spherical surface of aluminum. When this
+electrode is attached to a negative potential, a stream of negative
+ions or cathode rays is projected perpendicular to the surface of
+the electrode. By reason of its curvature, the electrode is therefore
+focused to produce a converging beam of cathode rays, the area of which
+is smallest where, in the centre of the tube, the tungsten block or
+anticathode is placed.
+
+According to whether the area selected for the location of the
+anticathode is small or large, the possibility to distinguish between
+fine, medium or broad focused tubes arises. The discharge from the
+negative electrode takes place, dependent upon conditions which give
+to the discharge either a high or a low velocity. If the velocity is
+high, the change from kinetic energy to Roentgen ray energy will be
+greater than if the velocity of the cathode ray stream is decreased.
+In the latter case, the radiations will have less penetrating power.
+The velocity of the discharge must therefore depend upon the magnitude
+of the charge on the negative electrode, and also upon the number of
+gas particles present in the tube at that time. If there is a large
+quantity of gas present, there will be a reduction in the speed of the
+ray, due to collision and impact with the gas. The penetration of the
+Roentgen rays depends therefore directly upon the potential produced
+by the apparatus and inversely on the gas pressure (or directly on the
+vacuum) of the tube.
+
+For the purpose of controlling the state of vacuum in the tube, a
+regulating system has been improvised which, when an electric current
+is passed through it, liberates a certain amount of gas which passes
+into the tube proper. This is a convenient device for reducing the
+vacuum of the tube. Up to the present time, no one has succeeded in
+inventing an efficient method or device for removing gas from the tube,
+or a means which would help to increase the vacuum. It is for that
+reason that operators should guard against reducing the tube unduly.
+It is a simple matter to reduce the vacuum but difficult to increase
+it. When a tube becomes low (when the gas content is high), resting the
+tube by allowing it to remain in its bracket for a period of time,
+will usually suffice to increase the vacuum.
+
+The proper care of the tube is essential for good radiograms. It should
+be kept free from dust, and before being used the degree of vacuum
+should be determined by the testing apparatus on the generator. If
+the tube is dusty or dirty, the passage of the rays through the glass
+will be hampered, as these particles tend to deflect the rays from
+their straight course. If the vacuum of the tube is too high, it will
+affect the quality of the plate, and if it is too low there will be no
+penetration and therefore a blank plate.
+
+[Illustration: TUBE STAND]
+
+=The Tube Stand.= The tubes used in Roentgenology are delicate
+structures and great care must be exercised so as to prevent breakage.
+To guard against such damage it is necessary to securely hold the tube
+in a proper device while it is being used. The tube stand should be
+so arranged that it is possible to raise or lower the tube, with its
+connections, without being compelled to touch the tube itself, to swing
+it from side to side, to tilt it forward or backward, or in or out.
+This is best accomplished by the modern tube stand which is so arranged
+that after having set the tube in its proper place, it is no longer
+necessary to touch the apparatus in order to secure all of the above
+named motions. A careful study of the accompanying photograph will make
+this clear.
+
+=The Roentgen or X-rays.= The rays generated in the apparatus
+heretofore described, and named after their discoverer, are of a
+peculiar character, and although they have proven a boon to mankind,
+serious trouble and even death has come to those who in their ignorance
+used the X-rays promiscuously. It has been discovered that there are
+three distinct rays generated when the high potential current is passed
+through the vacuum tube and they have been named after the first three
+letters of the Greek alphabet, namely: the alpha, the beta and the
+gamma rays. The _alpha_ ray is the ray that is seen in the tube and is
+of no consequence. The _beta_ and _gamma_ rays are invisible and it is
+these rays that penetrate the tissues of the body. To the gamma ray
+is attributed the harmful effects of Roentgen’s discovery. Although
+the X-ray is used as a therapeutic measure it should only be applied
+by those who have a thorough knowledge of its properties. Prolonged
+exposure will cause severe burns, and in some cases continued contact
+with the ray has caused cancer. Their action in this respect is due
+to the actinic quality of the gamma rays. The symptoms of a burn do
+not manifest themselves until a minimum of a week or ten days after
+exposure and, when they do appear, they are usually severe. Sloughing
+of the tissues takes place, and the wounds produced do not heal readily
+and, in consequence, ugly disfiguring scars remain.
+
+=Radiography.= This branch of Roentgenology is of most interest to the
+podiatrist. By means of photographic plates, properly exposed and well
+developed, it is often possible to make diagnoses where other means
+have failed. It is essential for one who would be correct in diagnosing
+X-ray plates, to have a thorough knowledge of the structure of the
+bones of the foot and to understand the meaning of the various shadows
+cast upon the plate.
+
+When the X-rays penetrate the foot they pass through the tissues, and
+when they strike a tissue of great density they cannot penetrate it
+as readily as the rays passing through a tissue of less density. The
+result is that as the rays pass through the foot they cast a series of
+shadows on the sensitized photographic plate beneath, the density of
+which depends upon the tissues through which the rays have passed. So,
+in reality, the plate when finished is not a photograph, as most laymen
+imagine, but a shadowgraph or, as it is variously termed, a radiogram
+or skiagram.
+
+For the purposes of producing radiographs that are clear and easily
+interpreted, it is necessary to have good materials and to follow
+the technic of developing and fixing the plate in every detail. The
+photographic plates used in general photography do not, as a rule,
+give satisfactory results. Plates, with specially prepared emulsions
+that are adapted for radiography, are preferred. These plates are
+sensitized with a gelatinous substance containing bromide of silver.
+When this substance is exposed to the action of the rays it undergoes
+chemical decomposition, the degree of which varies with the amount of
+exposure. It is upon this decomposition of the salt that the art of
+photography depends and so, too, the science of radiography. The plate
+is then developed.
+
+Developing of a photographic plate consists of making visible the
+metallic silver which is produced by the decomposition of the silver
+bromide. This is accomplished by the use of a mixture of chemicals
+called the developer. The plate is put into a tray about two inches
+deep and large enough to allow for its easy removal, and the developing
+solution is poured over the emulsion. Gradually the exposed portions of
+the negative will appear and developing must continue until every such
+exposed part has been brought out in its fullest detail. The unexposed
+portions are then dissolved by placing the plate in a solution of
+sodium hyposulphite, sometimes called the _fixer_ or the fixing bath.
+As its name implies, this solution permanently fixes the exposed
+silver, and if the plate were not treated in this manner the entire
+mass would become blackened upon exposure to light.
+
+The preparation of radiographic plates is carried on in a room that
+is protected from light with the exception of a dull, red glow from a
+“ruby lamp” which has no effect upon the plate. The plate is placed
+into an envelope made of black paper, and this in turn is placed, flap
+down, into a second envelope of red paper. This insures protection
+from light rays when the plate is brought out of the dark room. After
+exposure, the negative must be taken back to the dark room before it is
+removed from the envelope. After it has been developed and fixed it may
+be brought into the light with safety.
+
+The length of time required in making exposures varies with the
+different types of apparatus. When the flow of rays is great, it will
+require a proportionately shorter exposure. So, too, the length of
+exposure with a certain type of generator varies with the part being
+exposed. The bones of the fingers would require less time than those
+of the leg, while the bones of the head would require more time than
+either of the above for the production of a clear radiograph. It is
+essential in all branches of radiography to remember that the part to
+be skiagraphed be parallel to and in close proximity to the plate. This
+will prevent elongations and foreshortenings of the shadows cast.
+
+[Illustration: SPUR ON THE UNDER SURFACE OF THE HEEL]
+
+
+DIAGNOSIS OF RADIOGRAPHS
+
+There are several lesions of the foot commonly arising in the practice
+of the podiatrist, which are easily recognized by radiographic
+examination but which otherwise are difficult of diagnosis. Some of
+these cases are shown in the accompanying pictures, which were selected
+from a large collection at The First Institute of Podiatry of New
+York City. They are characteristic of the lesions they depict, and
+it is needless to emphasize their value as an aid to diagnosis. If a
+condition involves the bony structure of the foot, clinical symptoms
+are never so certain that an absolutely positive diagnosis can be made,
+but the X-ray plate readily reveals such disturbances so that there is
+no doubt left in the minds of the practitioner as to the exact nature
+of the trouble. Periostitis, exostosis, fractures, arthritis, bone
+abscesses, bone ulcers, etc., are thus easily distinguished.
+
+=Periostitis.= Periostitis is an inflammation of the periosteum, the
+outer covering of the bone. There are two types, the acute and the
+chronic, both of which are not really diseases themselves, but are
+indications of the reaction of the periosteum to some irritant. In
+acute periostitis the X-ray plate shows a slight destruction of the
+outer portion of the bone, and a slight thickening of the periosteum,
+and if suppuration is present, the lesion is a mild osteomyelitis
+rather than a periostitis.
+
+Chronic periostitis causes an increase in the osteogenetic cells of
+the periosteum and is common in a great many lesions. Trauma, blows
+or contusions cause a chronic thickening of the bone covering with
+additional bone formation, as do syphilis and superficial abscesses
+in the soft tissues, in the immediate vicinity of long bones. Thus
+chronic ulcer of the leg over the shaft of the tibia will produce this
+condition. The picture shows that the even line of the bone surface is
+lost, and there is a rough, uneven edge, with or without an increase
+in the bone cells. The entire shaft of the bone is often thicker than
+normal, especially in the metatarsals, and it is quite common to find
+one of these bones greatly increased in size. The fourth metatarsal is
+the one most usually affected.
+
+=Exostosis.= This lesion is common in the foot, and is a source of
+great pain and annoyance. It is usually the result of a chronic
+bursitis which has affected the periosteum over a localized area. Due
+to the destructive changes brought about by the inflammatory processes,
+the periosteum is absorbed and the bone cells beneath protrude in
+the form of a spur which shows on the plate. The most common site of
+exostosis of the foot is on the inferior surface of the os calcis,
+under the calcaneo bursa. The part is somewhat swollen and is extremely
+painful when pressure is brought to bear directly over the growth.
+The heads of the metatarsal bones on their lateral surfaces are
+occasionally affected, especially the outer side of the head of the
+first metatarsal. Lateral pressure gives rise to pain in this type of
+exostosis. The treatment for all exostoses is purely surgical.
+
+=Fractures.= There are several kinds of fracture, and they are
+classified variously, but for the purposes of the podiatrist, the
+following types, with the description of each, will prove sufficient:
+
+=Incomplete Fractures=, among which are the greenstick and the fissured
+fractures, are those in which there is not a complete separation of the
+fragments. The greenstick is really a bending rather than a breaking of
+the bone, and is found mostly in children under fifteen and then only
+rarely affects the bones of the leg. Fissured fractures are splits or
+cracks in the bone which do not separate it into two parts and occur
+occasionally in the fibula or in the metatarsals. They are easily seen
+in the radiograph by the dark shadow they produce in the region that
+would ordinarily appear light. This shadow extends over the entire
+length of the break.
+
+=Complete Fractures= are the most common type found in the lower
+extremity and are divided according to the line and the seat of the
+breach of continuity. Thus we have transverse, longitudinal, oblique
+and spiral fractures. The radiograph will reveal the nature of the
+break, and a dark shadow will be cast between the fragments of bone.
+The most common of these found in the leg are the oblique and the
+spiral fractures.
+
+=Comminuted Fractures= are those in which there is extensive
+splintering of the bone adjoining the fracture or one of the fragments.
+This class of fracture does not occur in the foot.
+
+=Impacted Fractures= are those in which the fragments are driven into
+each other, forming a wedge, thus preventing abnormal motion, so common
+in other types. This occurs mostly in the neck of the femur.
+
+=Crushing or Compression Fractures= are those in which the bones are
+crushed. The spongy portion and the cortical layer are both involved
+and in some cases the bones may be pulpified. The tarsal bones are
+subject to this type of fractures as the result of falls from heights,
+upon the soles of the feet. (See accompanying picture of fracture of
+the os calcis.)
+
+=A simple fracture= is one in which a wound of the skin is absent, or
+if present, there is no connection between it and the broken bone.
+
+If the bone is broken in two or more places or if two or more
+non-adjacent bones are simultaneously broken, the condition is called a
+=multiple fracture=.
+
+[Illustration: FRACTURE OF THE OS CALCIS]
+
+=A compound fracture= is one in which the fragments of bone pierce the
+soft tissues and protrude beyond the skin.
+
+It is essential in examining a patient who has suffered from a recent
+fracture, to obtain a history of the case as well as a description
+of the accident. An examination of the part should be made, and the
+various symptoms such as deformity, abnormal mobility and crepitus
+should be noted. The X-ray picture is then taken and if a fracture is
+found, the case should be put in the hands of a competent surgeon for
+immediate and proper treatment.
+
+=Sesamoid Bones.= The sesamoid bones which are found in the flexor
+tendons under the head of the first metatarsal bones, are subjected to
+injury in those who follow vocations in which the ball of the foot is
+put to great strains. Among such may be mentioned dancers and acrobats.
+The normal position of these bones is directly beneath the head of the
+first metatarsal bone, and when this part is put to a great strain, the
+bones may become fractured, or they may become displaced. The outer
+sesamoid is usually forced outward and the X-ray picture shows it in
+the first interosseous space. The inner sesamoid is not affected, but
+may also be forced outward, and is then found under the outer side of
+the first metatarsal, in the normal position of the outer sesamoid bone.
+
+Fracture of these bones is not unusual and is a result of a severe
+injury. The line of division is shown by a dark shadow, much the same
+as in other fractures. One or both of the bones may be involved. It is
+essential to remember that if the bone is broken, the opposite sides
+will fit into each other perfectly, whereas, in cases of a freakish
+nature, in which there are four sesamoid bones, this will not be the
+case.
+
+=Arthritis.= Arthritis, or inflammation of the joints, may involve
+any one or all of the structures which make up joints, viz., bone,
+cartilage, ligaments, synovial membrane and fibro-cartilage. The acute
+forms of inflammation are not detected by the radiogram, but the
+chronic type leaves its characteristic marks which, when present,
+are easily seen. The synovial covering of the ends of the bones
+is destroyed, and shows a rough, uneven surface. In cases of long
+standing, there is complete bony ankylosis, and the shadows of the
+joint line are completely obliterated. This is particularly true in the
+tarsal joints, in which the joint lines between the bones can hardly be
+seen. There is no motion in such joints, and in milder cases, in which
+no union has occurred, the sensation of crepitus is conveyed to the
+hand if the joints are moved passively. Tubercular arthritis shows a
+rarification of the bone with a thickening of the periosteum.
+
+=Arteriosclerosis=, or hardening of the arteries, is often detected
+by means of the X-ray picture. Light shadows cast in the normal dark
+shade produced by the soft tissues, which appear over the course of the
+arteries, are indications of this condition.
+
+This disease of the arteries causes a change in the vessels whereby
+there are calcareous salts deposited in the middle coat. These salts,
+containing the metal calcium, are not readily penetrated by the ray,
+and thus a difference between the artery and other soft tissues is
+established.
+
+There are many other conditions in which the X-rays are a valuable aid
+in making diagnosis, but these are of no interest to the podiatrist,
+being within the exclusive province of the physician and surgeon.
+The reader is referred to books which deal with the subject of
+Roentgenology exclusively, for further information upon the subject.
+
+[Illustration: HALLUX VALGUS]
+
+
+
+
+CHAPTER XXVI
+
+THE PODIATRIST’S OFFICE
+
+
+The equipment of an office of a professional man or woman, whether
+it be the surgeon, the dentist, the podiatrist or any other of the
+practitioners of the allied branches of medicine, cannot be set to an
+absolute standard. There are several factors that govern variations,
+one from the other, among which are considerations of finance and the
+amount of available space. Regardless of these differences, however,
+certain fundamental principles must be observed in equipping such
+an office, and these depend upon two cardinal requirements: (1)
+cleanliness, and (2) the comfort of the patient. Such an office must
+be fitted out with the laws of asepsis and antisepsis ever in mind,
+otherwise it will prove unsafe for the treatment of patients whose feet
+require surgical attention. Again, the patient must feel at ease while
+being treated, or revisits will be scarce.
+
+There are other and secondary standards which should be considered
+among which is the appeal to the eye. First impressions often are
+lasting ones, and an office which makes a favorable impression will
+help attract patients. One often hears the thoughtless layman express
+himself, “Go to Dr. Blank for treatment, he has a beautiful office.” So
+it often occurs that a professional person is judged by the equipment
+in his office, and the effects of such an impression should be
+considered.
+
+=The Waiting Room.= The waiting or reception room should be furnished
+with chairs upholstered in leather or made of solid wood. In waiting
+rooms in which many patients must wait at the same time, and space is
+valuable, smaller chairs with cane seats are very useful. The table
+should be of polished wood, covered with a plate glass top. The wood
+work of the room itself should be white, and the walls should be
+painted in preference to being papered. Buff is a pleasing color to the
+eye, and readily matches all kinds of furniture. The floor should be of
+hard wood, and may be covered by linoleum or rugs. Carpets should not
+be tolerated, as they are dirty; and even though frequently swept, they
+become the repositories of dust and of germs.
+
+=The Operating Room.= The operating room must be scrupulously clean.
+As a white background best shows dirt spots, that should prevail in
+furniture and in decorations. A door, either of glass and wood or
+entirely of wood, should separate the reception room and the operating
+room; if hangings must be used, they should be of some washable, white
+material, that can be readily changed. The floor should be of tile,
+marble or stone; if these materials are not available, hard wood
+floors, well polished, are permissible. No covering of any kind should
+be used for the floor of this room. The ceilings and walls should be
+painted white, and the wood work should be enameled the same color.
+Tile or marble walls are preferable to plaster or wood. No curtains
+should be used on windows or doors, and if necessary the glass can be
+frosted to secure privacy. A wash basin, with running hot and cold
+water, should be in the operating room, and the valves should be
+controlled by foot levers in preference to hand faucets.
+
+To summarize, everything in the operating room should be of such a
+character as to make it possible to wash it daily with soap and water.
+Nooks and corners that tend to collect dust and dirt must be thoroughly
+cleaned, bearing in mind that disease-producing bacteria will not grow,
+unless a breeding place be provided for them. Wall pictures and their
+frames should be selected with a view to having them equally sanitary.
+
+=The Equipment.= The equipment of a modern office is divided into three
+classes: (1) the furniture, which, when bought, is permanent; (2) the
+instruments; and (3) the supplies, which are replenished from time to
+time as they are exhausted.
+
+Furniture should consist of the following in the order of their
+importance:
+
+  Sterilizer
+  Operating Chair and Stool
+  Cabinet
+  Glass-Top Table
+  Drill
+  High Frequency Machine
+  Air Compressor
+  Galvanic Machine
+  Wall Cabinet and Extra Accessories.
+
+The authors are not interested in the wares of any manufacturer, and
+any equipment that is efficient and well made will answer the purposes
+of the podiatrist. There are many styles of chairs, cabinets, electric
+machines, etc., on the market and the selection of such furniture and
+equipment rests with the finances and the taste of the individual.
+
+Chairs should be roomy and have a suitable rest for the patient’s back
+and head. The foot rest should be adjustable and so arranged that the
+patient’s foot is made comfortable, regardless of the position in which
+it is held. This part of the chair is very important, as upon it often
+depends the result of the podiatrist’s work. If the foot and leg are
+held so that the patient is uncomfortable or so that muscular cramps
+are the result, both patient and operator are at a disadvantage which
+it is difficult to overcome.
+
+There are two types of foot-rests on the market which have proven
+efficient. One gives support along the entire length of the leg and
+allows the foot to hang free at the end, and the other gives support
+at the foot proper and is so arranged that it gives this support no
+matter in what position the foot be held. The chair itself should be so
+constructed that no matter how the weight of the patient’s body may be
+distributed, the chair will remain firm, with no danger of spilling
+its occupant. It is on this account that a chair with a heavy metal
+base or with heavy spreading legs is best. When the chair is placed in
+a horizontal position so that the patient is prone, it should be as
+firm as with the patient in a sitting posture. The stool should match
+the chair and should be adjustable.
+
+The cabinet is the most important part of the podiatrist’s equipment
+from an aseptic standpoint, for therein are kept the instruments,
+dressings, drugs, etc. There are many styles and shapes from which to
+select, but only those that afford proper protection from dust and
+dirt should be considered. Drawers should be provided for bandages and
+dressings, and one drawer should be divided into compartments for the
+various sized shields. This adds to the neatness as well as to the
+efficiency of the cabinet. Special movable racks which fit into shallow
+drawers should be provided for the instruments, so that, if necessary,
+they may be collectively removed, thus avoiding the need for handling
+each instrument separately. Instrument compartments of this type should
+be so made that the blades of the various instruments are suspended
+in the air; moreover such racks and drawers are easily cleaned. Drugs
+should be kept in special compartments provided with glass doors,
+or, if the cabinet has no such provision, the bottles should fit in
+metallic clamps arranged in the rear of the top of the cabinet. Glass
+tops on the cabinets are best for they are easily cleaned, but white
+enameled metal tops are quite as good. The towels should be kept in a
+compartment of the sterilizer, otherwise in a special compartment in
+the cabinet, one having a glass door being preferred.
+
+Sterilizers may be heated by gas or electricity and when boiling water
+is not available, even formaldehyde gas is better than nothing for
+sterilizing purposes. The sterilizer, a necessity and not an ornament,
+should be cleaned and polished and the water should be changed daily.
+Unfortunately in the past, practitioners of podiatry did not use the
+sterilizer with regularity, and one could enter many of these offices
+and not even find such a contrivance. This state of affairs, however,
+is becoming a memory because the practitioner, as well as the public,
+has learned the importance of asepsis and antisepsis. The podiatrist
+who fails to observe the needs of this dispensation is unworthy of the
+title he bears.
+
+The sterilizer should be kept on a white enameled table with a
+detachable metal top, so that boiling water or hot instruments will
+cause no damage to it, as might occur on a glass-topped table. This
+table should have a glass shelf below, on which may be kept additional
+remedial agents for which there is no room in the cabinet.
+
+The surgical drill or rotary file is a valuable asset to the podiatrist
+in treating the nails, and should be a part of the equipment. There are
+several makes of rotary files, all with the same fundamental structure.
+The motors and cables are of one type, and are held either by a wall
+bracket or suspended upon a metal hook, resting on a metal pedestal.
+When the instrument is kept in only one operating room, the former type
+is sufficient, but when the drill is moved from one room to another,
+the latter style is necessary.
+
+Other accessories in the office, such as an air compressor, high
+frequency coil, galvanic machine, wall cabinet, etc., should be
+selected with care as to quality, and with judgment as to their
+harmonizing with the other equipment. If space allows, all of these
+accessories are desirable because useful, but when quarters are
+contracted, care must be taken in arranging the paraphernalia that the
+effect is not such as to give the patient the impression that he is in
+a podiatry supply shop.
+
+“Cleanliness is next to Godliness,” should be the slogan of every
+practitioner of medicine in any and in all of its collateral branches
+and the manner in which he conducts his office should be evidence that
+such is the belief and the practice of every podiatrist.
+
+
+FOOTNOTES:
+
+[1] The District of Columbia has now a similar law, passed since the
+above was written. Ernest Stanaback, former President of the N. A.
+C., and Harry P. Kenison, the present President of the N. A. C., were
+potent factors in procuring most of the legislation in the above states.
+
+[2] Podiatrists are advised to refrain from using cocaine on account of
+its dangers.
+
+[3] Hypodermic and hypodermatic are synonymous terms although medical
+lexicographers, as a rule, give preference to the latter.
+
+[4] _Apothesine_ (Parke Davis & Co.) is a new synthetic preparation
+of definite chemical composition. It is ¹⁄₈ as toxic as cocaine, is
+very soluble in water and alcohol, and may be sterilized by boiling
+for five or ten minutes. It is used in a one per cent. solution and
+came into favor during the war, by reason of the scarcity of cocaine
+and novocaine. Apothesine is not a habit-forming drug and is therefore
+easily obtainable. At The First Institute of Podiatry this preparation
+and novocaine are almost exclusively used for producing local
+anesthesias.
+
+[5] Apothesine, lately introduced, is proving efficacious and reliable
+(see page 148).
+
+[6] These experiments were carried on at The First Institute of
+Podiatry under the direction of Monroe Redell and W. H. A. Fletcher,
+clinicians, and on the suggestion of Dr. F. Oefele.
+
+[7] (Capt. V. N. Sorapure, R. A. M. C., who has lectured to the
+students of The First Institute of Podiatry, has contributed to the
+literature on this subject; see Journal of the A. M. A., July 6, 1918).
+
+
+
+
+GLOSSARY
+
+
+A
+
+=a-, an.= A prefix conveying a negative meaning--without, not, away
+from.
+
+=aa.= A sign used in prescription writing to indicate equal parts of
+each ingredient so designated.
+
+=ab.= A prefix signifying from, away from, off.
+
+=abdominal.= Relating to the abdomen or belly.
+
+=abduction.= Rotation of the foot outward.
+
+=abnormal.= Not normal, contrary to the rule or type; irregular.
+
+=aboriginal.= Primitive, existing from the beginning.
+
+=abrasion.= A circumscribed removal of the epidermis of skin or mucous
+membrane.
+
+=abscess.= A circumscribed cavity in the tissues containing pus.
+
+=absorption.= The taking into the tissues, through the medium of the
+lymphatics or blood vessels, of any material in suitable form.
+
+=acetanilid.= An analgesic made from aniline by treating it with acetyl
+chloride.
+
+=acetic.= Relating to vinegar; acid.
+
+=acid.= A chemical compound containing replacible hydrogen, having a
+sour taste, and neutralizing a base to form a salt and water.
+
+=acidum.= Acid.
+
+    =a.= Aceticum, acetic acid; useful as a counter-irritant.
+
+    =a.= aceticum glaciale, glacial acetic acid; employed
+    externally as a caustic.
+
+    =a.= boricum, boric acid; dusting powder, antiseptic.
+
+    =a.= carbolicum, carbolic acid, phenol; antiseptic.
+
+    =a.= chromicum, chromic acid; caustic.
+
+    =a.= dichloraceticum, dichloracetic acid; caustic.
+
+    =a.= hydrochloricum, hydrochloric acid; escharotic.
+
+    =a.= iodicum, a white crystalline powder; antiseptic and
+    deodorant.
+
+    =a.= monochloraceticum, a white deliquescent powder; caustic.
+
+    =a.= nitricum, nitric acid; caustic.
+
+    =a.= nitricum fumans, fuming nitric acid; caustic.
+
+    =a.= nitrohydrochloricum; a fusing corrosive liquid; caustic.
+
+    =a.= salicylicum, salicylic acid; disintegrant.
+
+    =a.= sulphocarbolicum, sozolic acid; antiseptic and
+    disinfectant.
+
+    =a.= sulphuricum, sulphuric acid, oil of vitriol; caustic.
+
+    =a.= tannicicum, tannic acid, astringent.
+
+    =a.= trichloraceticum, trichloracetic acid; caustic.
+
+=acquired.= Noting a disease which is not congenital but has taken
+possession of one at some period after birth.
+
+=actinic.= Relating to chemically active rays.
+
+=actinotherapy.= The treatment of disease by radiant energy.
+
+=acute.= Of short and sharp duration, not chronic; said of a disease.
+
+=adduction.= Rotation of the foot inward.
+
+=adhesive.= Sticky; causing adhesion.
+
+=adipose.= Fatty; relating to fat.
+
+=adjacent.= Next to; along side of.
+
+=adjuvants.= Agents added to a prescription to assist or increase the
+action of the main ingredient.
+
+=adolescents.= Youths, those between the ages of puberty and the
+attainment of full growth.
+
+=adrenalin.= A principle obtained from the suprarenal glands having
+marked astringent and hemostatic powers.
+
+=agar.= A gelatinous substance prepared from seaweed, and used as a
+base for culture media.
+
+=agent.= Anything which produces an effect upon the organism.
+
+=agnail.= Hangnail, whitlow.
+
+=albumin.= A protein contained in the tissues of plants and animals.
+
+=albuminous.= Containing or consisting of albumin.
+
+=albuminuria.= The presence of albumin in the urine as voided.
+
+=alcohol.= One of a series of organic compounds, especially one whose
+formula is C_{2}H_{5}OH, and called ethyl alcohol.
+
+=algia.= A suffix indicating pain. (Exam. metatarsalgia--pain in the
+metatarsals).
+
+=alignment.= Alinement; the act of bringing into line.
+
+=alkaline.= Relating to an alkali; having the reaction of an alkali.
+
+=alkaloid.= A basic substance found in plants, usually constituting the
+active principle of the crude drug.
+
+=alum.= A double sulphate of aluminum; burnt a. alumen exsiccatum.
+
+=aluminum chloride.= A substance used as an astringent in hyperidrosis
+and bromidrosis.
+
+=alypin.= A crystalline powder used as a local anesthetic.
+
+=ammoniated mercury.= See unguentum, hydrarg, amm.
+
+=ampere.= The unit of strength of an electric current.
+
+=amyotrophic lateral sclerosis.= A form of progressive muscular atrophy
+with increased reflexes due to hardening of the lateral columns of the
+spinal cord.
+
+=anærobe.= A microorganism which thrives best or only when deprived of
+oxygen.
+
+=analgesic.= An agent which causes analgesia or freedom from pain.
+
+=anastomose.= To open one into the other directly or by connecting
+channels; said of blood vessels and nerves.
+
+=anatomy.= The science devoted to the study of the structure of
+organized bodies, more especially the human body.
+
+=anemia.= A condition in which the blood is reduced in amount, or is
+deficient in red blood cells or in hemoglobin.
+
+=anesthesia.= Loss of sensation, especially of tactile sensibility.
+
+=anesthetic.= 1. Insensible to touch or to pain or to other stimuli. 2.
+A drug which produces local or general anesthesia.
+
+=anesthetize.= To induce anesthesia; to render anesthetic.
+
+=aneurism.= A blood-containing tumor connecting directly with the lumen
+of an artery.
+
+=angioma.= A swelling or tumor due to dilatation of a blood vessel.
+
+=ankylosis.= Stiffening or fixation of a joint.
+
+=anterior.= In front of, or, in the front part of.
+
+=anterior poliomyelitis.= Inflammation of the anterior horns of the
+spine; infantile spinal paralysis.
+
+=antheloticum or remedium heloticum.= Remedy for helomata.
+
+=anti.= A prefix signifying against, opposing. (Exam.
+antifebrile--against fever).
+
+=anticathode.= The platinum or other plate in a Crookes tube on which
+the cathode rays impinge, giving origin to the X-rays.
+
+=antiphlogistic.= An agent which subdues or allays inflammation.
+
+=antisepsis.= The destruction of germs causing disease, fermentation or
+putrefaction.
+
+=antiseptic.= 1. Destructive to the germs of disease, fermentation or
+putrefaction. 2. A substance which prevents the action of the germs of
+fermentation, decomposition, or disease.
+
+=aperture.= An opening, orifice.
+
+=apex.= The summit or tip.
+
+=apodal.= Without feet.
+
+=apodia.= Congenital absence of feet.
+
+=apoplectic.= Relating to, predisposed to or suffering from apoplexy.
+
+=apoplexy.= A sudden loss of consciousness followed by paralysis, due
+to cerebral hemorrhage or blocking of an artery of the brain.
+
+=apothesine.= A synthetic product used to produce local anesthesia,
+which came into popular favor at a time when the usually employed local
+anesthetics were unobtainable because of war conditions.
+
+=apparatus.= A collection of instruments adapted for a special purpose.
+
+=appendage.= Any part, subordinate in size, attached to a main
+structure.
+
+=appendicitis.= Inflammation of the vermiform appendix.
+
+=applicator.= A slender rod of wood or metal by means of which with
+cotton, local applications may be made to a part.
+
+=apus.= A monster without feet.
+
+=aqua.= Water.
+
+=aqua cinnamomi.= Cinnamon water.
+
+=aqua fortis.= Nitric acid; see acidum nitricum.
+
+=aqueous.= Watery.
+
+=arch.= In anatomy, any vaulted or arch-like structure.
+
+=argentum.= The metal, silver.
+
+=aristol.= Trade name of thymol iodide, a local antiseptic.
+
+=armamentarium.= In podiatry, all the means (drugs, instruments, etc.)
+at the disposal of the podiatrist to fit him for the practice of his
+profession.
+
+=arsenic.= A steel-gray metal, one of the elements; arsenic trioxide,
+white arsenic.
+
+=arteria.= Artery: a blood vessel conveying blood away from the heart.
+
+=arteries of the foot=:
+
+    =a.= communicans; communicating branch of dorsalis pedis (to
+    plantar surface to join plantar arch).
+
+    =a.= digitales dorsales; digital branches of dorsalis pedis
+    (dorsal surface of the toes).
+
+    =a.= dorsalis pedis; dorsalis pedis artery (dorsum of foot).
+
+    =a.= metatarsae dorsales; metatarsal branch of dorsalis pedis
+    (dorsum of foot to metatarsus).
+
+    =a.= plantaris lateralis; external plantar artery (plantar
+    surface, joining communicating branch of dorsalis pedis,
+    completing the plantar arch).
+
+    =a.= plantaris medialis; internal plantar artery (plantar
+    surface of foot).
+
+    =a.= tarsae lateralis; tarsal branch of dorsalis pedis (dorsum
+    of foot to the tarsus).
+
+=arteriosclerosis.= Hardening of the arteries.
+
+=areolar.= A tissue made up of loose connective tissue, with many
+interspaces and found under the skin.
+
+=arsenical.= Relating to or containing any of the salts of arsenic.
+
+=arthritis.= Inflammation of the joints.
+
+=articulation.= A joining or connecting together loosely so as to allow
+of motion between the parts.
+
+=articular.= Relating to a joint.
+
+=ascites.= An accumulation of serous fluid in the peritoneal cavity.
+
+=asepsis.= A condition in which living bacteria are absent.
+
+=astasia-abasia.= Inability through muscular incoordination, to walk or
+stand, although the muscles functionate normally when the patient is
+lying down.
+
+=astragalus.= The ankle bone.
+
+=astringent.= An agent which causes contraction of the tissues or
+arrest of the secretions.
+
+=ataxia.= A loss of the power of muscular coordination.
+
+=ataxic.= Relating to ataxia.
+
+=atony.= Lack of tone or tension.
+
+=atrophy.= A wasting of the tissues of a part or of the entire body.
+
+=atypical.= Not typical.
+
+=auto.= A prefix denoting self. (Exam. autogenesis--self-production).
+
+=auto-serotherapic.= Relating to the treatment of certain conditions by
+the injection of the patient’s own blood serum.
+
+=axilla.= The armpit (pl. axillae).
+
+=axis.= A straight line passing through a spherical body between its
+two poles and about which the body may revolve.
+
+
+B
+
+=bacillus.= A bacterium; more especially, a rod-shaped or elongated
+variety.
+
+=bacillus aërogenes capsulatus.= The specific organism causing gas
+infection and gas gangrene. =b. of Welch=, the same; =b. perfringens=,
+the same.
+
+=bacteria.= Unicellular vegetable microorganisms, usually those which
+produce disease.
+
+=bactericidal.= Causing the death of bacteria.
+
+=bacterium fetidum.= A microorganism producing a stench. =b.
+prodigiosus.= A microorganism found on food, but not pathogenic.
+
+=bandage.= A piece of cloth or other material applied to any part of
+the body, to make compression, prevent motion and to retain surgical
+dressings.
+
+=base.= The lower part or bottom. In pharmacy, the chief ingredient of
+a compound. In chemistry, a compound which neutralizes an acid to form
+a salt.
+
+=belladonna.= Deadly nightshade. A perennial herb, the leaves and roots
+of which are used in medicine.
+
+=beneficent.= The disposition to do good; of help to.
+
+=benign.= Mild in character, said of an illness; not malignant.
+
+=benzine.= A purified distillate of American petroleum.
+
+=beriberi.= Endemic neuritis; a specific polyneuritis occurring in
+eastern and southern Asia. It prevails especially in armies, prisons,
+ships, etc., wherever large numbers of men are kept together.
+
+=bi.= A prefix denoting two, twice, or double. (Exam. bicuspid--having
+two prongs).
+
+=bichloride of mercury.= A chemical compound, HgCl_{2}, called
+corrosive sublimate and mercuric chloride. It is used as an antiseptic.
+
+=bifid.= Split or cleft bilateral. Having two sides, biped. Two-footed.
+
+=bismuth subgallate.= A yellowish dusting powder; trade name, dermatol.
+
+=bismuth subnitrate.= A white dusting powder with astringent properties.
+
+=bistoury.= A long, narrow-bladed knife, straight or curved on the
+edge, sharp or blunt pointed; employed for opening abscesses, slitting
+up sinuses, etc.
+
+=bleb.= A circumscribed area of separation of the epidermis due to the
+presence of a clear non-purulent fluid.
+
+=blister.= A bleb.
+
+=blood.= Sanguis, cruor; the red fluid circulating in the arteries,
+capillaries and veins. =b. plasma=, the fluid portion of the blood as
+it is contained in the vessels. =b. serum=, the fluid which is squeezed
+out by shrinkage of a blood clot.
+
+=bones.= The hard substances that make up the framework of the body.
+
+=bones of the foot=:
+
+    =astragalus.= Ankle bone.
+
+    =cuboid.= In front of the os calcis.
+
+    =internal, middle and external cuneiforms.= In front of the
+    scaphoid.
+
+    =metatarsals.= Five; in front of the tarsal bones.
+
+    =os calcis.= Heel bone.
+
+    =phalanges.= Fourteen; in front of the metatarsals, two in the
+    great toe and three in each of the four lesser toes.
+
+    =scaphoid.= In front of the astragalus.
+
+=boric acid.= A powder, soluble in water used as an antiseptic dusting
+powder.
+
+=bromidrosis.= Foul-smelling perspiration.
+
+=buckskin.= A leather made from the skin of the buck.
+
+=buffing.= Polishing by means of some soft material, attached to a
+rapidly revolving motor.
+
+=bulb.= Any globular or fusiform structure.
+
+=bulbar palsy.= Paralysis of the tongue and larynx.
+
+=bulla.= A bleb.
+
+=bullous.= Relating to or of the nature of bullae.
+
+=bunion.= An inflammatory swelling of the bursa over the
+metatarsophalangeal joint of the great toe.
+
+=bur.= A small disc or bulb, made to revolve rapidly and used by
+podiatrists in connection with their employment of the rotary drill, or
+file.
+
+=Burow’s solution.= A solution of alum and lead acetate.
+
+=bursa= (plural, bursae). A closed sac or pouch containing synovial
+fluid, found over joints and where tendons play over bones.
+
+=bursitis.= Inflammation of a bursa.
+
+
+C
+
+=caisson disease.= The bends, divers’ paralysis, tunnel disease; a
+symptom-complex, occurring in tunnel workers and others working in
+places under high air pressure when they return too suddenly to the
+normal atmosphere.
+
+=calamine.= Zinc carbonate; a pink powder used as an astringent.
+
+=calcaneoastragaloid.= Relating to the os calcis and the astragalus.
+
+=calcareous.= Chalky.
+
+=calcified.= Hardened by the deposition of lime salts in a part.
+
+=calcium.= A metallic element having a yellow color.
+
+=calibre.= The diameter of a canal or vessel.
+
+=callositas.= Callous, tyloma, a circumscribed thickening of the
+epidermic layers of the skin.
+
+=callous.= Callositas.
+
+=callus.= Callosity. The bone-like substance thrown out between and
+around the ends of a fractured bone.
+
+=calomel.= Hydrargyrum chloride mite.
+
+=calor.= Heat.
+
+=camphorated soap liniment.= Soap liniment, camphorated tincture of
+soap.
+
+=capillary.= One of the microscopic blood vessels forming the capillary
+system, intermediate between the arteries and the veins.
+
+=capsicum.= The dried fruit of Cayenne, African or red pepper.
+
+=capsule.= A membranous structure enveloping an organ or any other part.
+
+=carbolic acid.= Phenol.
+
+=carbon.= An element, occurring in the form of the diamond, graphite
+and coal.
+
+=carbon dioxide pencil.= A mass of solidified carbon dioxide used for
+the destruction of verruca, etc.
+
+=carborundum.= A very hard substance (carbide of silicon) used to
+sharpen instruments.
+
+=caries.= Molecular decay of a bone.
+
+=carpal.= Relating to the wrist.
+
+=carpus.= The wrist.
+
+=cartilage.= A connective tissue substance.
+
+=cashmere.= A woolen fabric made from goat hair.
+
+=cast.= An object formed by the solidification of a liquid poured into
+a mold.
+
+=castor oil.= Oleum ricini; a fixed oil from the seeds of Ricinus
+communis.
+
+=catalepsy.= A morbid state in which there is rigidity of the limbs.
+
+=cataplasma.= A poultice, a soft magma or mush, prepared by wetting or
+heating various powders or other absorbent substances.
+
+=catatonia.= Stupor.
+
+=cathode.= The negative pole of an electric current.
+
+=caustic.= Corrosive.
+
+=cautery.= An agent used for scarring or burning the skin or tissues by
+means of heat or of caustic chemicals.
+
+=c.c.= Abbreviation for cubic centimeter.
+
+=cell.= A minute structure, the living active basis of all plant and
+animal organization, composed of a mass of protoplasm and containing a
+nucleus.
+
+=cellulitis.= Inflammation of the cellular or connective tissue.
+
+=centigrade scale.= A thermometer scale, in which there are 100 degrees
+between the freezing point and the boiling point of water.
+
+=centimeter.= The hundredth part of a meter or .3937 (²⁄₅) of an inch.
+
+=cerate= (Lat. ceratum). An unctuous solid preparation, containing
+sufficient wax to prevent it from liquefying when applied to the skin.
+
+=cerebellar.= Relating to the cerebellum or hind-brain.
+
+=cerebral.= Referring to the brain.
+
+=cerebral cortex.= The external layer of gray matter covering the
+hemispheres of the brain.
+
+=cerebral hemisphere.= The large mass of brain substance on either side
+of the great longitudinal fissure.
+
+=cerebrospinal.= Relating to the brain and the spinal cord.
+
+=cerebrospinal meningitis.= An acute infectious inflammation of the
+brain and spinal cord caused by the meningococcus.
+
+=chamois.= The skin of the goat family, prepared for purposes of
+utility.
+
+=chancre.= The initial sore of syphilis.
+
+=characteristics.= The traits which mark a substance or condition, and
+differentiate it from others.
+
+=Charcot’s disease.= Amyotrophic lateral sclerosis.
+
+=chauffeur’s foot.= A painful condition of the anterior part of the
+foot.
+
+=chilblain.= An inflammation of the skin due to exposure to cold and
+dampness.
+
+=chimatlon.= Chilblains, an inflammation of the skin due to exposure to
+cold and dampness.
+
+=chiropodical.= Relating to chiropody (podiatry).
+
+=chiropodist.= One who treats the minor lesions of the foot. Originally
+probably, chirurg-podist, a surgeon of the foot.
+
+=chiropody.= The study of the minor lesions of the foot. Podiatry.
+
+=chisel.= The podiatrist’s instrument; helotomon.
+
+=chlorine.= An element in nature; an irritating, greenish, gaseous
+element used for disinfectant and bleaching purposes.
+
+=cholesterin.= A monatomic alcohol.
+
+=chorea.= A disorder of childhood characterized by spasmodic,
+involuntary movements of the limbs and facial muscles; St. Vitus’ dance.
+
+=chromidrosis.= A disease of the sweat glands in which the perspiration
+is colored.
+
+=chromium.= A very hard steel-gray element.
+
+=chronic.= Of long duration; noting a disease of slow progress and long
+continuance.
+
+=cicatricial.= Referring to scars or scar tissue.
+
+=cicatrix.= A scar.
+
+=circinate.= Circular, ring-shaped.
+
+=circum.= A prefix denoting a circular movement. (Exam.
+circumcision--to cut around).
+
+=circumduction.= Movement of a part in a circular direction.
+
+=circumscribed.= A definitely limited area.
+
+=claudication.= Limping.
+
+=claw-foot.= Muscular atrophy with caval contraction of the foot.
+
+=clavus.= Heloma, corn.
+
+=clinic.= An institution in which medical attention is given to
+patients who live elsewhere and do not require hospital care.
+
+=clonic.= Marked by alternate contraction and relaxation of muscle.
+
+=clot.= Coagulated blood.
+
+=club-foot.= Talipes.
+
+=coagulation.= Clotting, the process of changing from a liquid state to
+that of a soft, jelly-like solid.
+
+=coalesce.= To grow together, to become one.
+
+=coaptation.= The joining together of two surfaces, as in sewing up a
+wound or setting a fracture.
+
+=cocaine.= An alkaloid derived from coca and used for producing local
+anesthesia.
+
+=cocoon dressing.= A dressing made of absorbent cotton covered with
+collodion.
+
+=cohesion.= The power of attraction between the molecules of any
+substance, keeping the mass from falling apart.
+
+=collateral.= Secondary or subordinate.
+
+=collodial.= Glue-like. A substance which remains permanently suspended
+in a liquid, but does not dissolve.
+
+=collodion= (Collodium). A solution of guncotton in ether and alcohol.
+
+=coma.= A state of profound unconsciousness from which one cannot be
+roused.
+
+=comatose.= A state of coma.
+
+=comminuted.= Broken into a number of fragments, as in a multiple
+fractured bone.
+
+=compound.= Not simple but made up of two or more parts. In chemistry,
+a substance formed by the chemical union of two or more elements.
+
+=compress.= A pad of gauze or other material placed over a part to make
+compression.
+
+=concave.= A surface which is evenly curved inward.
+
+=concentrated.= Referring to a solution which has been made strong by
+evaporation or other means.
+
+=concentric.= Having a common centre.
+
+=concomitant.= Accompanying; occurring at the same time.
+
+=concrete.= Hardened; solidified into a mass.
+
+=condyle.= A rounded articular surface at the extremity of a long bone.
+
+=configuration.= External form.
+
+=congelation.= Freezing.
+
+=congenital.= Existing at birth.
+
+=congestion.= The presence of an abnormal amount of blood in the
+vessels of a part.
+
+=connective.= Binding, joining.
+
+    =c. tissue.= The general supporting or uniting tissue of the
+    body.
+
+=constitutional.= Relating to the system as a whole; not local.
+
+=contact.= The touching or apposition of two bodies.
+
+=contagion.= Transmission of an infectious disease.
+
+=contamination.= Pollution, soiling with infectious matter.
+
+=continuity.= Without a break; absence of interruption.
+
+=contour.= The outline of a part, the surface configuration.
+
+=contra.= A prefix signifying against or opposite. (Exam.
+contra-lateral--relating to the other side).
+
+=contra-indicated.= Not indicated, as in the purposed use of a remedy
+or in the consideration of a surgical procedure.
+
+=contract.= To shorten.
+
+=contracture.= A permanent muscular contraction, due to tonic spasm or
+to loss of muscular equilibrium, the antagonists being paralyzed.
+
+=contused.= Bruised.
+
+=convex.= A surface which is evenly curved outward.
+
+=coordination.= The harmonious working together of several muscles or
+groups of muscles.
+
+=core.= The central mass of necrotic tissue in a boil.
+
+=corium.= Cutis vera, true skin; the deeper or connective tissue layers
+of the skin.
+
+=corn.= Heloma, an overgrowth of the epidermic layers of the skin,
+containing a radix, or nucleus.
+
+=cornification.= Conversion into a horny substance.
+
+=corpuscle.= A primary atom.
+
+=corrode.= To wear away gradually.
+
+=corrosive sublimate.= Bichloride of mercury.
+
+=cortex.= The outer portion of an organ.
+
+=cosmetic.= Relating to the care of a person with a view to improving
+the appearance.
+
+=cotton.= The white fluffy fibrous covering of the seeds of the plant,
+genus gossypium, used in surgical dressings.
+
+=counterextension.= The resistance, or back-pull, made to extension on
+a limb.
+
+=counter-irritant.= An agent which causes counter-irritation.
+
+=counter-irritation.= Inflammation or irritation of the skin excited
+for the purpose of relieving an inflammation of the deeper structures.
+
+=coup de fouet.= Rupture of the plantaris muscle; lawn tennis leg.
+
+=c. p.= Abbreviation for chemically pure.
+
+=cramp.= A painful tonic muscular contraction; spasm.
+
+=creosote.= A substance obtained from beechwood tar.
+
+=crepitus.= The sensation (a crackling) felt when the hands are placed
+over the seat of a fracture, and the broken ends of the bones are moved
+against each other.
+
+=cretinism.= A disease occurring in the first three years of life, and
+resulting in the arrest of bodily growth and of mental development.
+
+=crinoline.= A stiff material with a coarser mesh, and heavier than
+gauze or cheesecloth.
+
+=criss-cross.= Referring to plaster applied to a part, each strip when
+applied being at an angle to the strip previously applied.
+
+=Crookes tube.= See Chapter, “X-rays in Podiatry.”
+
+=croupous.= Marked by a fibrinous exudation.
+
+=crural.= Relating to the leg or thigh.
+
+=crystalline.= Clear, transparent.
+
+=cuboid.= A bone of the tarsus.
+
+=cuneiform.= Three bones of the tarsus.
+
+=curettage.= Scraping the interior of a cavity for the removal of the
+abnormal tissues, with the curette.
+
+=cutaneous.= Relating to the skin.
+
+=cuticle.= Epidermis or outer horny layer of the skin.
+
+=cutis.= The skin.
+
+=cylinder.= A geometric figure formed by the revolution of a rectangle
+around one of its sides.
+
+=cylindrical.= Relating to or the shape of a cylinder.
+
+=cyst.= An abnormal sac containing gas, fluid or a semi-solid material.
+
+=cytoplasm.= Protoplasm, the substance of the cell, exclusive of the
+nucleus. It is composed of spongioplasm and hyaloplasm.
+
+
+D
+
+=D.= Abbreviation in prescription writing for da, give, detur, let
+there be given.
+
+=dactyl.= A finger or toe.
+
+=Dakin Solution.= A solution compounded by Dr. Dakin for the treatment
+of wounds by means of chlorine gas in solution, applied directly to the
+parts affected or injured.
+
+=dancer’s foot.= A painful condition of the great toe joint.
+
+=decay.= Slow destruction of an organic substance.
+
+=débris.= Fragments; broken rubbish.
+
+=deformity.= A deviation from the normal shape or size, resulting in
+disfigurement.
+
+=degeneration.= Deterioration; sinking from a higher to a lower level
+of a type.
+
+=dehydrating.= Losing water; being deprived of water.
+
+=deliquesce.= To become damp or liquid by absorbing water from the
+atmosphere.
+
+=delirium.= A condition of extreme mental excitement, marked by
+confused ideas.
+
+=demarcation.= A setting of limits, determining a boundary. =Line of
+d.=, a zone of inflammatory reaction separating a gangrenous area from
+healthy tissue.
+
+=dementia paralytica.= General paresis, or paralysis, of the insane.
+
+=denuded.= Deprived of a covering; bared.
+
+=deodorant.= An agent which destroys odors, especially disagreeable
+odors.
+
+=depressed.= Flattened from above downward. as in fractures of that
+type.
+
+=derma.= The connective tissue layer of the skin; the true skin.
+
+=dermatalgia.= Skin pain.
+
+=dermatitis.= Inflammation of the skin.
+
+=dermatitis calorica.= Inflammation of the skin resulting from the
+action of cold or heat.
+
+=dermatol.= Trade name of bismuth subgallate.
+
+=dermatorrhea.= Excessive skin secretion.
+
+=dermosynovitis.= Perforating ulcer of the foot.
+
+=desiccant.= A skin-drying agent.
+
+=desiccation.= Drying.
+
+=desquamation.= The shedding of the cuticle in scales or shreds.
+
+=developer.= A solution of chemicals used to develop photographic and
+X-ray plates.
+
+=devitalized.= Deprived of vitality or energy.
+
+=dexter.= Right, in contradistinction to sinister, left.
+
+=diabetes.= A disease in which sugar is excreted in the urine, and is
+also present in the blood. There are two types, insipidus and mellitus.
+The latter is the diabetes in which sugar is excreted. In the former,
+large quantities of pale urine are excreted.
+
+=diachylon.= Lead plaster.
+
+=diagnosis.= The determination of the nature of a disease.
+
+=diapedesis.= The passage of the blood cells through the unruptured
+walls of the blood vessels.
+
+=diathesis.= A constitutional state predisposing to any disease or
+group of diseases.
+
+=digit.= A finger or toe.
+
+=diet.= Food and drink in general. A prescribed course of eating and
+drinking.
+
+=dietetics.= The therapeutics of food and drink in relation to health
+and disease.
+
+=diffuse.= Spread about; not confined.
+
+=dioxygen.= Trade name for hydrogen peroxide.
+
+=diphtheria.= A specific infectious disease caused by the
+Klebs-Loeffler bacillus.
+
+=direct cautery.= Actual fire or heat applied to a part to destroy it.
+
+=disbasia angiosclerotica.= A disease characterized by intermittent
+limping.
+
+=disease.= Illness, sickness; an interruption of the function of any
+part of the body.
+
+=disintegration.= Separation of the component parts of a substance.
+
+=dislocation.= A disturbance of the relation of the bones entering into
+a joint.
+
+=dissection.= The act of cutting apart or separating the tissues of
+the body in the study of anatomy. In an operation, to separate the
+structures along natural lines. In podiatry, to remove a growth in its
+entirety and as a whole.
+
+=disseminatum.= Widely scattered, referring to heloma d., which is so
+scattered.
+
+=distal.= Farthest from the centre or median line. Opposed to proximal.
+
+=distension.= The act of stretching.
+
+=dorsal.= Referring to the upper or posterior surface, or the back of
+any part.
+
+=douche.= A current of water or other fluid, directed against the
+surface or projected in a cavity.
+
+=drain.= To draw off the fluid from a cavity.
+
+=dressings.= The materials applied to a wound for the purpose of
+excluding the air, stimulating repair, etc.
+
+=drop-foot.= Paralysis of the dorsal flexor muscles of the foot.
+
+=dropsy.= An excessive accumulation of clear watery fluid in any of the
+tissues or cavities of the body. (Latin--hydrops).
+
+=duck shield.= A dressing for heloma molle, devised by Alfred Ahrens.
+
+=duct.= A tubular structure giving exit to the secretion of a gland, or
+conducting any fluid.
+
+=ductility.= The quality possessed by some metals to spread and
+elongate without breaking.
+
+=dys.= A prefix meaning bad or difficult. (Exam. dysphasia--an
+impairment in the sense of touch).
+
+=dyspnea.= Shortness of breath, difficult respiration.
+
+
+E
+
+=ebullition.= Boiling.
+
+=ecchymosis.= A purplish patch of the skin caused by extravasation of
+blood.
+
+=ectrodactylia.= A congenital malformation in which one or more fingers
+or toes are absent.
+
+=eczema.= Salt rheum, tetter; an inflammation of the skin,
+characterized by weeping and itching.
+
+=edema.= An abnormal amount of clear watery fluid in the lymph spaces
+of the tissues.
+
+=edematous.= Dropsical, marked by edema.
+
+=effusion.= Escape of fluid from the blood vessels or lymphatics into
+the tissues or a cavity.
+
+=electrode.= One of the two poles of an electric battery or of the ends
+of the conductors connected therewith.
+
+=electrolysis.= Decomposition of the tissues by means of electricity.
+
+=eleidin.= A deeply staining substance forming the granules of the
+stratum granulosum of the epidermis.
+
+=element.= A simple substance which has not been subdivided.
+
+=elephantiasis.= Barbados leg. Hypertrophy of the skin and subcutaneous
+tissues.
+
+=eliminants.= Agents promoting the removal of waste.
+
+=emaciation.= Extreme loss of flesh.
+
+=embolism.= Obstruction of a vessel due to a clot or foreign matter,
+which has been transported to it, usually from a thrombus.
+
+=emollient.= Soothing to the skin.
+
+=emphysema.= The presence of air in the spaces of the connective
+tissues of a part.
+
+=empiric.= Founded on experience; the treatment of disease based on
+experience; opposed to rational.
+
+=encapsulated.= Inclosed in a sheath or capsule.
+
+=encysted.= Encapsuled; surrounded by a closed membrane.
+
+=endarteritis.= Inflammation of the inner coat of an artery.
+
+=endemic.= Noting a disease common to a region.
+
+=endo.= A prefix signifying within. (Exam. endotoscope--a form of ear
+speculum).
+
+=endosmosis.= Osmosis in a direction towards the interior of a cavity.
+
+=endothelium.= A layer of flat cells lining serous cavities, blood
+vessels, etc., and cavities not exposed to the air.
+
+=enervation.= Failure of nerve force.
+
+=engorgement.= Distension with fluid or other material; congested.
+
+=enucleate.= To remove in its entirety.
+
+=epidemic.= Noting a disease which attacks, nearly simultaneously, a
+large number of people in a community.
+
+=epidermis.= The epithelial layer of the skin; the scarf skin or outer
+skin.
+
+=epithelioid.= Resembling epithelium.
+
+=epithelioma.= A cancerous growth originating from squamous epithelium.
+
+=epithelium.= The purely cellular, non-vascular layer covering all
+cavities and surfaces exposed to the air, such as the epidermis, mucous
+membrane, etc.
+
+=eponychium.= The skin adherent to the nail at its root; the nail skin.
+
+=eradicated.= Removed.
+
+=ergot.= Spurred rye, rye smut; a drug made from rye.
+
+=erosion.= A wearing away.
+
+=erysipelas.= An acute spreading inflammation of the skin and
+subcutaneous tissues.
+
+=erythema.= A redness of the skin; rose-rash.
+
+=erythematous.= Relating to or marked by redness.
+
+=eschar.= A slough following a burn or cauterization of the skin.
+
+=escharotic.= Caustic, corrosive; an agent producing an eschar.
+
+=Esmarch’s bandage.= A rubber bandage wound tightly about a limb in
+order to exsanguinate the member preparatory to offering a bloodless
+field for operation.
+
+=essence of geranium.= A solution of the volatile oil of geranium.
+
+=essence of thyme.= A solution of the volatile oil of thyme.
+
+=ether.= An organic oxide, more especially ethyl ether
+(C_{2}H_{5})_{2}O.
+
+=ethics.= The principles of correct professional conduct as they relate
+to the public, to the practitioner, and to his fellow-practitioners.
+
+=ethyl bromide.= A colorless liquid employed as a local anesthetic.
+
+=ethyl chloride.= A colorless liquid employed as a local anesthetic, by
+spraying.
+
+=ethylate of soda.= A reddish yellow powder, employed in aqueous
+solution in the treatment of lupus and other skin diseases.
+
+=etiology.= The causes of disease.
+
+=eucalyptol oil.= Oleum eucalypti; an oil distilled from the leaves of
+the Eucalyptus globulus.
+
+=evaporate.= To change from liquid to vapor form.
+
+=evaporation.= A change from liquid to vapor form.
+
+=eversion.= A turning outward.
+
+=ex.= A prefix denoting out of, from, away from. (Exam. excision--to
+cut out).
+
+=excavator.= A spoon-shaped instrument used to scrape out pathologic
+tissue.
+
+=excision.= The operative removal of a limb, organ or other part.
+
+=excrementitious.= Relating to any cast-out waste material.
+
+=excrescence.= Any outgrowth from the surface, especially a pathologic
+growth.
+
+=excretion.= The process whereby the waste material is thrown out of
+the body.
+
+=excretory.= Relating to excretion.
+
+=exfoliate.= To strip off in layers or sheets, noting especially a form
+of desquamation.
+
+=exostosis.= A bony tumor springing from the surface of a bone.
+
+=expansion.= Spreading out; an increase in size.
+
+=exsanguinate.= To make bloodless.
+
+=exsiccant.= A dusting or drying powder.
+
+=extension.= The act of extending a limb; the position of a limb that
+is extended.
+
+=extr. cannabis indica.= A soft solid (Indian hemp) of blackish-green
+color.
+
+=extravasated.= Exuded from, or passed out of a vessel into the tissues.
+
+=exuberant.= Copious, plentiful, as exuberant granulations.
+
+=exudate.= To exude; a fluid, or formed elements of the blood, which
+enters the tissues or any cavity.
+
+
+F
+
+=F.= Abbreviation for Fahrenheit temperature.
+
+=fabella.= One of two small fibro-cartilages or sesamoid bones in the
+tendons of the gastrocnemius muscle.
+
+=fabric.= The structure of anything.
+
+=fabrics.= Materials constructed for manufacturing purposes.
+
+=facet.= A small smooth area on a bone or other firm structure.
+
+=Fahrenheit scale.= The degree markings on the F. thermometer in which
+the freezing point is 32° and the point of boiling water is 212°.
+
+=faradic.= Relating to induced electricity.
+
+=fasciculi.= Small bands or bundles of fibres, usually of muscle or
+nerve tissue.
+
+=fascia.= A sheet of fibrous tissue enveloping the body beneath the
+skin and also enclosing the muscles.
+
+=fatty degeneration.= A retrogressive change associated with
+the appearance of fat in the cells and formed within them. =f.
+infiltration.= A deposit of fat in abnormal quantity between and in the
+cells, and not formed within them.
+
+=felon.= Paronychia, inflammation around the nail. Whitlow.
+
+=felt.= Matted wool, unwoven. Used for podiatry dressings.
+
+=femur.= The thigh bone.
+
+=fermentation.= A chemical change induced in an organic compound by the
+action of a ferment.
+
+=ferrum.= The metal iron; the basic ingredient of tincture of the
+subsulphate of iron.
+
+=festination.= The peculiar acceleration of gait noted in paralysis
+agitans and some other nervous affections.
+
+=fetid.= Foul-smelling; having a rank odor.
+
+=fibre.= A filamentous element; an elongated cell or cell process.
+
+=fibrillae.= Minute fibres.
+
+=fibrin.= An elastic filamentous substance derived from the blood after
+coagulation.
+
+=fibroblast.= A cell produced by the connective tissue in the formation
+of fibrous tissue.
+
+=fibula.= The external and smaller of the two bones of the leg.
+
+=filament.= A fibril, a fine fibre, or thread-like structure.
+
+=fish skin.= A preparation used as a covering to wounds, etc.; a
+substitute for oil-silk.
+
+=fissure.= A furrow, cleft or slit.
+
+=fistula.= A sinus leading from an abscess cavity to the surface.
+
+=flaccid.= Relaxed; flabby; without bone.
+
+=flail-like.= Resembling an instrument used for thrashing or beating.
+
+=flat foot.= Pes planus; a foot in which the arch is sunken.
+
+=flax-seed.= Linseed. Used in making poultices.
+
+=flexion.= Bending; bending of a joint so as to approximate the parts
+they connect.
+
+=fluctuation.= A wave-like motion felt on palpating a cavity containing
+fluid.
+
+=fluffy.= Feathery.
+
+=fluoroscope.= An apparatus for rendering visible the effects of the
+X-rays.
+
+=fluoroscopy.= Examination of the inner parts of the body by means of
+the fluoroscope.
+
+=flux.= Flow of electricity or other substance.
+
+=focal infection.= An infectious process which starts at a point remote
+from the part where the symptoms manifest themselves.
+
+=follicle.= A simple tubular gland.
+
+=fomentation.= The application of warmth and moisture in the treatment
+of disease; poulticing.
+
+=foot.= Pes; the lower, pedal, extremity of the leg.
+
+=forceps.= An instrument for seizing anything and for making
+compression or traction.
+
+=formaldehyde.= An antiseptic gas with a pungent odor. The water
+solution, formalin, is used in podiatry.
+
+=fracture.= A break, especially of a bone.
+
+=friction.= Rubbing.
+
+=Friedreich’s ataxia.= Hereditary spinal ataxia.
+
+=frost bite.= Inflammation of the skin and deeper tissues due to
+exposure to severe cold. Chimatlon severe.
+
+=fulguration.= Lightning stroke. Treatment of tumors by means of the
+sparks of the high frequency current.
+
+=function.= The special action or physiologic property of a part.
+
+=fusiform.= Spindle-shaped; tapering at both ends.
+
+=fusion.= Liquefaction by heat; melting.
+
+
+G
+
+=G.= Abbreviation for gram.
+
+=gait.= Specific manner of walking; manner of stepping.
+
+=gallic acid.= A yellowish-white substance used as an astringent.
+
+=gallstone.= A concretion, chiefly of cholesterin, formed in the gall
+bladder or bile-duct.
+
+=galvanic.= Constant current electricity produced by chemical action.
+
+=gangrene.= Death of the soft tissues, en masse.
+
+=gas gangrene.= Gangrene caused by the bacillus of Welch; gaseous
+gangrene.
+
+=gastric.= Relating to the stomach.
+
+=gastrocnemius.= One of the calf muscles.
+
+=gastro-intestinal.= Referring to the stomach and the intestines.
+
+=gauze.= A thin loose-meshed cloth employed for dressings, bandages,
+etc.
+
+=genitalia.= The genitals.
+
+=genu.= The knee.
+
+=germ.= A rudiment. A microbe.
+
+=germicide.= An agent which destroys germs or microorganisms.
+
+=ginglymus.= A hinge joint.
+
+=glands.= Secreting organs or excreting organs, such as the sebaceous
+or sweat glands.
+
+=gliomatous.= Relating to a tumor formed of the nerves of the brain and
+spinal cord.
+
+=glucose.= Grape sugar.
+
+=gluteal.= Relating to the buttocks.
+
+=glycerin.= Glycerinum; a sweet, oily fluid obtained by the
+saponification of fats and fixed oils.
+
+=golfer’s foot.= A painful condition of the dorsum of the foot.
+
+=gomenol.= A germicidal, ethereal oil obtained from a plant.
+
+=gonococcus.= The specific organism causing gonorrhea.
+
+=gonorrheal heel.= A focal infection of the heel caused by an original
+urethral infection with the gonococcus.
+
+=Goulard’s extract.= A solution of lead subacetate.
+
+=gout.= A disease of metabolism characterized by recurrent attacks of
+arthritis, particularly in the metatarsophalangeal joint of the great
+toe, though any joint may be attacked, by deposits of sodium biuret
+in and around the affected joints, and by inflammation of fibrous
+structures elsewhere (Stedman).
+
+=grain.= A unit of weight, ¹⁄₆₀ dram.
+
+=gram=, =gramme=. A unit of weight equal to 15.4 grains.
+
+=granulation.= The formation of minute, rounded, fleshy projections on
+the surface of a wound in the process of healing.
+
+=gross.= Large, coarse, macroscopic in contradistinction to microscopic.
+
+=growth.= The increase in size of a living being or any of its parts.
+
+=gt.= (plural gtt.). Abbreviation of drop or drops.
+
+=gumma.= An infectious granuloma, the characteristic lesion of late or
+tertiary syphilis.
+
+=guncotton.= Pyroxylin.
+
+=gutta percha.= The dried milky juice of a Malay tree.
+
+=gypsum.= Calcium sulphate. =Dried g.= Calcii sulphas exsiccatus,
+plaster of Paris.
+
+
+H
+
+=hair follicle.= A cylindrical pit dipping down through the corium and
+containing the root of the hair.
+
+=hallux.= The great toe; the first digit of the foot.
+
+=hallux dolorosus.= Painful toe.
+
+=hallux flexus.= Hammer toe.
+
+=hallux rigidus.= Stiff toe.
+
+=hallux valgus.= A deformity in which the great toe is bent outwards.
+
+=hallux varus.= Deviation of the great toe to the inner side of the
+foot away from its neighbor.
+
+=hammer toe.= A condition of permanent flexion of the mid-phalangeal
+joint of one or more of the toes; hallux flexus.
+
+=heloma (plural, helomata).= Corn; clavus; an overgrowth of the
+epidermis, with a central core or nucleus.
+
+=heloma durum.= Hard corn.
+
+=heloma miliare.= Seed corn.
+
+=heloma molle.= Soft corn.
+
+=heloma neurofibrosum.= Corn containing nerve fibres.
+
+=heloma vasculare.= Vascular corn.
+
+=helosis.= The condition of having heloma.
+
+=helotomeia.= The surgery of helomata.
+
+=helotomon.= The knife for cutting helomata.
+
+=hematidrosis.= The excretion of sweat stained with blood.
+
+=hematocele.= A blood cyst; hematocist.
+
+=hemi.= A prefix signifying one-half. (Exam. hemiplegia--half
+paralysis).
+
+=hemichorea.= Chorea involving the muscles of one side, only.
+
+=hemiplegia.= Paralysis of one side of the body.
+
+=hemoglobin.= The coloring matter of the blood.
+
+=hemorrhage.= Bleeding; a flow of blood.
+
+=hemorrhoids.= Piles; a varicose condition of the external hemorrhoidal
+veins causing painful swellings at the anus.
+
+=hemostatic.= Arresting hemorrhage; styptic.
+
+=hereditary.= Transmitted from parent to offspring.
+
+=hermetically.= In an air-tight manner; noting a vessel closed or
+sealed in such a way that air can neither enter it nor issue from it.
+
+=hidrosis.= Sweating, especially heavy sweating; hyperidrosis;
+sudoresis.
+
+=high frequency.= An electric current with a high voltage, and a rapid
+change in direction from one pole to the other.
+
+=hirsute.= Hairy; pertaining to hair.
+
+=histology.= The branch of anatomy which deals with the cells and the
+minute structure of the tissues; microscopic anatomy.
+
+=homogeneous.= Of uniform structure or composition throughout.
+
+=homo heloticus.= The person having helomata.
+
+=hone.= A flat stone or a piece of leather used to sharpen knives.
+
+=hookworm.= A worm of the genus ankylostoma or uncinaria.
+
+=hornification.= Conversion into horn; cornification.
+
+=Huntington’s chorea.= Hereditary chorea.
+
+=hydrocephalus.= A condition, usually congenital, marked by an
+extensive effusion of serum into the cerebral ventricles.
+
+=hydrochloric acid.= See acidum.
+
+=hydrogen.= An odorless, colorless, tasteless gaseous element, the
+lightest substance known.
+
+=hydro-therapeutics.= The treatment of disease by the use of water, in
+a scientific way; hydrotherapy.
+
+=hygiene.= The science of health.
+
+=hyper.= A prefix denoting excessive. (Exam. hyperidrosis--excessive
+sweating).
+
+=hyperemia.= The presence of an increased amount of blood in a part;
+congestion.
+
+=hyperesthesia.= Excessive sensibility to touch, to pain or to other
+sensory stimuli.
+
+=hyperidrosis.= Hyperhidrosis; excessive sweating.
+
+=hyperporosis.= Excessive formation of callus after fracture of a bone.
+
+=hypertonicity.= A greater degree of tension.
+
+=hypertrophy.= Overgrowth; general increase in a part, not due to tumor
+formation.
+
+=hypodermatic.= Hypodermic; under the skin.
+
+=hysteria.= A chronic neurosis or psycho-neurosis, characterized by
+disorders of the will, and partial cessation or exaltation of the
+individual functions of the brain.
+
+
+I
+
+=iasis.= See osis.
+
+=ichnogram.= An imprint of the soles of the feet, showing a series of
+steps.
+
+=ichorous.= Relating to a thin watery discharge from an ulcer.
+
+=ichthyol.= Ichthyolum; a brownish oil, used in medicine and in
+podiatry because of the sulphur (from fossil fish) which it contains.
+
+=ichthyosis.= A congenital rough skin due to hypertrophy of the horny
+layer of the epidermis with diminished sweat and sebaceous secretion;
+fish-skin disease.
+
+=idiopathic.= Noting a primary disease, one originating without
+apparent extrinsic cause.
+
+=idiosyncrasy.= An individual mental or physical characteristic or
+peculiarity.
+
+=immersion.= The placing of a body under water or other liquid.
+
+=immobility.= Incapability of moving; the fixed position of a part.
+
+=immune.= Free from the possibility of infection.
+
+=impacted.= Pressed closely together so as to be immovable as in
+=impacted= fracture.
+
+=impermeable.= Impervious.
+
+=impervious.= Impassable, impenetrable, to fluids.
+
+=impingement.= Used in podiatry to denote the pinching of tissues
+between two adjacent or opposite bones or muscles.
+
+=incipient.= Just beginning.
+
+=incision.= A cut; a division of the soft parts made with a knife.
+
+=incompatible.= Not capable of being mixed without undergoing radical
+changes.
+
+=incoordination.= Lack of harmonious action, as of muscles.
+
+=indentation.= The act of notching or pitting.
+
+=indolent.= Inactive; sluggish; painless, or nearly so.
+
+=induction.= Production or causation.
+
+=induction coil.= An apparatus for the induction of a secondary
+electric current.
+
+=induration.= Hardening.
+
+=inert.= Slow in action, sluggish.
+
+=infant.= A child during the first two years of life; a babe.
+
+=infection.= Invasion by living pathogenic bacteria of a part of the
+body where conditions are favorable to their growth and whence they act
+injuriously upon the tissues.
+
+=infiltration.= The act of passing into or interpenetrating a cell or
+tissue; said of gases and fluids.
+
+=inflammation.= The reaction of the tissues against injury or bacterial
+invasion, characterized by heat, redness, pain, swelling and impaired
+function.
+
+=inflation.= Distension of a part by a gas or a liquid.
+
+=inflection.= An inward bending.
+
+=influenza.= The grip; an acute infectious disease caused by Pfeiffer’s
+bacillus.
+
+=in-footed.= Pigeon-toed; standing or walking with toes turned in.
+
+=ingrown toe nail.= Onychocryptosis.
+
+=inhibition.= The diminution or arrest of function in an organ.
+
+=injection.= The introduction of a substance in fluid form into the
+tissues or cavities of the body.
+
+=innervation.= Distribution of the nerves in a part.
+
+=innocuous.= Harmless.
+
+=inoculate.= To introduce the virus of a disease into the tissues or
+blood vessels.
+
+=in situ.= In position.
+
+=instep.= The arch, or highest part of the dorsum of the foot.
+
+=instrument.= A tool or implement.
+
+=integument.= The enveloping membrane of the body; the skin.
+
+=inter.= A prefix denoting between or among. (Exam.
+interdigital--between the fingers or toes).
+
+=intercellular.= Between or among cells.
+
+=interosseous.= Between bones.
+
+=interphalangeal.= Between the phalanges.
+
+=intertrigo.= Dermatitis occurring between two folds of the skin.
+
+=intestinal.= Relating to the intestine or belly.
+
+=intima.= The inner coat of a blood vessel.
+
+=intoe.= Hallux valgus.
+
+=intoxication.= Acute alcoholism; drunkenness.
+
+=inunction.= The administration of a drug in ointment form by rubbing
+it into the skin.
+
+=inversion.= Bending inward.
+
+=involuntary.= Independent of the will; not volitional.
+
+=involution.= The return of an enlarged organ to normal size.
+
+=iodine.= A non-metallic element occurring in lustrous steel-gray
+crystals, soluble in water and alcohol and used externally as a
+counter-irritant and antiseptic.
+
+=iodoform.= Iodoformum; a yellow crystalline powder having a strong,
+disagreeable odor; employed as an antiseptic dusting powder to wounds
+and syphilitic sores.
+
+=ions.= A group of atoms carrying an electric charge.
+
+=irritation.= Extreme reaction of the tissues to an insult or injury;
+incipient inflammation.
+
+=ischemia.= Local anemia due to mechanical obstruction of the blood
+supply.
+
+=ischidrosis.= Suppression of the perspiration.
+
+=ist.= An affix denoting an agent. (Exam. podiatrist).
+
+=itis.= A suffix grown to mean inflammation of. (Exam.
+osteitis--inflammation of bone).
+
+
+J
+
+=jaborandi.= See pilocarpin.
+
+=joint-capsule.= Capsular ligament of a joint.
+
+=joint-muscle.= A muscle which causes motion at a joint.
+
+
+K
+
+=kakidrosis.= Bromidrosis.
+
+=keloids.= Lesions of a skin disease marked by patches of a whitish
+color surrounded by a purplish border.
+
+=keratin.= A scleroprotein present in hair, in nails, in horn, etc.
+
+=keratogenesis.= The production of horny cells or tissue.
+
+=keratohyalin.= Eleidin.
+
+=keratoma.= A horny tumor.
+
+=keratosis.= Circumscribed overgrowth of horny tissue.
+
+=kilogram.= One thousand grams weight.
+
+=kinesiatrics.= The therapeutic employment of movements; movement-cure.
+
+=kinetic.= Relation to motion or muscular movements.
+
+=Kneipp method.= The treatment of disease by water; hydrotherapy.
+
+=knock-knee.= Genu valgum.
+
+=kolionychia.= Spoon-nail; a malformation of the nails in which the
+outer surface is concave.
+
+=Korsakoff’s disease.= Polyneuritic psychosis.
+
+=kyllosis.= Club-foot.
+
+
+L
+
+=labyrinthine.= Perplexing, intricate, involved.
+
+=laceration.= A tear or torn wound.
+
+=laity.= Non-professional persons.
+
+=lamb’s wool.= A material used in shielding.
+
+=lamelia.= In osteology, a thin sheet or scale of bone.
+
+=lancet.= A surgical knife with a short, sharp pointed, two-edged blade.
+
+=lancinating.= Noting a sharp cutting or tearing pain.
+
+=Landry’s disease.= Acute ascending paralysis.
+
+=Langerhans’ cells.= Star-shaped cells in the deeper part of the
+stratum germinativum of the epidermis.
+
+=lanolin.= An oily substance extracted from the wool of sheep; adeps
+lanae.
+
+=larynx.= The organ of voice production.
+
+=larvae.= The worm-like forms of insects on issuing from the egg.
+
+=Lassar’s paste.= An ointment containing salicylic acid, talcum, zinc
+oxide and vaseline; it is used for eczema.
+
+=lateral.= On the side, as distinguished from medial.
+
+=lathyrism.= Lupinosis; poisoning by flour adulterated with chick-pea.
+
+=lead.= A metallic element.
+
+=lead and opium wash.= A solution of lead acetate and tr. opium in
+water; used to allay pain.
+
+=lead neuritis.= Inflammation of the nerves, due to poisoning by lead.
+
+=lead palsy.= Paralysis of the extensor muscles of the wrist, due to
+poisoning by lead; wrist drop.
+
+=leprosy.= A chronic disease believed to be due to the presence of
+the bacillus leprae, or Hansen’s bacillus. It occurs in two forms;
+tubercular, affecting the skin; anesthetic, affecting the nerves.
+
+=lesion.= A more or less circumscribed pathologic change in the tissues.
+
+=lethal.= Fatal, mortal, causing death.
+
+=leucocyte.= A white blood cell.
+
+=leuconychia.= The occurrence of white spots or patches under the nails.
+
+=leucorrhea.= A discharge from the vagina of a white, viscid fluid
+containing mucous and pus cells.
+
+=leverage.= The mechanical power gained by using a lever.
+
+=lichen planus.= A skin disease occurring on the soles of the feet.
+
+=ligaments.= Bands of fibrous tissue connecting two or more bones.
+
+=ligation.= The application of a ligature.
+
+=ligature.= A thread, wire or piece of catgut, tied tightly around a
+blood vessel, a pedicle or a tumor in order to constrict it.
+
+=limewater.= A solution of calcium hydroxide.
+
+=line of demarcation.= A zone of inflammatory reaction separating a
+healthy from a gangrenous area.
+
+=liniment.= A solution of a medicament in mucilage, starch or other
+substance, in combination with the white of egg.
+
+=linseed.= Flaxseed; used in making poultices.
+
+=lint.= A soft, absorbent material used in surgical dressings.
+
+=lipoma.= A tumor of fatty tissue.
+
+=liquor ferri subsulphate.= Monsel’s solution.
+
+=liquor potassae.= A 5% solution of potassium hydroxide.
+
+=lisle.= A material woven from cotton and silk.
+
+=liter.= A measure of capacity equal to a trifle over a quart; 1000
+cubic centimeter.
+
+=lithemia.= The presence of uric acid, in excess, in the blood.
+
+=Lobstein’s disease.= Constitutional fragility of the bones, fractures
+being produced by slight injuries.
+
+=locomotion.= Movement from one place to another.
+
+=longitudinal.= Running lengthwise; in the direction of the long axis
+of the body.
+
+=lordosis.= Curvature of the spine with the convexity looking
+anteriorally.
+
+=lues.= A plague or pestilence; specifically, syphilis.
+
+=luetin skin reaction.= The reaction of the skin in a specific test for
+syphilis.
+
+=lumen.= The space in the interior of a tubular structure, such as an
+artery.
+
+=lunula.= The opaque whitish semi-lunar area near the root of the nail.
+
+=lycopodium.= Vegetable sulphur. A yellow tasteless powder used as a
+dusting powder.
+
+=lymphangitis.= Inflammation of the lymphatic vessels.
+
+=lymph.= A clear light, straw-colored fluid, which circulates in the
+lymph spaces or lymphatic vessels of the body.
+
+=lymphatics.= A series of vessels acting as auxiliaries to the venous
+system, and containing the lymph.
+
+=lysis.= The gradual subsidence of the symptoms of an acute disease.
+
+=lysol.= Trade name of a mixture of soaps and phenols, used as a
+disinfectant dressing and hand-wash.
+
+
+M
+
+=M.= Abbreviation for (1) mille, a thousand; (2) in prescriptions, for
+misce, mix; (3) minim, a drop; (4) meter, French measure.
+
+=macerate.= To soften by soaking or steeping.
+
+=maceration.= Softening by the action of a liquid.
+
+=mackintosh.= A waterproof cloth or tissue used for surgical dressings.
+
+=macrodactylism.= Abnormal size of a finger or of a toe.
+
+=macroscopic.= Observable to the naked eye, in contradistinction to
+microscopic.
+
+=maculae.= Small spots or patches on the skin, not elevated above the
+general surface.
+
+=Madura foot.= Mycetoma; a disease occurring in the East Indies,
+characterized by large subcutaneous tubercles and nodules which break
+down and discharge pus.
+
+=mal.= A prefix meaning bad. (Exam. malposition--bad position).
+
+=malalignment.= Not in normal position.
+
+=malaria.= A disease caused by the presence of a protozoan parasite
+(plasmodium) of the red blood cells.
+
+=malignant.= Resistant to treatment; occurring in severe form; tending
+to grow worse, and (in the case of a tumor) to recur after removal. Not
+benign.
+
+=malingerer.= One who feigns disease.
+
+=malpractice.= Mistreatment of a patient’s ills through carelessness,
+ignorance or criminal intent.
+
+=malleolus.= One of the two rounded prominences on either side of the
+ankle joint.
+
+=manicure.= To care for the hands and finger-nails, cosmetically.
+
+=marasmus.= Extreme emaciation occurring in children.
+
+=massage.= A scientific method of manipulation of the body by rubbing,
+pinching, kneading, tapping, etc.
+
+=masseur.= A male who massages.
+
+=masseuse.= A female who massages.
+
+=massotherapy.= The therapeutic uses of massage.
+
+=materia medica.= The branch of medicine which treats of the origin,
+preparation, doses and modes of administration of drugs.
+
+=matrix.= The formative portion of a nail.
+
+=maximum.= The highest limit, the greatest amount possible in
+contradistinction to minimum, the least limit.
+
+=M.Cp.= Abbreviation of Master of Chiropody.
+
+=mechanotherapy.= Treatment of disease by means of apparatus or
+mechanical appliances.
+
+=medicament.= A medicine; a remedy.
+
+=medicine.= The art of preventing or curing disease. A drug.
+
+=medullated.= Having a soft marrow-like structure, especially in the
+centre of a part.
+
+=megalodactylism.= Abnormal size of a finger or toe.
+
+=membrana propria.= The basement layer of the epidermis, and separating
+it from the true skin.
+
+=membrane.= A thin sheet or layer of tissue serving as a covering or
+envelope of a part.
+
+=meningeal.= Relating to the meninges or membranous envelope of the
+brain and spinal cord.
+
+=menthol.= A camphor obtained from oil of peppermint.
+
+=mercuric chloride.= Corrosive sublimate.
+
+=mercury.= An element (quicksilver), compounds of which are used in
+podiatry.
+
+=metabolism.= Tissue change, the sum of the chemical changes whereby
+the function of nutrition is regulated.
+
+=metacarpal.= Referring to the long bones of the hand between the
+carpus and the phalanges.
+
+=metacarpophalangeal.= Relating to the metacarpus and the phalanges.
+
+=metamorphosis.= A change in form, structure, or function.
+
+=metastasis.= The shifting of a disease from one part of the body to
+another.
+
+=metatarsal.= Relating to the bones in front of the tarsus, and called
+the metatarsal bones; they are five in number.
+
+=metatarsalgia.= Pain in the metatarsal region.
+
+=metatarsophalangeal.= Between the metatarsal and phalanx.
+
+=meter.= A measure of length the equivalent of 39.4 inches.
+
+=methyl.= The radical of wood alcohol.
+
+=methylene blue.= A compound of methylene, used as a caustic in
+treating verruca.
+
+=microbe.= A minute one-celled creation, animal or vegetable; a
+microorganism.
+
+=microorganism.= A microscopic plant or animal, a bacterium or
+protozoan.
+
+=microscopic.= Of minute size, visible only through a microscope; the
+reverse of macroscopic.
+
+=miliaria.= An eruption of minute vesicles due to retention of fluid at
+the mouth of the sweat glands.
+
+=miliary.= Representing a millet seed in size.
+
+=milligram.= One-thousandth of a gram--1-65 grain.
+
+=milliliter.= One-thousandth of a liter--about 15 minims.
+
+=millimeter.= One-thousandth of a meter 1-25 inch.
+
+=milliampere.= An electric unit of current-strength, the thousandth of
+an ampere.
+
+=milliamperemeter.= An instrument used for measuring milliamperes of
+electric current.
+
+=millet seed.= A small seed of the millet plant; a grain.
+
+=minim.= One-sixtieth of a fluid drachm, equivalent to about one drop
+of water.
+
+=misce.= Mix; the character which directs the druggist to mix the
+ingredients of a prescription.
+
+=mistura.= A pharmacal mixture.
+
+=mobility.= The quality of being movable.
+
+=molecular.= Relating to the smallest possible unit of existence of any
+substance.
+
+=moleskin.= An adhesive substance used in shielding.
+
+=mollifying.= Calming; softening.
+
+=mono.= A prefix denoting the participation of a single element or
+part. (Syn. uni). (Exam. monodactyl--a single finger or toe).
+
+=Monsel’s solution.= Liquor ferri subsulphatis.
+
+=morbid.= Diseased; pathologic.
+
+=morphine.= The chief active principle of opium.
+
+=morphologic.= Relating to the structure of the tissues of the body.
+
+=morphology.= The science which treats of the external configuration or
+the structure of animals and plants.
+
+=Morton’s disease.= Morton’s neuralgia.
+
+=Morton’s neuralgia.= A pain in the metatarsophalangeal joint of the
+fourth toe; also called Morton’s toe.
+
+=motile.= Having the power of spontaneous movement.
+
+=mucous.= Relating to mucous or to the mucous membrane (m. membrane),
+a membrane which secretes mucus, and lines the cavities connected with
+the outer air.
+
+=multiple.= Occurring in several parts at the same time.
+
+=mummification.= Dry gangrene, shriveling.
+
+=muscle.= One of the contractile organs of the body, by which the
+movements of the various organs and parts are effected.
+
+=muscle-corpuscle.= The nucleus of a muscle-fiber.
+
+=muscle-fiber.= One of the cylindrical fibers, an inch or more in
+length and about 1-500 inch in diameter, composing voluntary muscle
+tissue.
+
+=muscle-plasma.= The fluid portion of muscle tissue.
+
+=musculature.= The arrangement of the muscles in a part or in the body
+as a whole.
+
+=musculus.= Muscle. Important muscles of the foot.
+
+    =m.= Abductor hallucis.
+
+    =m.= Abductor obliquus hallucis.
+
+    =m.= Adductor transversis hallucis.
+
+    =m.= Extensor digitorum brevis.
+
+    =m.= Extensor digitorum longus.
+
+    =m.= Extensor hallucis longus.
+
+    =m.= Flexor accessorius.
+
+    =m.= Flexor brevis hallucis.
+
+    =m.= Flexor brevis minimi digiti.
+
+    =m.= Flexor digitorum brevis.
+
+    =m.= Flexor digitorum longus.
+
+    =m.= Flexor hallucis longus.
+
+    =m.= Gastrocnemius.
+
+    =m.= Interosseous dorsalis.
+
+    =m.= Interosseous plantaris.
+
+    =m.= Lumbricalis (4).
+
+    =m.= Peroneus brevis.
+
+    =m.= Peroneus longus.
+
+    =m.= Peroneus tertius.
+
+    =m.= Plantaris.
+
+    =m.= Soleus.
+
+    =m.= Tibialis anticus.
+
+    =m.= Tibialis posticus.
+
+=mustard.= The dried, ripe seeds of the white or black mustard plant.
+
+=mycetoma.= Madura foot; a disease of the foot occurring in the East
+Indies.
+
+=myelitis.= Inflammation of the spinal cord, or of the bone marrow
+(osteomyelitis).
+
+=myeloma.= A tumor due to hyperplasia of the bone marrow.
+
+=myocellulitis.= Inflammation of muscle and cellular tissue.
+
+=myoclonia.= Any disorder characterized by muscular twitching.
+
+=myocyte.= A muscle cell.
+
+=myodynia.= Muscle pain; myalgia.
+
+=myology.= The branch of science which deals with muscles and their
+accessory parts.
+
+=myositis.= Muscle inflammation.
+
+=myotonia.= Any disorder characterized by tonic spasm or temporary
+rigidity of a muscle.
+
+
+N
+
+=naevus.= A congenital mark or discolored patch of the skin; a mole.
+
+=nafalan.= A proprietary remedy containing Caucasian naphtha in a soap
+base.
+
+=nail.= Unguis; the horny plate covering the dorsal surface of the
+distal half of the terminal phalanx of each finger and toe.
+
+=nail bed.= A portion of the distal phalanx covered by the nail.
+
+=nail fold.= A groove in the skin in which lie the margins and the
+proximal edge of the nail.
+
+=nail groove.= A groove in the distal phalanx in which the nail lies.
+
+=nail plate.= The horny substance which makes up the nail proper.
+
+=nanomelous.= Having very small extremities.
+
+=narcosis.= Stupor or general anesthesia produced by some narcotic drug.
+
+=narcotic.= Relating to or causing narcosis; an agent which produces
+narcosis.
+
+=navicular.= One of the bones of the tarsus of the foot.
+
+=nebulizer.= An atomizer; a vaporizer; an apparatus for throwing a
+liquid in a fine spray.
+
+=necrosis.= Local death; the death of more or less extensive groups of
+cells.
+
+=neo.= A prefix noting new or recent. (Exam. neoplasm--new growth).
+
+=neoplasm.= A new growth; tumor.
+
+=nephritis.= Inflammation of the kidney.
+
+=nerve.= A collection of fibres in the form of a whitish cord through
+which stimuli are transmitted from the central nervous system to the
+periphery, or the reverse.
+
+=nervousness.= A condition of unrest and of irritability to the nervous
+system.
+
+=nervus.= Nerve; a whitish cord made up of nerve fibres.
+
+=nerves of the foot=:
+
+    =n.= musculocutaneus; musculo-cutaneous nerve (dorsal surface
+    and in front of leg).
+
+    =n.= plantaris externus; external plantar nerve (plantar
+    surface).
+
+    =n.= plantaris internus; internal plantar nerve (plantar
+    surface).
+
+    =n.= saphenus externus; external saphenous nerve (dorsal
+    surface and in front of leg).
+
+    =n.= tibialis anticus; anterior tibial nerve (dorsal surface
+    and in front of leg).
+
+    =n.= tibialis posticus; posterior tibial nerve (back of leg).
+
+=neuralgia.= Nerve-pain; pain of a severe, throbbing or stabbing
+character in the course of a nerve.
+
+=neurasthenics.= Those suffering from neurasthenia, or nervous
+exhaustion.
+
+=neuritis.= Inflammation of the nerves.
+
+=neuro-fibrous.= Containing nerve fibres; said of an heloma.
+
+=neuroma (plural neuromata).= A tumor made up of nerve tissue.
+
+=N. F.= Abbreviation for National Formulary, a book issued by the
+American Pharmaceutical Association containing formulas of preparations
+not official in the Pharmacopeia.
+
+=nitric acid.= HNO_{3}. Employed as a caustic for verrucæ.
+
+=nodule.= A small node or circumscribed swelling.
+
+=Noguchi test.= A test for tabes dorsalis depending upon an albumin
+reaction of the spinal fluid; a test for syphilis--a modification of
+the Wassermann test.
+
+=non.= A latin prefix denoting a negation or absence of the quality or
+fact expressed in the word to which it is prefixed.
+
+=non-medullated.= Without a medulla or medullary substance.
+
+=non-striated.= Without stripes or bands.
+
+=normal.= Typical; usual; healthy.
+
+=nostrum.= A quack remedy.
+
+=novocaine.= A synthetic local anesthetic.
+
+=noxious.= Injurious; harmful.
+
+=nucleus.= The centre of functional activity of a cell; the central
+portion of an heloma.
+
+=nutrient.= Carrying nourishment.
+
+
+O
+
+=obesity.= An abnormal increase of fat in the subcutaneous connective
+tissues; corpulence; fatness; general adiposis.
+
+=obliterated.= Destroyed by the effects of time; effaced.
+
+=occlusive.= Noting a dressing which excludes the air.
+
+=official.= Authoritative; noting a drug or chemical found in the
+Pharmacopeia.
+
+=ohm.= The unit of electric resistance.
+
+=oid.= A suffix denoting resemblance to the thing indicated by the
+other part of the word. (Exam: osteoid--resembling bone).
+
+=oil stone.= A hone upon which oil is used.
+
+=oiled silk.= A waterproof substance used in surgical dressings.
+
+=ointment.= A medicated fatty mixture with the consistency of butter,
+and employed externally.
+
+=oligodactylia.= A deformity marked by fewer than five fingers or toes
+on each hand or foot.
+
+=ology.= A suffix denoting a special branch of study. (Exam:
+podology--the branch of medical science which has to do with the feet
+in all their relations).
+
+=oma.= A suffix noting a tumor or neoplasm. (Exam: neuroma--a nerve
+tumor).
+
+=onychatrophia.= Atrophy of the nails.
+
+=onychauxis.= Hypertrophy of the nails.
+
+=onychia (onychitis).= Inflammation of the nail bed or matrix.
+
+=onychocryptosis.= Ingrown toe nail.
+
+=onychogryphosis.= Hypertrophy of the nails with curvature or deformity.
+
+=onychoid.= Resembling a nail in structure or in form.
+
+=onycholysis.= Loosening or shedding of the nails.
+
+=onychoma.= A tumor arising from the nail bed.
+
+=onychomalacia.= Absence of rigidity of the nails; hapalonychia.
+
+=onychomycosis.= Any parasitic disease of the nails, such as tinea or
+favus.
+
+=onychotrophy.= Nutrition of the nails.
+
+=onychopathy.= Any disease of the nails; onychosis.
+
+=onychophag.= A victim of the nail-biting habit.
+
+=onychophosis.= Calloused nail groove.
+
+=onycophyma.= Swelling or hypertrophy of the nails.
+
+=onychoptosis.= Falling off of the nails.
+
+=onychorrhexis.= Brittle nails.
+
+=onyx.= The greek word for finger-nail or toe nail.
+
+=oozing.= Flowing slowly; gradually escaping.
+
+=operation.= Any surgical procedure.
+
+=opisthotonos.= A tetanic spasm in which the spine and extremities are
+bent with convexity forward, the body resting on the head and heels.
+
+=organ.= Any part of the body exercising a specific function.
+
+=origin.= The less movable of the points of attachment of a muscle.
+
+=orthoform.= A white crystalline powder used as a local anesthetic and
+antiseptic.
+
+=orthopedics.= A branch of surgery which has to do with the treatment
+of chronic diseases of the joints and spine, and the correction of
+deformities.
+
+=orthopedist.= One who practices orthopedics; orthopaedist.
+
+=os.= A bone.
+
+=os calcis.= The calcaneus; the heel bone.
+
+=oscillate.= To vibrate.
+
+=osis.= A suffix noting an Increase. (Exam. tuberculosis--an increase
+in tubercles).
+
+=osmidrosis.= (See bromidrosis).
+
+=osmosis.= The passage of certain fluids through an animal membrane or
+other porous substance.
+
+=ossification.= The formation of bone.
+
+=ossiferous.= Containing bone.
+
+=ostealgia.= Bone pain.
+
+=osteanabrosis.= Bone atrophy.
+
+=osteanaphysis.= Bone reproduction.
+
+=osteotomy.= Surgical removal of bone.
+
+=osteitis.= Bone inflammation.
+
+=osteoarthritis.= Inflammation of the articular extremity of a bone
+involving the contiguous joint structure.
+
+=osteochondritis.= Inflammation of a bone and its cartilage.
+
+=osteogenesis.= The formation of bone.
+
+=osteoma.= A bone tumor.
+
+=osteomyelitis.= Inflammation of the bone marrow.
+
+=osteopsathyrosis.= Bone fragility; fragilitas ossium.
+
+=osteotomy.= Bone cutting, usually by means of a saw or a chisel.
+
+=ounce= (abr. oz.). A weight containing 48.0 grains, apothecaries’
+weight.
+
+=oxidation.= A combination with oxygen.
+
+=oxygen.= A gaseous element, symbol, O.
+
+=ozone.= A condensed form of oxygen, containing three atoms in a
+molecule.
+
+
+P
+
+=pachyacria.= A bulbous thickening of the extremities of the fingers or
+toes.
+
+=pachydactylous.= Abnormal thickness of fingers or of toes.
+
+=pachydermia.= Elephantiasis.
+
+=pachypodous.= Having large thick feet.
+
+=pacinian.= Named after Filippo Pacini, an Italian anatomist, and
+noting especially the Pacinian body or corpuscle found in the skin, and
+which is a touch organ.
+
+=palliative.= Mitigating; reducing the severity of; noting a method of
+treatment of a disease or of its symptoms.
+
+=pallor.= Paleness.
+
+=palpate.= Examining by feeling and pressing with the palms of the
+hands and with the fingers.
+
+=pan.= A prefix implying all, entire. (Exam: panhidrosis--perspiration
+of the entire body).
+
+=panaris.= Paronychia.
+
+=papilla.= A conical elevation found beneath the epidermis, and
+containing capillary loops and nerve endings.
+
+=papillary layer.= The outer connective tissue layer of the true skin,
+and made up of numbers of papillæ.
+
+=papilloma.= A circumscribed overgrowth or hypertrophy of the papillæ
+of a cutaneous or mucous surface.
+
+=papoid.= A digestive enzyme from the fruit of the pawpaw, resembling
+papain.
+
+=papule.= A small circumscribed elevation of the skin containing no
+fluid; a pimple.
+
+=papulosquamous.= Relating to both papules and scales.
+
+=para.= A prefix denoting (1) a departure from normal; (2) an
+involvement of like parts. (Exam: (1) parachroma--abnormal coloration
+of the skin or other parts; (2) paraplegia--paralysis of both lower
+extremities).
+
+=paraffin.= A white solid hydrocarbon, having the consistency of wax.
+
+=paralysis.= Palsy; loss of power of voluntary movement in a muscle
+through injury or disease of its nerve supply; loss of any function.
+
+=paralysis agitans.= Parkinson’s disease; shaking palsy; a disorder
+marked by muscular weakness, stiffness and tremor.
+
+=paralysis, pseudo-bulbar.= Paralysis of the lips and tongue due to a
+cerebral lesion.
+
+=paralyzant.= Causing paralysis; any agent causing paralysis.
+
+=paramyoclonus multiplex.= An affection characterized by sharp,
+frequently repeated clonic, muscular contractions.
+
+=paraplegia.= Paralysis of both lower extremities and also of more or
+less of the trunk.
+
+=parasite.= An animal or vegetable organism which lives on or in
+another from which it draws its nourishment.
+
+=parasiticide.= Destructive to parasites.
+
+=paresis.= Cortical paralysis.
+
+=paresthesia.= An abnormal sensation, such as burning, pricking,
+numbness, etc.
+
+=paretic.= Relating to, or suffering from paresis.
+
+=paronychia.= Inflammation of the tissues around the nail, felon;
+panaris; whitlow.
+
+=parresine.= A paraffin preparation used for burns.
+
+=passive.= Not active.
+
+=pathogenic.= Causing disease.
+
+=pathognomonic.= Characteristic of a disease, noting certain typical
+symptoms.
+
+=pathology.= The science that deals with the change in function or in
+structure of an organ or tissue in a diseased state.
+
+=pedal.= Relating to the feet.
+
+=pedarthrocace.= Joint disease in children.
+
+=pediculis corporis.= The body louse.
+
+=pedicure.= One who treats the feet cosmetically.
+
+=pedunculated.= Stalked, having a peduncle; not sessile.
+
+=pellagra.= An affection characterized by gastro-intestinal
+disturbances and mental disorders.
+
+=pelma.= The sole of the foot.
+
+=pelmatogram.= An imprint of the sole of the foot made by resting the
+inked foot on a sheet of paper, or by pressing the greased foot on a
+plaster of Paris paste.
+
+=pelvis.= Any basin-like or cup-shaped cavity.
+
+=pemphigus.= An infection of the skin characterized by the production
+of bullae.
+
+=per.= A prefix denoting through. (Exam: perennial--lasting through
+several years).
+
+=perforating.= Piercing with one or more holes.
+
+=peri.= A prefix denoting around or about. (Exam: periosteum--around
+the bone).
+
+=periarthritis.= Inflammation of the parts surrounding a joint.
+
+=periodic.= Recurring at regular intervals.
+
+=perionychia.= (See paronychia.)
+
+=periosteum.= The thick fibrous membrane covering the entire surface of
+a bone except its articular cartilage.
+
+=periphery.= The outer part or surface; away from the centre.
+
+=periphlebitis.= Inflammation of the outer coat of a vein or of the
+tissues surrounding a vein.
+
+=pernio.= Chilblains; chimatlon mild.
+
+=perodactylus.= A monster with defective fingers and toes.
+
+=peronei.= Relating to the peroneus muscles.
+
+=peropus.= A monster with defective feet.
+
+=peroxide of hydrogen.= Oxygenated water, H_{2}O_{2}, used as an
+antiseptic and deodorant.
+
+=perspiration.= The excretion of fluid by the sweat glands. The fluid
+excreted by the sweat glands; transpiration.
+
+=perverted.= Turned from what is normal or proper.
+
+=pes=, =gen. pedis=, =pl. pedes=. The foot.
+
+=pes cavus.= Hollow-foot.
+
+=pes planus.= Flat foot.
+
+=petrogen.= The proprietary name of refined mineral oil, used as a base
+for remedial agents. =p. iodine.= Iodine mixed with petrogen.
+
+=petrolatum.= Vaseline; a yellowish mixture of the softer members of
+the paraffin or methane series of the hydrocarbons, obtained from
+petroleum as an intermediate product in its distillation.
+
+=phadena.= A sloughing ulcer.
+
+=phagocytosis.= The process of ingestion and digestion by the cells;
+the substances ingested are other cells, bacteria, bits of necrosed
+tissue, foreign particles, etc.
+
+=phalanges.= Long bones of the fingers or toes, fourteen in number, two
+on each great toe and three on each of the remaining toes.
+
+=phenol.= Carbolic acid.
+
+=phenomenon.= A symptom; any unusual fact or occurrence.
+
+=phlebitis.= Inflammation of a vein.
+
+=phlegmon.= Acute suppurative inflammation of the subcutaneous
+connective tissue.
+
+=phosphoridrosis.= Phosphorescent sweating.
+
+=physical.= Relating to the body as distinguished from the mind.
+
+=physics.= The branch of science which deals with the phenomena of
+matter.
+
+=physiology.= The science that treats of the functions of the organs
+and tissues of the human body.
+
+=picric acid.= A yellowish, crystalline powder used in burns and eczema.
+
+=pigment.= Coloring matter; the coloring matter found in the epidermis.
+
+=pilocarpin.= An alkaloid obtained from the leaves of pilocarpus; used
+externally to stimulate the growth of hair.
+
+=pit.= Any natural depression on the surface of the body.
+
+=pityriasis.= A dermatosis marked by branny desquamation; =p. rubra
+pilaris=, an eruption of papules surrounding the hair follicles.
+
+=plantar.= Relating to the sole of the foot.
+
+=plantar flexion.= A term used to indicate extension of the foot
+forward at the ankle joint.
+
+=plaster.= A solid preparation which can be spread when heated and
+which becomes adhesive at the temperature of the body.
+
+=plaster of Paris.= Gypsum, calcium sulphate; used in podiatry for
+dressings and to make casts.
+
+=plasticity.= The capability of being formed or moulded.
+
+=platinum.= A silver white metal.
+
+=pledget.= A small mass or tuft of wool, cotton or lint.
+
+=plexiform.= Resembling a plexus or network.
+
+=plexus.= A network or interjoining of structures in the body,
+especially of veins, nerves or lymphatics.
+
+=pliability.= The capability of being pliable or flexible.
+
+=plumbism.= Lead poisoning.
+
+=podagra.= Gout, especially of the great toe.
+
+=podalgia.= Pain in the foot.
+
+=podarthritis.= Inflammation of any of the tarsal or metatarsal joints.
+
+=podiatrist.= One who practises podiatry.
+
+=podiatry.= The scientific care of the foot in health and in disease.
+
+=poisoning.= Administering of poison; state of being poisoned.
+
+=policeman’s heel.= A painful condition of the inferior surface of the
+os calcis.
+
+=poliomyelitis.= Inflammation of the grey matter of the spinal cord.
+
+=poly.= A prefix conveying the notion of multiplicity. (Exam.:
+polyarthritis--simultaneous inflammation of several joints).
+
+=polydactylism.= More than five digits on either the hand or the foot.
+
+=polyneuritis.= Multiple neuritis.
+
+=polynuclear.= Multinuclear, having more than one nucleus.
+
+=pompholyx.= An inflammatory eruption of the skin of the hands and
+feet, accompanied by itching and burning.
+
+=popliteal.= Relating to the posterior surface of the knee.
+
+=positive pole.= Anode; the chemically active pole of an electric
+battery, the one connected with the electronegative element.
+
+=pore.= One of the minute openings of the sweat glands of the skin.
+
+=post.= A prefix denoting after. (Exam.: postmortem--after death).
+
+=posterior.= Behind or after.
+
+=post-operative.= Following a surgical operation.
+
+=posture.= The term applied to the position of the body in space.
+
+=potassium hydroxide.= Caustic potash, a white crystalline mass used in
+solution form to treat verruca.
+
+=potassium iodide.= A white, crystalline powder used in the internal
+treatment of syphilis.
+
+=potassium permanganate.= A violet substance used as a deodorant in
+bromidrosis.
+
+=potential cautery.= A caustic; an agent such as potassium hydroxide
+which forms an eschar without the agency of actual fire.
+
+=potentiality.= A state of tension in an electric source.
+
+=poultice.= Cataplasma; a soft mush prepared by wetting absorbent
+substances with fluids and usually applied hot to the surface.
+
+=pre.= A prefix to words formed from Latin roots, denoting anterior or
+before. (Exam.: prepatellar--in front of the patella or knee cap).
+
+=precursor.= Forerunner.
+
+=predisposing.= Affecting the body in such a way as to render it
+vulnerable to the action of the exciting cause.
+
+=pregnancy.= Gestation; the state of a female after conception until
+the birth of the child.
+
+=prescription.= A written formula for the preparation and
+administration of any remedy or remedies.
+
+=process.= A projection or outgrowth.
+
+=profuse.= Exuberant; liberal to excess.
+
+=prognosis.= The foretelling of the probable course of a disease.
+
+=progression.= Advance; the act of walking.
+
+=proliferation.= Exuberant growth by reproduction of similar cells.
+
+=prophylaxis.= The prevention of disease.
+
+=propulsion.= The tendency to fall forward that causes festination in
+paralysis agitans.
+
+=protonuclein.= Trade name of a nuclein preparation derived from
+lymphoid tissue.
+
+=protoplasm.= Living matter, of which animal and vegetable tissues are
+formed.
+
+=prototype.= The primitive form.
+
+=proud flesh.= Exuberant granulations; a fungus growth from a
+granulating surface which shows no tendency toward cicatrization.
+
+=proximal.= Nearest the trunk or point of origin; opposed to distal.
+
+=pruritus.= Itching.
+
+=pseudo.= A prefix denoting a resemblance, like. (Exam.:
+pseudomania--pretended insanity).
+
+=pseudoarthritis.= Hysteric joint inflammation.
+
+=pseudoankylosis.= False ankylosis, fibrous ankylosis.
+
+=pseudo-hypertrophic paralysis.= Progressive muscular atrophy, a
+disease of childhood in which fat takes the place of wasted muscle.
+
+=pseudo-tabetic (pseudataxic).= False wasting; false locomotor ataxia.
+
+=psoriasis.= A skin disease characterized by the formation of white
+scales over rounded, red patches. It appears mostly on the extensor
+surfaces of the elbows and knees.
+
+=psychosis.= A disorder of the mind; =p. polyneuritica=, psychosis
+associated with polyneuritis characterized by failure of memory,
+hallucinations, and imaginary reminiscences.
+
+=pterygium.= A forward growth of the eponychium with adherence to the
+surface of the nail.
+
+=puncture.= To make a hole with a small pointed object, such as a
+needle.
+
+=purpura.= An affection characterized by hemorrhage into the skin.
+
+=purulent.= Suppurating, containing or forming pus.
+
+=pus.= A fluid product of inflammation, consisting of exuded serum,
+leucocytes and the débris of dead cells.
+
+=pustule.= A small circumscribed elevation on the skin, containing pus.
+
+=puttees.= Leather leggings worn by soldiers and others who ride horses.
+
+=putrefaction.= Decomposition; the cleavage or splitting up of the
+molecules of a protein, resulting in the formation of other substances
+of less complex constitution, accompanied by the formation of ammoniac
+and sulphur gases.
+
+=pyemia.= The presence of pus in the blood.
+
+=pyogenic.= Pus-forming; relating to pus formation.
+
+=pyrogallic acid.= A substance obtained from gallic acid; used in
+podiatry in the treatment of verruca.
+
+=pyrogallol.= Pyrogallic acid.
+
+=pyroxylin.= Gun cotton, an ethereal solution of which makes collodion.
+
+
+Q
+
+=quinine and urea hydrochloride.= A mixture of quinine, as its name
+indicates, used as a local anesthetic.
+
+
+R
+
+=radical.= As a radical operation, one which removes every trace of
+possibly diseased tissue, or makes recurrence impossible.
+
+=radiograph.= An X-ray machine.
+
+=radiogram.= An X-ray picture.
+
+=radiography.= The science of obtaining X-ray pictures.
+
+=radioscopy.= Fluoroscopy.
+
+=radix.= The hard, usually central portion of a corn, root. =r.
+unguis.= The root of the nail.
+
+=rancid.= Characterizing an oil or other fat which is decomposing.
+
+=rational.= Reasonable; not delirious or comatose.
+
+=rays.= Lines of light, heat or other forms of radioactivity. =alpha
+rays.= Rays charged with positive electricity. =beta rays.= Rays
+charged with negative electricity. =gamma rays.= Waves of motion not
+charged with electricity.
+
+=Raynaud’s disease.= Symmetrical gangrene of the extremities.
+
+=receptacle.= A storage place.
+
+=R.= The abbreviation of the latin word recipe--take, used as the
+superscription of a prescription.
+
+=recumbent.= Lying down.
+
+=recurrent.= Returning; applied to symptoms.
+
+=redintol.= A paraffin preparation used for burns.
+
+=reduce.= To replace, as a fracture or a dislocation.
+
+=redundant.= Exuberant, more than normal.
+
+=reenforcement.= Augmented enforcement, as of a bandage or a dressing.
+
+=reflex.= A reaction; an involuntary movement or exercise of function
+in a part.
+
+    =ankle r.=, ankle-jerk; a sudden contraction of the calf
+    muscles, extending the foot when the tendo Achillis is tapped,
+    the subject kneeling on a chair with the foot hanging loosely.
+
+    =Babinski’s r.=; extension of the toes follows tickling of the
+    sole; usually a sign of organic disease of the pyramidal tracts.
+
+    =patellar r.=, a sudden contraction of the anterior muscles of
+    the thigh from a tap on the patellar tendon, which brings up
+    the foot, the subject being seated on the edge of a chair with
+    legs loosely crossed; knee-jerk.
+
+    =plantar r.=; a flexion of the toes following scratching or
+    tickling the sole of the foot.
+
+    =tarsophalangeal, r.=; flexion of the 2nd and 3rd (sometimes
+    2nd to 5th) toes when the dorsum of the foot is lightly tapped,
+    indicating an organic lesion of the motor nerve-centres.
+
+    =tendo Achillis r.=; a contraction of the calf muscles when the
+    tendo calcaneus is sharply struck.
+
+    =toe r.=; strong passive flexion of the great toe excites
+    contraction of the flexor muscles in the leg; sudden passive
+    extension causes rhythmical contraction of the great
+    toe--toe-clonus.
+
+=regeneration.= Reproduction or repair of lost or injured parts.
+
+=relapse.= Return of a disease after it has once spent its force.
+
+=relax.= To loosen; to slacken.
+
+=remedy.= An agent applied to cure a disease or to alleviate its
+symptoms.
+
+=renal.= Relating to the kidneys.
+
+=repair.= Restoration after injury.
+
+=resect.= To cut off, especially to cut off the articular ends of a
+bone or bones forming a joint.
+
+=resin.= The residue after the distillation of turpentine.
+
+=resolution.= The arrest of an inflammatory process without
+suppuration; the absorption or breaking down and removal of the
+products of inflammation.
+
+=resonator.= An apparatus for producing sounds.
+
+=resorcin.= A phenol derivative used for ulcers.
+
+=respiration.= A function common to all living plants or animals,
+consisting in man in the taking in of oxygen and the throwing off of
+the products of oxidation.
+
+=resorption.= Removal of an exudate, a blood clot, pus, etc., by
+absorption.
+
+=rete Malpighii.= Stratum germinativum, the lowest layers of cells of
+the epidermis; the reproducing cells of the epidermis.
+
+=reticular layer.= The inner layer of the corium, composed of
+connective tissue bundles.
+
+=retrogressive.= Degenerative; a reversal of metabolic changes.
+
+=retropulsion.= An involuntary backward running or walking occurring in
+certain nervous affections; a pushing back of any part.
+
+=reversed.= Turned backward or in an opposite direction.
+
+=rheostat.= A resistance coil; an instrument used to regulate the
+degree of resistance in an electric current.
+
+=rickets.= Rachitis, a disease occurring in infants and young children;
+it is characterized by softening of the bones, etc.
+
+=ridge.= A linear bone elevation.
+
+=rigid.= Stiff; inflexible.
+
+=rigor.= Rigidity.
+
+    =rigor mortis.=; stiffening of the body from one to seven hours
+    after death.
+
+=Roentgen rays.= X-rays.
+
+=roentgenography.= Radiography.
+
+=roentgenoscopy.= Fluoroscopy.
+
+=roentgenotherapy.= The treatment of disease by the X-rays.
+
+=root.= In anatomy, the base, foundation or beginning of any part;
+radix.
+
+    =radix unguis=; the root of the nail.
+
+=rotary file.= An instrument used for grinding nails.
+
+=rubefacient.= A mild counter-irritant which reddens the skin.
+
+=rubor.= Redness; one of the classical symptoms of inflammation.
+
+=ruby lamp.= A lamp colored red, and used in the dark room for
+developing purposes. It does not affect the sensitized plates.
+
+=runaround.= A superficial paronychia.
+
+=rupture.= A tear or solution of continuity.
+
+
+S
+
+=S.= Abbreviation of Latin, signa, remark, the usual introduction to
+the directions in a prescription.
+
+=sac.= A pouch, a bursa; the capsule of a tumor, the envelop of a cyst.
+
+=sacro-iliac disease.= A disease occurring in the region of the sacrum
+and ilium.
+
+=salicylic acid.= An acid derived from the oil of wintergreen. Largely
+used in podiatry to remove helomata and verrucæ.
+
+=saline solution.= A solution of sodium chloride and water in the
+proportion in which it exists in the blood.
+
+=salol.= Phenyl salicylate.
+
+=saltatory.= Relating to or marked by dancing or leaping.
+
+=salvarsan.= Trade name of Ehrlich’s 606, employed in the treatment of
+syphilis.
+
+=salve.= An ointment, ceratum, unguentum.
+
+=sandal.= An old form of footgear.
+
+=sanguineous.= Relating to the blood.
+
+=sapo.= Soap.
+
+=saponaceous.= Soapy; resembling soap.
+
+=sapremia.= Septicemia.
+
+=sarcoma.= A malignant connective tissue neoplasm.
+
+=saturated.= Impregnated to the greatest possible extent; said of a
+solution; a liquid holding all of a given solute that it can dissolve.
+
+=saturnism.= Lead poisoning.
+
+=scab.= A crust formed by the drying of the pus on the surface of an
+ulcer or excoriation.
+
+=scalloped.= Cut in curves.
+
+=scalpel.= A pointed knife with a convex edge.
+
+=scarfskin.= Epidermis.
+
+=scar tissue.= White fibrous tissue formed in the healing of wounds;
+cicatrix.
+
+=scarify.= To make a number of superficial incisions in the skin.
+
+=scarlet red.= An organic dye-stuff used in ointment form as an
+antiseptic and as a stimulant in the treatment of ulcers.
+
+=sciatic.= Relating to sciatica.
+
+=sciatica.= Sciatic neuritis. Neuralgia of the sciatic nerve.
+
+=sclerodactylia.= Scleroderma affecting the digits of the hands or feet.
+
+=scleroderma.= A hardening and thickening of the skin with loss of
+elasticity.
+
+=scleronychia.= Induration and thickening of the nails.
+
+=sclerosis.= Induration or hardening, of chronic inflammatory origin.
+
+=scoliosis.= Lateral curvature of the spine.
+
+=scorbutus.= Scurvy.
+
+=scrofula.= A constitutional state, occurring in the young and marked
+by a lack of tissue resisting power.
+
+=scurvy.= A disease marked by inanition, debility, anemia, edema of the
+dependent parts; a spongy condition, sometimes with ulceration of the
+gums and hemorrhages into the skin and from the mucous membranes.
+
+=sebaceous.= Carrying or producing sebum.
+
+=sebum.= The fluid excreted by the sebaceous glands of the skin.
+
+=seborrhea.= Overaction of the sebaceous glands.
+
+=secondary.= One of the symptoms of syphilis, following the development
+of the chancre.
+
+=secretion.= The product (solid, liquid or gaseous) of cellular or
+glandular activity. A secretion is stored up in or utilized by the
+animal or plant in which it is produced, thereby differing from an
+excretion which is intended to be expelled from the body.
+
+=secretory.= Relating to secretion or to the secretions.
+
+=sedative.= An agent which quiets nervous excitement.
+
+=semi.= A prefix denoting one-half or partly. (Exam.
+semi-flexion--midway between flexion and extension).
+
+=semis.= One-half; noted in prescription writing as ss.
+
+=senility.= Old age.
+
+=sensitized.= Rendered sensitive.
+
+=sensory.= Relating to sensation.
+
+=septic.= Unclean, contaminated with bacteria.
+
+=septicemia.= A systemic disease caused by the presence of
+microorganisms or their toxins in the blood; sepsis.
+
+=septum.= A thin wall dividing two cavities or masses of softer tissue.
+
+=sequestrum.= A piece of necrosed bone which has become separated from
+the surrounding healthy osseous tissue.
+
+=serofibrinous.= Noting an exudate composed of serum and fibrin.
+
+=sero-purulent.= Containing both serum and pus.
+
+=serous.= Relating to, containing or producing serum.
+
+=serpiginous.= Noting an ulcer or other cutaneous lesion which extends
+gradually over the surface on one side while usually healing on the
+other.
+
+=serrated.= Notched, toothed.
+
+=serum.= A clear, watery fluid that moistens the surface of serous
+membranes. The fluid portion of the blood obtained after coagulation.
+
+=sesamoid.= Resembling in size or shape a grain of sesame; an oval
+nodule of bone or fibro-cartilage in a tendon playing over a joint
+surface; most common in the metacarpo and metatarsophalangeal
+articulations and other joints of the fingers and toes.
+
+=sessile.= Having a broad base of attachment, not pedunculated.
+
+=sheath.= Any enveloping structure, such as the membranous covering of
+a muscle, nerve or blood vessel.
+
+=sheepskin.= Prepared skin of the sheep, used for shields.
+
+=shield.= An agent used in podiatry to protect a part from friction or
+pressure.
+
+=shock.= A sudden physical or mental disturbance.
+
+=silver.= Argentum; a metal of lustrous white color.
+
+    =s. nitrate=; largely used in podiatry as a caustic, escharotic
+    and stimulant.
+
+    =s. stick=; fused silver nitrate in stick form.
+
+=sinew.= Tendon.
+
+=sinister.= Of evil import, of bad prognosis; Latin for left, in
+contradistinction to dexter, meaning right.
+
+=sinistrapodeal.= Left footed.
+
+=sinuous.= Tortuous, bending in several directions.
+
+=sinus.= A tortuous tract opening on a free surface and leading down to
+an abscess cavity.
+
+=sirenomelia.= A monstrosity having two lower limbs fused in one.
+
+=skiagram.= A print made from a photographic plate exposed to the
+action of the X-rays.
+
+=skiagraphy.= Radiography.
+
+=skiascopy.= Fluoroscopy.
+
+=skin.= The membranous covering of the body, cutis, integumentum.
+
+=skin grafting.= The placing of bits of epidermis or larger strips of
+the entire skin on a denuded surface in order to supply defects or to
+stimulate a new skin growth.
+
+=skiving.= The process of thinning shields at their borders.
+
+=skiving knife.= An instrument used for skiving.
+
+=slough.= Necrosed tissue separated from the living structure.
+
+=sodium.= A metallic element. The following salts of sodium are used in
+podiatry.
+
+    =s. bicarbonate=; used as a dusting powder in acidity of the
+    skin.
+
+    =s. borate=; (borax) used as an antiseptic.
+
+    =s. chloride=; (common salt) used as an antiseptic.
+
+    =s. ethylate=; used as a caustic in verruca.
+
+    =s. hydroxide=; (caustic soda) used as a caustic.
+
+    =s. sulphide=; used to remove superfluous hair.
+
+=soggy.= Soaked; wet.
+
+=sole.= The under part of the foot, the plantar surface.
+
+=solution.= The incorporation of a solid or gas in a fluid.
+
+=spasm.= An involuntary convulsive muscular contraction; cramp.
+
+=spastic.= Spasmodic, convulsive.
+
+=spatula.= A flat blade used for spreading plasters and ointments.
+
+=spatulate.= Shaped like a spatula.
+
+=specific.= Relating to an individual infectious disease, one caused by
+a special microorganism; in a special restricted sense, syphilis.
+
+=sphacelous.= Necrotic, gangrenous, sloughing.
+
+=spheroidal.= Resembling a sphere.
+
+=spica.= A form of bandage with overlapping turns.
+
+=spinal.= Relating to the vertebral column.
+
+=spiral.= Coiled; winding around a center.
+
+=spiritus (spirit).= An alcoholic solution of a gaseous or volatile
+substance.
+
+=Spirochaeta pallida.= The protozoan which when present in the blood
+indicates syphilis.
+
+=splay-foot.= Flat foot, talipes valgus.
+
+=splint.= An apparatus for rendering a part immobile, as in fractures.
+
+=spontaneous.= Occurring without external stimulation.
+
+=sporadic.= Occurring singly; neither endemic nor epidemic.
+
+=spur.= A dull spine or projection from a bone.
+
+=staphylococcus.= A group of cocci in which the individuals are
+arranged in irregular masses somewhat resembling a bunch of grapes.
+
+=stasis.= Stagnation of the blood or other fluids.
+
+=static.= In a state of equilibrium or rest; not in action.
+
+=static ataxia.= Inability to preserve equilibrium in standing through
+loss of the deep sensibility.
+
+=station.= Power of standing more or less firmly on one’s feet.
+
+=stereognosis.= Ascertaining the form of an object by means of touch.
+
+=sterile.= Surgically clean; free from bacteria.
+
+=sterilization.= The act of making a person or thing sterile.
+
+=sterilizer.= An apparatus for making anything aseptic or germ free.
+
+=stimulant.= An agent that arouses organic activity.
+
+=stimulation.= The arousing of the body or any of its parts or organs
+to increased functional activity.
+
+=stovaine.= A local anesthetic, used especially to induce spinal
+anesthesia.
+
+=stratum.= Layer.
+
+=streptococcus.= A group of cocci in which the arrangement resembles
+chains.
+
+=streptococcus viridans.= A form of streptococcus which grows in green
+colonies and is not hemolytic; the bacterium responsible for most focal
+infections in the teeth.
+
+=striated.= Striped.
+
+=stroma.= The framework made of connective tissue.
+
+=strychnine.= An alkaloid of nux vomica.
+
+=stump-foot.= Club-foot.
+
+=styptic.= Astringent, hemostatic.
+
+=sub.= A prefix denoting beneath, less than normal or typical;
+inferior; corresponds to hypo. (Exam. subastragular--under the
+astragalus).
+
+=subacute.= Not frankly acute, yet not chronic, noting the course of a
+disease.
+
+=subcutaneous.= Beneath the skin.
+
+=subluxation.= An incomplete luxation or dislocation.
+
+=sudamina.= Minute vesicles due to retention of fluid at the mouth of a
+sweat follicle.
+
+=sudoriferous.= Carrying or producing sweat.
+
+=sulphur.= Brimstone; a chemical element; used in ointment form as a
+stimulant.
+
+=super.= A prefix signifying in excess, above, superior, same as supra
+and hyper. (Exam. supertension--extreme tension).
+
+=superficial.= Near the surface; cursory, not thorough.
+
+=superfluous.= More than sufficient.
+
+=supernumerary.= More than normal in number.
+
+=supersaturated.= Said of a solution which holds more than a normal
+quantity of a solute, and caused by heating the liquid.
+
+=suppurate.= To form pus.
+
+=supra.= A prefix denoting a position above. (Exam. supracostal--above
+the ribs).
+
+=surgery.= The branch of medicine which has to do with the treatment of
+disease by means of operative procedures.
+
+=suture.= The surgical uniting of two surfaces by means of stitches,
+with silk thread, catgut, wire, etc., the material by which the two
+surfaces are held in apposition.
+
+=swab.= A tuft of cotton or other like material attached to the end of
+a stick or wire; used for cleansing cavities or applying remedies.
+
+=sweat gland.= One of the tubular coil-glands in the corium and
+subcutaneous connective tissue, secreting sweat.
+
+=swell-foot.= Swelling and redness of the metatarsus, with pain and
+disability, due to sprain of the ligaments which are frequently
+detached from the bones.
+
+=symptomatology.= The science of the symptoms of disease.
+
+=symptoms.= Any morbid phenomenon or departure from the normal in
+function, appearance or sensation experienced by the patient and
+indicative of disease. =Objective s.=, one which is evident to the
+observer. =Subjective s.=, one apparent only to the patient.
+
+=synarthrosis.= A fixed articulation.
+
+=syndactylous.= Having webbed fingers or toes.
+
+=synonyms.= Words having the same meaning as others.
+
+=synovia.= A clear fluid secreted by a synovial membrane and used to
+lubricate the joints.
+
+=synovial membrane.= The lining membrane of a joint, secreting the
+synovia.
+
+=synthetic.= Relating to the formation of chemical compounds by the
+union of simpler compounds.
+
+=syphilide.= Any skin lesion of syphilitic origin.
+
+=syphilis.= An infectious disease spread by inoculation, usually by
+sexual intercourse, and due to the spirochaeta pallida.
+
+=syphiloderma.= Syphilis of the skin.
+
+=syringe.= An instrument for injecting fluids.
+
+=syringomyelia.= The presence of cavities in the spinal cord due to the
+breaking down of gliomatous new formations.
+
+=systemic.= Relating to the entire organism as distinguished from any
+of its individual parts.
+
+=systremma.= A muscular cramp in the calf of the leg.
+
+
+T
+
+=tabes dorsalis.= Locomotor ataxia, a disease of the spinal ganglia and
+roots usually found in middle age and often the sequel of syphilis.
+
+=tactile.= Relating to touch or to the sense of touch.
+
+=talipes.= Kyllosis; club-foot in general.
+
+    =t. calcaneovalgus=; t. calcaneus and t. valgus, combined;
+
+    =t. calcaneovarus=; t. calcaneus and t. varus, combined;
+
+    =t. calcaneus=; permanent dorsal flexion of the foot, so that
+    the weight of the body rests on the heel, only;
+
+    =t. cavus=; hollow-foot, an exaggeration of the normal arch of
+    the foot.
+
+    =t. equinovalgus=; t. equinus and t. valgus, combined;
+
+    =t. equinovarus=; t. equinus and t. varus, combined;
+
+    =t. equinus=; permanent extension of the foot so that only the
+    ball rests on the ground;
+
+    =t. percavus=; an extreme degree of t. vagus;
+
+    =t. planovalgus=; t. valgus;
+
+    =t. planus=; flat foot, splay-foot--a condition in which the
+    arch of the foot is broken down, the entire sole touching the
+    ground;
+
+    =t. spasmodicus=; a temporary distortion of the foot, usually
+    t. equinus, due to muscular spasm;
+
+    =t. vagus=; permanent eversion of the foot, the inner side
+    alone of the sole resting on the ground;
+
+    =t. varus=; inversion of the foot, the outer side of the foot
+    only touching the ground.
+
+=talus.= Ankle bone, astragalus.
+
+=tampon.= To plug a canal with gauze, cotton wool or other substance;
+the substance used for the above purpose is also known by the same name.
+
+=tangent.= A straight line that touches or meets a circle or curve, but
+does not cut it.
+
+=tannoform.= Trade name of a compound of tannin with ferric aldehyde.
+
+=tarsal.= Relating to a tarsus in any sense.
+
+=tarsalgia.= Podalgia; policeman’s disease; pain in the tarsus usually
+due to incipient flat foot or to a shortening of the tendo Achillis.
+
+=tarsometatarsal.= Relating to the tarsal and metatarsal bones of the
+foot or region.
+
+=tarsophalangeal.= Relating to the tarsus and the phalanges.
+
+=tarsus.= The root of the foot, or instep.
+
+=T. B. C. (tuberculosis).= A specific disease caused by the presence of
+bacillus tuberculosis; it may affect almost any tissue or organ of the
+body, the most common seats of the disease being the lungs and joints.
+
+=teat.= Any nipple-like protuberance.
+
+=technic.= The manner of performance of any surgical operation.
+
+=temper.= Elasticity or hardness in steel.
+
+=tenalgia.= Pain referred to a tendon.
+
+=tendo Achillis.= The tendon of insertion of the gastrocnemius and the
+soleus muscles into the tuberosity of the os calcis.
+
+=tendon.= A fibrous cord or band which connects the muscle to its bony
+attachment.
+
+=tenotomy.= The surgical division of a tendon.
+
+=tension.= The act of stretching.
+
+=tepid.= Lukewarm, for a bath, 86°F.
+
+=tertiary.= The final stages of syphilis.
+
+=tetanus.= An infectious disease marked by painful tonic muscular
+contractions; caused by the toxin of bacillus tetani acting upon the
+central nervous system.
+
+=tetany.= A disorder marked by intermittent tonic muscular contractions.
+
+=tetradactyl.= Having only four fingers or toes on a hand or foot.
+
+=therapeutic.= Relating to the treatment of disease; curative.
+
+=thermal.= Relating to warmth or heat.
+
+=thermocautery.= The actual cautery; destruction of tissue by heat.
+
+=Thiersch’s solution.= An antiseptic solution containing boric acid and
+salicylic acid.
+
+=Thomsen’s disease.= Myotonia congenita. An hereditary disease marked
+by momentary tonic spasms which occur when a voluntary movement is
+attempted.
+
+=thrombosis.= Formation or presence of a thrombus.
+
+=thrombus.= A plug more or less completely occluding a blood vessel or
+one of the cavities of the heart.
+
+=tibia.= Shin-bone; the inner and larger of the two bones of the leg.
+
+=tinctura.= An alcoholic solution or extract of a non-volatile
+vegetable substance; a tincture.
+
+    =t. arnicae=; used for sprains and bruises;
+
+    =t. benzoini comp.=; used for sunburn, chimatlon, etc.;
+
+    =t. calendulae=; used for sprains and bruises;
+
+    =t. cresolis saponata=; used as an antiseptic;
+
+    =t. ferri chloridi=;
+
+    =t. iodi=;
+
+    =t. iodi (Churchill)=;
+
+    =t. iodi decolorata=;
+
+    =t. saponis viridis=.
+
+=tinea unguium.= Ringworm of the nail.
+
+=tip-foot.= Talipes equinus.
+
+=tissue.= A collection of cells or of cell derivatives forming a
+definite structure.
+
+=titubation.= A staggering or stumbling in trying to walk, due to
+spinal lesion; restlessness.
+
+=toe.= Digitus pedis, one of the digits of the feet.
+
+    =great t.=, the toe on the inner, tibial side of the foot
+    corresponding to the thumb.
+
+    =hammer t.=, permanent flexion at the mid-phalangeal joint.
+
+=toe drop.= A drooping of the anterior portion of the foot, due to
+paralysis.
+
+=toe separator.= An instrument used for separating the toes.
+
+=toe webs.= The skin at the base of the toes.
+
+=tonic.= In a state of continuous, unremitting action, noting
+especially a muscular contraction. Increasing physical or mental tone
+or strength, invigorating. A remedy given or applied to tone up the
+system.
+
+=touch corpuscles.= Special bodies found in the true skin, especially
+at the ends of the fingers, and used for the sense of touch.
+
+=tourniquet.= An instrument for arresting the flow of blood through a
+part.
+
+=toxemia.= Blood-poisoning; the presence of toxins in the blood.
+
+=toxic.= Poisonous. Relating to a toxin.
+
+=toxin.= A poisonous substance of undetermined chemical nature,
+developed during the growth of pathogenic bacteria.
+
+=transient.= Not permanent; coming and going.
+
+=transition.= Passage from one condition or one part to another.
+
+=trauma.= A wound or injury.
+
+=traumatic.= Relating to or caused by a wound or injury.
+
+=tremor.= Trembling, shaking; a disorder of the muscular tonus or loss
+of equilibrium, the normal inappreciable tonic contractions being
+exaggerated.
+
+=trench foot.= A disease of the present war. See full description in
+the body of the book as per index.
+
+=tropacocaine.= An alkaloid obtained from Java coca leaves; a local
+anesthetic.
+
+=trophic.= Relating to or dependent upon nutrition.
+
+=tuberculosis.= A specific disease caused by the bacillus tuberculosis;
+it may affect any tissue of the body.
+
+=tumor.= Neoplasm; a circumscribed growth, not inflammatory in
+character.
+
+=tungsten.= A metallic element, symbol W, atomic weight 184, occurring
+as a gray powder of metallic lustre. A form of incandescent electric
+lamp is made of a tungsten filament.
+
+=turpentine.= Terebinthina. Prepared in the form of oil and of spirit
+for external applications.
+
+=tyloma.= Callosity, tylosis.
+
+=tyroma.= A caseous (cheese-like) tumor.
+
+=typhoid.= Typhus-like; stuporous from fever; same as typhoid fever.
+
+
+U
+
+=ulcer.= A circumscribed open sore which shown no tendency to heal;
+ulcus.
+
+=uncinariasis.= Hookworm disease.
+
+=undertoe.= Displacement of the great toe beneath the second toe.
+
+=ungual.= Relating to the nail.
+
+=unguentum.= Ointment, salve.
+
+    =u.= acidi borici, boric acid ointment; used in burns and
+    abrasions.
+
+    =u.= acidi salicylici, salicylic acid ointment; used as a
+    disintegrant.
+
+    =u.= acidi carbolici, carbolic acid or phenol ointment; used in
+    burns and in superficial wounds.
+
+    =u.= balsam Peruvianum, balsam of Peru ointment; stimulating.
+
+    =u.= camphorae, camphor ointment; stimulating.
+
+    =u.= cantharidis, cantharidal ointment; rubefacient.
+
+    =u.= capsici, capsicum ointment; rubefacient.
+
+    =u.= creosoti, creosote ointment; applied to chilblains,
+    indolent ulcers and various skin affections.
+
+    =u.= diachylon, Hebra’s lead ointment; employed in hyperidrosis.
+
+    =u.= hamamelidis, witch hazel ointment; a soothing application.
+
+    =u.= hydrargyri ammoniati, white precipitate ointment; applied
+    in chronic skin conditions and in tubercular syphilides.
+
+    =u.= hydrargyri oxide rubri, red precipitate ointment; used in
+    the treatment of indolent ulcers.
+
+    =u.= ichthyoli, ichthyol ointment; emollient.
+
+    =u.= iodi, iodine ointment; used in chilblains and in glandular
+    enlargements.
+
+    =u.= picus compositum, compound tar ointment; employed in
+    wounds and in burns.
+
+    =u.= plumbi acetatis, lead acetate ointment; astringent
+    application to burns and superficial inflammations.
+
+    =u.= resorcini compositum, “soothing ointment”; astringent and
+    antiseptic.
+
+    =u.= scarlet red, scarlet red ointment; stimulating.
+
+    =u.= sulphuris, sulphur ointment; used in scabies.
+
+    =u.= zinci oxidi, ointment of zinc oxide; a soothing mild
+    astringent application in skin diseases, burns and abrasions.
+
+=unguis.= Nail; a thin, horny, transparent plate covering the dorsal
+surface of the distal end of each terminal phalanx of fingers and toes.
+
+=Unverricht’s progressive myoclonus.= See Thomsen’s disease.
+
+=uric acidemia.= See lithemia.
+
+=uridrosis.= The excretion of urea or uric acid in the sweat.
+
+=union.= The joining together of the opposing parts of a wound.
+
+=unofficial.= Not official; said of a remedial agent not described in
+the pharmacopeia.
+
+=uremia.= An auto-intoxication occurring in certain cases of nephritis
+or in anuria from any cause.
+
+=U. S. P.= Abbreviation for the United States Pharmacopeia.
+
+
+V
+
+=vacuum.= A space from which the air has been practically extracted.
+
+=valgus.= Bending outward; noting a condition of the great toe, in
+which it is bent outward; knock-knees; see talipes valgus.
+
+=vanadium chloride.= A yellowish substance used in bromidrosis.
+
+=varicose.= Relating to or affected with large and tortuous veins.
+
+=variola.= Smallpox.
+
+=varix.= An enlarged and tortuous vein, artery or lymphatic vessel.
+
+=vascular.= Relating to or containing blood vessels.
+
+=vasoconstrictors.= Agents which cause narrowing of the blood vessels;
+nerves, stimulation of which cause vascular constriction.
+
+=vasodilators.= Agents which cause dilatation of the blood vessels; a
+nerve, stimulation of which results in dilatation of the blood vessels.
+
+=vasomotor.= The nerves which have the power of dilating or
+constricting the blood vessels.
+
+=vein.= A blood vessel conveying blood towards the heart. Lat. vena.
+
+=veins of the foot=:
+
+    =v.= plantaris interna; internal plantar vein (plantar surface,
+    deep).
+
+    =v.= plantaris externa; external plantar vein (plantar surface,
+    deep).
+
+    =v.= saphena brevis; external or short saphenous vein (dorsal
+    surface, superficial).
+
+    =v.= saphena longa; internal or long saphenous vein (dorsal
+    surface, superficial).
+
+    =v.= tibialis anticus; anterior tibial vein (dorsal surface,
+    deep).
+
+        No veins on the superficial plantar surface.
+
+=verbatim.= Word for word.
+
+=vermiform appendix.= A blind sac of the intestine, extending from the
+head of the cecum.
+
+=verruca.= A circumscribed overgrowth of the layers of the skin,
+including those of the derma (plural, verrucæ).
+
+=vertebral caries.= Molecular death of the bones of the spinal column.
+
+=vertigo.= Dizziness, giddiness.
+
+=vesicant.= An agent which when applied to the skin produces a blister.
+
+=vesicle.= A small circumscribed elevation on the skin, containing
+non-purulent fluid; a blister.
+
+=vesicular.= Relating to a vesicle; containing vesicles.
+
+=vibration.= A shaking, oscillation.
+
+=vice versa.= The terms in the case being reversed.
+
+=virulent.= Extremely poisonous.
+
+=vocational.= Referring to occupation.
+
+=volatile.= Not permanent; evaporating spontaneously.
+
+=voltage.= The electromotive force of a current expressed in volts.
+
+=vulcanizing.= Adhering rubber by means of heat.
+
+
+W
+
+=wart.= A circumscribed hypertrophy of the papillæ of the corium. (See
+verruca).
+
+=Wassermann test.= A diagnostic test for syphilis, based upon the
+theory of complement fixation.
+
+=web.= The skin found at the base of the fingers or toes.
+
+=wheal.= An acute, circumscribed elevation of the skin due to edema in
+the derma.
+
+=whitlow.= Felon, paronychia, inflammation of the tissues around the
+nail.
+
+=whorl.= A set of organs arranged in a circle around an axis.
+
+=wick.= A piece of gauze or other material used for draining cavities.
+
+=wipe.= A piece of gauze or cotton used in wiping instruments.
+
+=wool fat.= Adeps lanae. Used as an embrocation in podiatry. Lanolin.
+
+=Woulfe’s bottle.= A bottle with two or three necks, for working with
+gases (washing, drying, etc.).
+
+=wound.= Loss in continuity upon the surfaces of the body.
+
+=wrist drop.= Paralysis of the extensors of the wrist and fingers.
+
+
+X
+
+=X-rays.= Roentgen rays.
+
+=xystus.= Scraped lint; lint made by scraping linen with a sharp
+instrument.
+
+
+Z
+
+=Zander’s system.= Treatment by means of mechanical apparatus giving
+passive movements.
+
+=zinc oxide.= A white powder used as an astringent.
+
+=zinc stearate.= A white powder used as an antiseptic dusting powder.
+
+=zymotic.= Relating to fermentation; noting an infectious disease.
+
+       *       *       *       *       *
+
+(We are obligated to Stedman’s Practical Medical Dictionary for many of
+the definitions of medical terms above noted--Editor).
+
+
+
+
+CROSS REFERENCE INDEX
+
+
+  A
+
+  Acetanilid, 296
+
+  Acetic acid, 191
+
+  Acriflavin, 34
+
+  Actinotherapy, 385
+
+  Adenoids, 379
+
+  Adipose tissue, 14
+
+  Advent of foot clothing, 47
+
+  Alcohol, 27, 131, 198, 215, 218, 225, 228, 250, 253, 273, 275, 301,
+        331, 334
+
+  Aluminum acetate, 219, 224, 225, 289, 295
+
+  Aluminum chloride, 301
+
+  Alternate foot bath, 53, 299
+
+  Alternating current, 386
+
+  Alypin, 144
+
+  Ambrene, 70
+
+  Ammoniated mercury, 29, 221, 254
+
+  Anidrosis, 303
+    definition of, 303
+    derivation of, 303
+    etiology of, 303
+    symptoms of, 303
+    synonyms of, 303
+    treatment of, 303
+
+  Anterior arch, 184
+
+  Antisepsis, 19, 20, 21, 24, 33
+
+  Antiseptics, general, 24
+    chlorinated lime, 26
+    formaldehyde, 25
+    heat, 25
+    lime, 25
+    sublimed sulphur, 26
+    sunlight, 24
+
+  Antiseptics, local, 26
+    alcohol, 27
+    balsam of Peru, 27
+    borate of sodium, 27
+    borax, 27
+    boric acid, 27
+    boroglycerine, 27
+    bichloride of mercury, 29
+    calomel, 29
+    Dakin solution, 27
+    di-chloramin-T, 28
+    glycerinum, 28
+    hydrogen dioxide, 28
+      peroxide, 28
+    iodoform, 29
+    iodine, 28
+    liquor alumini acetatis, 27
+      cresolis compositas, 29
+    lysol, 30
+    mercuric chloride, 29
+    mercurous chloride, 29
+    peroxide of hydrogen, 28
+    potassium permanganate, 30
+    sulphur, 30
+    phenol, 29
+    thymol, 30
+    thymol iodide, 30
+    unguentum hydrargyri, 29
+      hydrargyri ammoniatum, 29
+    sulphuris, 30
+
+  Apothesine, 148
+
+  Applicators, 91
+
+  Areolar tissue, 14
+
+  Aristol, 30, 220, 249, 262, 320, 332, 334
+
+  Arsphenamine, 378
+
+  Arteriosclerosis, 404
+
+  Arthritis, 402
+
+  Asepsis, 19, 32
+
+  Aseptic gauze, 62
+
+  Atrophy of the nails, 244
+
+
+  B
+
+  Bacillus aërogenes capsulatus, 369
+
+  Baking, 273
+
+  Balsam of Peru, 27, 180, 193, 198, 199, 221, 247, 262, 277, 295, 320,
+        327, 332, 335
+
+  Bandage scissors, 89
+
+  Bandages, description of, 75, 76, 77
+
+  Bandaging, 73
+
+  Belgian hone, 92
+
+  Belladonna, 298, 299
+
+  Benzoated collodion, 69
+
+  Bichloride of Mercury, 29, 199, 218, 273, 274, 289, 318, 328, 334
+
+  Bismuth subgallate, 220, 249, 262, 313, 332
+
+  Bismuth subnitrate, 220, 249, 262, 313, 332
+
+  Blebs, 248, 251, 289, 333
+    treatment of, 334
+
+  Blisters, 248, 251
+    definition of, 251
+    etiology of, 251
+    pathology of, 252
+    prognosis of, 256
+    treatment of, 253
+      ordinary conditions, 252
+      broken conditions, 254
+    usual points of location of, 252
+
+  Bones of the foot, 50
+    borate of sodium, 27, 362
+
+  Borated gauze, 63
+
+  Borax, 27, 362
+
+  Boric acid, 27, 220, 225, 239, 273, 275, 302, 303, 318, 320, 334
+
+  Boroglycerine, 27, 312
+
+  Brilliant Green, 35
+
+  Bromidrosis, 302
+    definition of, 302
+    derivation of, 302
+    etiology of, 302
+    pathology of, 302
+    symptoms of, 302
+    synonyms of, 302
+    treatment of, 302
+
+  Buckskin, 97
+
+  Bullae, 248, 251, 289
+
+  Burns, 248, 256
+    definition of, 256
+    pathology of, 257
+    treatment of, 257
+
+  Burnt alum, 226
+
+  Burow’s solution, 318
+
+  Burs, 91
+
+  Bursitis, 263
+    definition of, 263
+    characteristics of, 265, 266
+    etiology of, 264
+    location of, 264
+    pathology of, 265
+    removal of pressure for, 268
+    rest for, 268
+    strapping of, 269
+    symptoms of, 265
+      objective, 265
+      subjective, 265
+    treatment of, 266
+      non-radical, 267
+      palliative, 267
+      radical, 267
+
+
+  C
+
+  California College of Chiropody, 5
+
+  Callositas, 182
+    definition of, 182
+    derivation of, 182
+    diagnosis of, 183
+    etiology of, 182
+    pathology of, 183
+    prognosis of, 183
+    symptoms of, 182
+    synonyms of, 182
+    treatment of, 184
+
+  Callosity, 182
+
+  Callous, 182
+
+  Callous ulcer, 306, 314
+    differential diagnosis, 316
+    etiology of, 315
+    general causes, 315
+    local causes, 315
+    symptoms of, 315
+    treatment of, 317
+      cleansing, 318
+      sterilization, 318
+
+  Calloused nail groove, 205, 237
+    definition of, 205
+    etiology of, 206
+    symptoms of, 206
+    treatment of, 206
+      surgical, 207
+      medical, 208
+
+  Callus, 182
+
+  Calomel, 29, 320
+
+  Calamine lotion, 302
+
+  Camphor, 361, 362, 363
+
+  Camphorated oil, 365
+
+  Camphorated soap liniment, 290
+
+  Cannabis indica, 277
+
+  Capsicum, 279
+
+  Carbon dioxide pencil, 179, 191, 203
+
+  Carbon dioxide snow, 145
+
+  Carrel method, 21
+
+  Catalepsy, 355
+
+  Chamois, 97
+
+  Chauffeur’s foot, 340
+    etiology of, 340
+    treatment of, 341
+
+  Chicago School of Chiropody, 5
+
+  Chilblains, 283
+
+  Chimatlon mild, 283
+    definition of, 283
+    derivation of, 283
+    diagnosis of, 286
+    differential diagnosis of, 288
+    etiology of, 283
+    pathology of, 285
+    predisposition to, 284
+    prognosis of, 288
+    symptoms of, 284
+    synonyms of, 283
+    treatment of, 288
+
+  Chimatlon severe, 291
+    definition of, 291
+    derivation of, 291
+    diagnosis of, 293
+    etiology of, 291
+    pathology of, 292
+    prognosis of, 294
+    recurrence of, 294
+    symptoms of, 292
+    synonyms of, 291
+    treatment of, 294
+
+  Chiropodists of America, 2
+
+  Chisel, 81
+
+  Chlorazene, 37, 168
+
+  Chlorinated lime, 26
+
+  Chromic acid, 301, 303
+
+  Chromidrosis, 304
+    definition of, 304
+
+  Clippers, 86
+
+  Cocaine, 143
+
+  Cocoon dressing, 65, 184, 335
+
+  Cold applications, 271
+
+  Collodial silver, 363
+    gold, 364
+
+  Collodion, 68
+    benzoated, 69
+    ichthyolated, 69
+    iodized, 69
+    medicated, 68
+    salicylated, 70
+
+  Colorado Pedic Society, 9
+
+  Connecticut Pedic Society, 9
+
+  Copper sulphate, 320
+
+  Corium, 13
+
+  Corns, 149
+
+  Corrosive sublimate gauze, 62
+
+  Cotton, 64
+
+  Counter-irritation, 270, 278
+
+  Creolin, 318
+
+  Cutaneous manifestations of super-acidity, 329
+    characteristics of, 329
+    definition of, 329
+    etiology of, 330
+
+  Cuticle scissors, 89
+
+
+  D
+
+  Dancer’s foot, 341
+    treatment of, 341
+
+  Dakin solution, 21, 27, 35, 168, 318
+
+  Deodorant, 26
+
+  Derma, 13
+    blood supply of, 14
+
+  Dermatitis calorica, 291
+
+  Dermatitis congelationes, 283
+
+  Dermatol, 220, 320, 334
+
+  Diachylon, 300
+
+  Diagnosis of radiographs, 397
+
+  Di-chloramin-T, 28, 37
+
+  Direct cautery, 191, 202, 222, 224
+
+  Direct current, 386
+
+  Disinfectant, 26
+
+  Dressings, 60, 218, 258
+    moist, 60
+    evaporating moist, 60
+    non-evaporating moist, 60
+    occlusive, 61
+    dry, 61
+    ointment, 61
+
+  Drill, 90
+
+  Dry dressings, 61, 220, 312
+
+  Duck shield, 173
+
+
+  E
+
+  Electric experiments, 385
+
+  Electricity, 270, 280, 296
+
+  Electrolysis, 178, 191, 200
+
+  Ephidrosis, 297
+
+  Epidermis, 12
+
+  Epithelioma, 189
+
+  Ergot, 298
+
+  Erythema pernio, 283
+
+  Ethyl bromide, 145
+
+  Ethyl chloride, 145
+
+  Ethylate of soda, 196
+
+  Evaporating moist dressings, 60
+
+  Excavator, 84
+
+  Excessive sweating, 297
+
+  Excision, 191, 198, 222
+
+  Exostosis, 399
+
+
+  F
+
+  Fabrics for dressings, 62
+
+  Faradic Current, 281, 290, 296, 304
+
+  Felon, 239
+
+  Felt, 98
+
+  Felt, adhesive, 99
+
+  Ferri subsulphate, 227, 232
+
+  Ferric chloride, 232
+
+  Fish skin, 73
+
+  Fissured toe webs, 171
+
+  Fissures, 248, 330
+    definition of, 248
+    etiology of, 248
+    treatment of, 248, 331
+    technic, 249
+
+  Flat foot, 340
+    symptoms of, 340
+    treatment of, 340
+
+  Flavin, 34
+
+  Fluoroscopy, 385
+
+  Focal infection, 379
+    modes of, 380
+    relationship between the foot and, 380
+    treatment of, 381
+
+  Foot care of adolescents, 55
+
+  Foot care of adults, 56
+
+  Foot care of infants, 53
+
+  Foot care of soldiers, 57
+
+  Footgear, modern, 47
+
+  Forceps, 85, 88
+
+  Formaldehyde, 25, 44, 299, 301
+
+  Formalin, 319
+
+  Fractures, 399
+    comminuted, 400
+    complete, 400
+    compound, 402
+    compression, 400
+    crushing, 400
+    impacted, 400
+    incomplete, 399
+    multiple, 400
+    simple, 400
+
+  Freezing method of anesthesia, 146
+
+  Frost bite, 291
+
+  Fulguration, 177, 191, 199
+
+
+  G
+
+  Gall bladder, 379
+
+  Gallic acid, 298, 332
+
+  Galvanic current, 304
+
+  Gangrene, 293, 294
+
+  Gas gangrene, 365, 368, 369
+
+  Gas infection, 369
+    antitoxin for, 372
+    bacteriologic diagnosis, 372
+    destruction of bacillus, 371
+    etiology of, 369
+    removal of necrotic tissue, 371
+    symptoms of, 370
+    treatment of, 370
+
+  Gauze, 62
+    borated, 63
+    corrosive sublimate, 62
+    iodoform, 62
+    plain aseptic, 62
+    squares, 63, 64, 219, 314
+    uses of, 63
+
+  Geissler air pump, 386
+
+  Glands, 14
+
+  Glossary, 411
+
+  Glycerinum, 28
+
+  Golfer’s foot, 341
+
+  Gonorrheal heel, 380
+
+  Ground itch, 368
+    treatment of, 369
+
+  Guaiacol, 290
+
+  Gutta percha tissue, 72
+
+
+  H
+
+  Hard corn, 150
+
+  Heat, 25
+
+  Heloma, 149
+    definition of, 150
+    derivation of, 149
+    synonyms of, 150
+
+  Heloma disseminatum, 179
+    definition of, 179
+    diagnosis of, 180
+    etiology of, 179
+    pathology of, 180
+    prognosis of, 180
+    symptoms of, 179
+    treatment of, 179
+
+  Heloma durum, 150
+    diagnosis of, 154
+    etiology of, 151
+    pathology of, 152, 153
+    prognosis of, 155
+    symptoms of, 150
+    treatment of, 156
+      dissection, 160
+      non-radical, 159
+      palliative, 157
+      preventive, 156
+      operative, 158
+      radical, 158
+      shaving, 159
+
+  Heloma miliare, 179
+
+  Heloma molle, 169
+    definition of, 169
+    diagnosis of, 170
+    etiology of, 170
+    pathology of, 170
+    prognosis of, 171
+    symptoms of, 169
+    treatment of, 172
+
+  Heloma vasculare, 174, 190
+    diagnosis of, 175
+    etiology of, 174
+    pathology of, 174
+    prognosis of, 175
+    symptoms of, 174
+    treatment of, 175
+
+  Helotomon, 81
+
+  Hematidrosis, 304
+    definition of, 304
+
+  Hemorrhage, 31
+
+  Hidrosis, 297
+
+  High frequency current, 177, 199, 281, 290, 296
+
+  High heels, 48
+
+  Honing, 92
+
+  Hookworm, 368
+
+  Hot applications, 270, 304
+
+  Hydradenitis, 305
+    definition of, 305
+
+  Hydrogen dioxide, 28
+
+  Hydrogen peroxide, 28, 218, 228, 289
+
+  Hydrocystoma, 304
+    definition of, 304
+
+  Hydrotherapy, 270
+
+  Hygiene of the foot, 51-59
+
+  Hyperidrosis, 297
+    definition of, 297
+    derivation of, 297
+    etiology of, 297
+    pathology of, 297
+    prognosis of, 298
+    symptoms of, 298
+    synonyms of, 297
+    treatment of, 298
+
+  Hypodermic method of anesthesia, 145
+
+  Hypodermic syringe, 90, 146
+    uses of, 147
+
+
+  I
+
+  Ichthyol, 180, 193, 198, 199, 251, 254, 262, 276, 290, 295, 296, 320,
+        332
+
+  Ichthyolated collodion, 69
+
+  Idrosis, 297
+
+  Illinois College of Chiropody, 5
+
+  Illinois Pedic Association, 8
+
+  Impervious coverings, 72
+
+  Incorporated Society of Chiropodists (England), 6
+
+  Indolent ulcer, 306, 314
+    etiology of, 315
+    symptoms of, 315
+
+  Infection, 213
+    treatment of, 227
+
+  Infected heloma, 167
+
+  Inflammation, symptoms of, 177
+
+  Ingrown nail clippers, 86
+
+  Ingrown nail forceps, 85
+
+  Ingrown toe nail, 205, 210, 237
+
+  Instruments, 78
+    applicators, 91
+    burs, 91
+    care of, 92
+    chisel, 81
+    excavator, 84
+    helotomon, 81
+    history of, 79
+    honing of, 92
+      Belgian hone, 92
+      oil stone, 93
+      Swatty hone, 93
+      technic, 93
+    hypodermic syringe, 90
+    ingrown nail clippers, 86
+      forceps, 85
+    iris tooth forceps, 88
+    nail chisel, 82
+      clippers, 86
+      file, 91
+      groove gouge, 83
+      scraper, 84
+    polishing, 94
+    rotary file, 90
+    scalpel, 80
+    scissors, 88
+      bandage, 89
+      cuticle, 89
+    selection and care of, 7
+    skiving knife, 92
+    soft corn spoon, 83
+    spatula, 84
+    special, for ingrown nail, 85
+    standardization of, 80
+    thumb forceps, 86
+    toe separators, 91
+    wiping of, 95
+
+  Iodoform, 29, 320
+
+  Iodoform gauze, 62
+
+  Iodine, 28, 215, 295
+
+  Iodized collodion, 69
+
+  Iris tooth forceps, 88
+
+
+  J
+
+  Jaborandi, 304
+
+
+  L
+
+  Lamb’s wool, 99
+
+  Lanolin, 276
+
+  Lassar’s paste, 320
+
+  Laws governing chiropody
+    New York, 3
+    California, 8
+
+  Lead and opium wash, 273, 275, 318
+
+  Lewi, Maurice J., 4
+
+  Lime, 25
+
+  Lint, 66
+    shielding, 67
+
+  Liquor alumini acetatis, 27, 273, 274
+
+  Liquor cresolis compositas, 29
+
+  Lister, Joseph, 22
+
+  Local anesthesia, 143, 158, 198
+    reaction of, 148
+    technic of, 145
+
+  Locomotion as an aid in diagnosis, 343
+    classification of gaits, 347
+      Ataxic gait, 352
+        static ataxic, 352
+          static spinal ataxic, 353
+        cerebellar, 353
+          titubating, 353
+          reeling or staggering, 354
+      Choreic, 354
+        festination, 354
+        hysteria, 355
+        myotonia, 355
+        saltatory, 355
+        stumbling, 354
+      Paretic gait, 347
+        mild, 347
+          Charlie Chaplin, 349
+          hobbling, 347
+          intermittent limping, 348
+          pompous, 347
+          shuffling, 348
+          tottering, 348
+          waddling, 348
+          wobbly, 348
+        moderate or flaccid, 349
+          prancing, 350
+          steppage, 349
+        spastic or severe, 350
+          cross-legged, 351
+          dragging, 352
+          dromedary, 352
+          ill-defined spastic, 352
+          mowing or hemiplegic, 351
+          small step, 351
+    elements of, 343
+      gait, 344
+      posture, 343
+      station, 344
+    methods of diagnosis, 345
+      ichnogram, 345
+      observation, 345
+
+  Lymphatics, 15
+
+  Lysol, 30, 318
+
+
+  M
+
+  Massage, 250, 270, 279, 289, 296, 304
+
+  Mazamorro, 368
+
+  Medicated collodion, 69
+
+  Menthol, 276
+
+  Mercuric chloride, 29, 273, 274
+
+  Mercurous chloride, 29
+
+  Mercury, 378
+
+  Metatarsalgia, 139, 141, 382
+    treatment of, 383
+
+  Methylene blue, 196
+
+  Miliaria, 304
+    definition of, 304
+
+  Miscellaneous foot lesions, 357
+
+  Moist dressings, 60, 270, 273
+
+  Moleskin, 195
+
+  Moleskin, adhesive, 97
+
+  Monochloracetic acid, 191
+
+  Monsel’s solution, 227, 232
+
+  Morton’s neuralgia, 382
+
+  Morton’s toe, 139, 140, 382
+    treatment of, 382
+
+  Muscles, 15
+
+  Mustard, 279
+
+
+  N
+
+  Nail chisel, 82, 215
+
+  Nail clippers, 86
+
+  Nail file, 91
+
+  Nail groove gouge, 83
+
+  Nail matrix, 16
+
+  Nails, 16, 50
+
+  Nail scraper, 84
+
+  Naked foot, 46
+
+  National Association of Chiropodists, 3, 9, 10
+
+  Necrosis, 293
+
+  Nerves, 15
+    medullated nerve fibres, 15
+    non-medullated nerve fibres, 15
+
+  Nitric acid, 176, 191, 194, 225
+
+  Non-evaporating moist dressings, 60
+
+  Novocaine, 144, 198, 216
+
+
+  O
+
+  Occlusive dressings, 61
+
+  Office, 405
+    accessories, 409
+    cabinet, 408
+    chair, 407
+    cleanliness of, 405
+    comfort of patient, 405
+    equipment, 406
+    operating room, 406
+    rotary file, 409
+    sterilizer, 408
+    waiting room, 405
+
+  Office equipment, 405, 406
+
+  Ohio College of Chiropody, 5
+
+  Oil stone, 93
+
+  Oiled silk, 72
+
+  Ointment dressings, 61, 220, 270, 275, 313
+
+  Onychatrophia, 244
+    derivation of, 244
+    diagnosis of, 246
+    etiology of, 244
+    pathology of, 245
+    treatment of, 246
+
+  Onychauxis, 241
+    derivation of, 241
+    diagnosis of, 242
+    etiology of, 241
+    pathology of, 242
+    treatment of, 243
+      palliative, 243
+      radical, 244
+
+  Onychia, 238
+    derivation of, 238
+    diagnosis of, 238
+    etiology of, 238
+    pathology of, 238
+    treatment of, 238
+
+  Onychitis, 238
+
+  Onychocryptosis, 210, 237
+    definition of, 210
+    derivation of, 237
+    etiology of, 210
+    complications, 212
+    prognosis of, 229
+    treatment of, 214
+      allowing nail to grow long, 234
+      complicated cases, 221
+      excision, 222
+      method of procedure, 223
+      no lateral cutting, 235
+      palliative method, 216
+      proper boots and hosiery, 235
+      packing, 233
+      prophylaxis, 230
+      radical method, 216
+      uncomplicated cases, 215
+
+  Onychophosis, 237
+
+  Onychoptosis, 247
+
+  Onychorrhexis, 247
+
+  Onychygrophosis, 241
+
+  Orthoform, 320
+
+  Osmidrosis, 302
+
+  Oxygen, 300, 366
+
+
+  P
+
+  Painful feet in women, 381
+
+  Panaris, 239
+
+  Panighao, 368
+
+  Papillary layer, 13
+
+  Papilloma, 185
+
+  Paraffin No. 7., 70
+
+  Paraffin No. 7-11., 70
+
+  Paraffin preparations, 70, 258
+    application of, 71
+    conclusions, 261
+    precautions in using, 258
+    removing dressings of, 259
+
+  Parresine, 71
+
+  Paronychia, 239
+    derivation of, 239
+    diagnosis of, 240
+    etiology of, 239
+    pathology of, 240
+    synonyms of, 239
+    treatment of, 240
+
+  Paronychitis, 239
+
+  Pasteur, 22
+
+  Pasteur serum, 365
+
+  Pedic items, 2
+
+  Pedic Society, State of California, 7
+
+  Pedic Society, New York State, 1
+    officers, 1
+
+  Perforating ulcer, 324
+    characteristics of, 325
+    etiology of, 324
+    prognosis of, 327
+    symptoms of, 326
+    treatment of, 326
+
+  Periostitis, 397
+
+  Pernio, 291
+
+  Peroxide of hydrogen, 28
+
+  Petrogen camphor, 280
+    iodine, 280
+
+  Phenol, 29, 198, 289, 302
+
+  Pilocarpin, 304
+
+  Plaster, 105, 106, 107, 117, 120
+
+  Plaster of Paris bandage, 74
+
+  Podiatrist, 2
+
+  Podiatrists office, 405
+
+  Policeman’s heel, 341
+    treatment of, 341
+
+  Polyidrosis, 297
+
+  Potassium hydroxide, 176, 184, 191, 195, 196, 209, 225
+
+  Potassium iodide, 378
+
+  Potassium permanganate, 30, 301, 303
+
+  Potential cautery, 191, 192
+
+  Poultice, 272
+
+  Pressure method of anesthesia, 146
+
+  Proflavin, 34
+
+  Protonuclein, 320
+
+  Proud flesh, 213, 216, 221, 251
+
+  Pruritis, 333
+
+  Pyrogallic acid, 191, 196
+
+
+  Q
+
+  Quinine and urea hydrochloride, 144
+
+
+  R
+
+  Radiography, 385-395
+
+  Radioscopy, 385
+
+  Redintol, 71
+
+  Reticular layer, 14
+
+  Rhode Island Chiropody Society, 9
+
+  Roentgenography, 385
+
+  Roentgenology, 385
+
+  Roentgenoscopy, 385
+
+  Roentgenotherapy, 385
+
+  Rotary file, 90, 149
+
+
+  S
+
+  Salicylated collodion, 70
+
+  Salicylic acid, 173, 176, 181, 184, 191, 197, 208, 232, 277, 378
+
+  Salvarsan, 379
+
+  Sandal, 47
+
+  San Francisco Chiropody Association, 6
+
+  Scalpel, 80
+
+  Scarlet red, 221, 277, 314, 320, 327, 332
+
+  School of Chiropody of New York, 4
+
+  Scissors, 88
+
+  Sebaceous glands, 14, 15, 17
+
+  Seborrhea, 305
+    definition of, 305
+
+  Seed corn, 179
+
+  Sesamoid bones, 402
+
+  Sheep skin, 98
+
+  Shields and shielding, 96, 173, 269
+    adhesive substances, 104
+    aperture for, 101
+    definition, 96
+    location of parts to be shielded, 100
+    manufacture of, 99
+    materials, 96
+      adhesive felt, 99
+      adhesive moleskin, 97
+      buckskin, 97
+      chamois, 97
+      felt, 98
+      lamb’s wool, 99
+      sheepskin, 98
+    method of skiving, 103
+    preparation of, 99
+    skiving of, 101
+    strapping of, 105, 107
+    thickness of, 100
+
+  Shielding, specific, 107
+    dorsal surfaces, 138
+    fifth toe, 120
+      built up, half-moon, 127
+      dorsal surface, 120
+        strapping for, 121, 126
+      lateral surfaces, 128
+        strapping for, 128
+      interdigital surfaces, 128
+        strapping for, 128
+    great toe, 107, 113
+    interdigital surfaces, 118, 119
+      strapping for, 120
+    intermediate toes, 113
+      dorsal surfaces, 113, 115
+      ends of, 116
+      strapping for, 117
+    lateral borders, 137
+    lateral plantar half-moon, 136
+    metatarsalgia, 139, 141
+    Morton’s toe, 139, 140
+    metatarsophalangeal articulation, 130
+      oval, 130
+      half-moon, 131
+      modified half-moon, 132
+    os calcis region, 137
+    plantar surfaces, 132, 133
+      strapping for, 134, 135
+
+  Silver nitrate, 191, 195, 226, 231, 248, 249, 250, 256, 290, 319,
+        320, 332
+
+  Simple ulcers, 306, 311
+    treatment of, 311
+
+  Skiagraphy, 385
+
+  Skiascopy, 385
+
+  Skin, 11
+    anatomy of, 12
+    layers of, 12
+    physiology of, 17
+
+  Skiving, 101, 103
+
+  Skiving knife, 92, 104
+
+  Spatula, 84
+
+  Sodium bicarbonate, 332
+
+  Sodium hydroxide, 191
+
+  Soft corn, 169
+
+  Soft corn spoon, 83
+
+  Soft soap, 362
+
+  Sterilization, 39
+    dressings, 40
+    field of operation, 30, 40
+    hands of operator, 41
+    instruments, 39
+
+  Sterilizing apparatus, 42
+
+  Sterilizers, 42, 408
+
+  Strapping, 105, 106, 107, 117, 120, 121, 128, 134, 269
+
+  Stratum corneum, 12
+
+  Stratum granulosum, 12
+
+  Stratum lucidum, 12
+
+  Stratum mucosum, 13
+
+  Subcutaneous areolar tissue, 14
+
+  Sublimed sulphur, 26
+
+  Sudamen, 304
+    definition of, 304
+
+  Sudorrhea, 297
+
+  Sudatoria, 297
+
+  Sudoriferous glands, 15, 17, 49
+
+  Sulphur, 30, 33, 299, 335
+
+  Sunlight, 24
+
+  Sutures, 198
+
+  Swatty hone, 93
+
+  Syphilitic ulcer, 327
+    symptoms of, 327
+    treatment of, 328
+
+  Syphilis, 189, 241, 373
+    blood tests for, 377
+      Wassermann, 377
+      Noguchi, 377
+      luetin, 378
+    color of, 374
+    course and duration of, 378
+    definition of, 373
+    derivation of, 373
+    diagnosis of, 374
+    differential diagnosis of, 377
+    distribution of, 374
+    etiology of, 373
+    form of, 374
+    pathology of, 373
+    plantar syphilide, 375
+    synonyms of, 373
+    treatment of, 378
+
+
+  T
+
+  Tannic acid, 248, 332
+
+  Tannoform, 249, 332
+
+  Teeth, 379
+
+  Temple University, 5
+
+  Tetanus, 365
+
+  The First Institute of Podiatry, 5
+
+  Thiersch’s solution, 318
+
+  Thumb forceps, 86
+
+  Thymol, 30
+
+  Thymol iodide, 30, 220, 249, 262, 312, 332, 334
+
+  Tr. Benzoin Comp., 249, 251, 289, 331
+
+  Tr. Iodine, 184, 278
+
+  Toe separators, 91
+
+  Tonsils, 379
+
+  Trench fever, 358
+
+  Trench foot, 357
+    complications in, 365
+    crust formation in, 363
+    etiology of, 358
+    extensive invasion in, 364
+    general treatment of, 365
+    prevention of, 361
+    prognosis of, 360
+    reparation stage of, 365
+    simple edematous, 362
+    stages of, 357
+    symptoms of, 359
+    treatment of, 360
+    vesicular, 363
+
+  Trichloracetic acid, 191, 194
+
+  Turpentine, 279
+
+  Tyloma, 182
+
+  Tylosis, 182
+
+
+  U
+
+  Ulcers, 306
+    callous, 306
+    definition of, 306
+    etiology of, 306
+    exciting causes of, 308
+    granulation of, 310
+    indolent, 306
+    pathology of, 308
+    perforating, 306
+    predisposing causes of, 307
+    simple, 306
+    syphilitic, 306
+    varicose, 306
+
+  Uncinarial dermatitis, 368
+
+  Ung. Acidi borici, 313
+
+  Ung. Acidi tannici, 313
+
+  Ung. Balsam of Peru, 314
+
+  Ung. Eucalypti, 314
+
+  Ung. hydrargyri, 29
+
+  Unguentum hydrargyri ammoniati, 29, 221, 313, 332
+
+  Unguentum sulphuris, 30, 221, 262, 276
+
+  Ung. zinci oxidi, 314
+
+  University of Massachusetts, 5
+
+  Urethra, 379
+
+  Uric acid diathesis, 212
+
+  Uric acid and the nails, 335
+    changes in size and shape, 336
+      treatment of, 337
+    discoloration, 335
+      treatment of, 335
+    prognosis, 337
+    texture changes, 336
+      treatment of, 336
+
+  Uridrosis, 304
+    definition of, 304
+
+  Uterus, 379
+
+
+  V
+
+  Vanadium chloride, 300
+
+  Varicose ulcer, 321
+    bandaging for, 324
+    etiology of, 321
+    symptoms of, 322
+    treatment of, 322
+
+  Vascular corn, 174
+
+  Venereal warts, 190
+
+  Verruca, 185
+    definition of, 185
+    derivation of, 185
+    diagnosis of, 189
+    etiology of, 185
+    pathology of, 187
+    prognosis of, 190
+    synonyms of, 185
+    treatment of, 191
+    varieties of, 188
+    where found, 187
+
+  Verruca arida, 185, 188
+
+  Verruca humida, 185, 189
+
+  Verruca vulgaris, 188
+
+  Vibration, 281
+
+  Vocational foot disorders, 339
+
+
+  W
+
+  Walking, 57
+
+  Water, 52
+    properties of, 52
+
+  Water itch, 368
+
+  Water pox, 368
+
+  Water sores, 368
+
+  Weak foot, 339
+    appearance of, 339
+    symptoms of, 339
+    treatment of, 339
+
+  Welch bacillus, 369
+
+  Wet dressings, 60, 218, 239, 270, 273, 311
+
+  White precipitate, 29, 221, 254, 378
+
+  Whitlow, 239
+
+
+  X
+
+  X-ray apparatus, 388
+    generator, 388
+      coil, 390
+      interrupterless, 390
+    tubes, 391
+      vacuum regulators, 392
+    tube stand, 394
+
+  X-ray plates, 394
+    developing of, 396
+    fixing of, 396
+
+  X-rays, 300, 385, 394
+    dangers of, 387
+    discovery of, 386
+    experiments leading up to, 387
+
+
+  Z
+
+  Zinc oxide, 261, 313, 320
+
+  Zinc stearate, 313
+
+  Zinc sulphate, 320
+
+
+
+
+                           PRACTICAL PODIATRY
+
+             is the second volume of a series of books known
+                    as a complete System of Podiatry.
+
+                            The first volume
+
+                                 SURGERY
+                                  WITH
+                      SPECIAL REFERENCE TO PODIATRY
+
+              has proven of worth and will be found in the
+              libraries of all advanced podiatrists and of
+                      many progressive physicians.
+
+                          PODIATRY ORTHOPEDICS
+
+               will be the next volume of the System to be
+              published and will be followed by other books
+              along special lines bearing upon a knowledge
+                     of foot lesions and their care.
+
+Transcriber’s Notes.
+
+Italic text is indicated with _underscores_, bold text with =equals=.
+Small/mixed capitals have been replaced with ALL CAPITALS.
+
+Evident typographical and punctuation errors have been corrected
+silently. Inconsistent spelling/hyphenation has been normalised.
+
+A half-title page has been discarded, and a publishers blurb for a
+companion volume moved to the end of the book.
+
+End of page footnotes have been sequentially numbered and relocated to
+the end of the text.
+
+To improve text flow, illustrations have been relocated between
+paragraphs.
+
+Cover art created for this eBook is granted to the public domain.
+
+
+*** END OF THE PROJECT GUTENBERG EBOOK 79224 ***
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+
+<body>
+<div style='text-align:center'>*** START OF THE PROJECT GUTENBERG EBOOK 79224 ***</div>
+
+<main>
+
+<div class="title">
+<p><span class="pagenum"><a id="Page_i"></a><a id="Page_ii"></a><a id="Page_iii"></a>[Pg iii]</span></p>
+
+<h1>
+PRACTICAL PODIATRY
+</h1>
+
+
+<p class="center"><span class="sm">BY</span></p>
+
+<p class="center">ALFRED JOSEPH</p>
+
+<p class="center"><i>Senior Professor of Podiatry, The First Institute of Podiatry;
+Ex-President, Nat’l. Ass’n. Chiropodists; Editor, Pedic Items.</i></p>
+
+<p class="center p2">E. K. BURNETT</p>
+
+<p class="center"><i>Professor of Clinical Podiatry, The First Institute of Podiatry;
+Vice-President, Nat’l. Ass’n. Chiropodists; Editor, The Podiatrist.</i></p>
+
+<p class="center p2">REUBEN H. GROSS</p>
+
+<p class="center"><i>Professor of Didactic Podiatry and Registrar, The First Institute of
+Podiatry; Associate Editor, Pedic Items.</i></p>
+
+
+<p class="center p2"><span class="sm">EDITED BY</span></p>
+
+<p class="center">MAURICE J. LEWI, M.D.</p>
+
+<p class="center"><i>President, The First Institute of Podiatry; Ex-Secretary, N. Y.
+State Board of Medical Examiners; formerly Professor of Medical
+Jurisprudence, Albany Law School; Ex-President, Albany Co. Medical
+Society; formerly Instructor, Albany Medical College; Member, American
+Medical Association; Member, N. Y. State Medical Society; Member N. Y.
+Co. Medical Society, etc.</i></p>
+
+
+<p class="center p4"><span class="sm">PUBLISHED BY</span><br>
+THE FIRST INSTITUTE OF PODIATRY<br>
+<span class="sm">213-215-217 WEST <span class="allsmcap">125TH</span> STREET<br>
+</span><span class="sm">NEW YORK</span></p>
+</div>
+
+
+<p><span class="pagenum" id="Page_iv">[Pg iv]</span></p>
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+
+<div class="chapter">
+<p class="center">
+  <span class="smcap">Copyright, Maurice J. Lewi, 1918</span><br>
+  <br>
+  <br>
+  <span class="smcap">The William G. Hewitt Press</span><br>
+  <span class="smcap">Brooklyn, N. Y.</span>
+</p>
+
+<p><span class="pagenum" id="Page_v">[Pg v]</span></p>
+</div>
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+
+<div class="chapter">
+<p class="center">
+  TO THE MEMORY OF<br>
+  <br>
+  <span class="smcap">George Erff</span><br>
+  <span class="smcap">and</span><br>
+  <span class="smcap">Elliott W. Johnson</span>,<br>
+  <br>
+  builders of the foundation upon which<br>
+  the edifice of modern podiatry is<br>
+  reared, this book is reverently and<br>
+  appreciatively dedicated.
+</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+
+<div class="chapter">
+<p><span class="pagenum" id="Page_vi">[Pg vi]</span></p>
+</div>
+
+
+<p>The beauties of contour of the human foot,
+coupled with its strength to perform the functions
+for which it was created, caused the
+ancient Greeks to glorify it in song and in art.
+Medically and surgically it has always been a
+negligible factor in the world of science, notwithstanding
+the burdens which it is made to
+bear and in spite of the interference with locomotion
+and with general health which this
+non-care has occasioned for all centuries since
+creation. Our propaganda recognizes the importance
+of this part of the anatomy and is
+causing the race to realize the need for foot care
+in health and for scientific foot treatment
+in disease.</p>
+</div>
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_vii">[Pg vii]</span></p>
+
+
+  <h2 class="nobreak" id="CONTENTS">
+    CONTENTS
+  </h2>
+</div>
+
+
+<p><span class="pagenum" id="Page_viii">[Pg viii]</span></p>
+<table class="autotable3">
+<tr>
+<td class="tdr">
+</td>
+<td class="tdl">
+FOREWORD
+</td>
+<td class="tdr">
+<a href="#FOREWORD">ix</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+I
+</td>
+<td class="tdl">
+THE RECENT HISTORY OF PODIATRY
+</td>
+<td class="tdr">
+<a href="#CHAPTER_I">1</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+II
+</td>
+<td class="tdl">
+THE SKIN
+</td>
+<td class="tdr">
+<a href="#CHAPTER_II">11</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+III
+</td>
+<td class="tdl">
+ASEPSIS AND ANTISEPSIS
+</td>
+<td class="tdr">
+<a href="#CHAPTER_III">19</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+IV
+</td>
+<td class="tdl">
+STERILIZATION
+</td>
+<td class="tdr">
+<a href="#CHAPTER_IV">39</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+V
+</td>
+<td class="tdl">
+THE CARE OF THE FOOT
+</td>
+<td class="tdr">
+<a href="#CHAPTER_V">46</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+VI
+</td>
+<td class="tdl">
+DRESSINGS AND BANDAGING
+</td>
+<td class="tdr">
+<a href="#CHAPTER_VI">60</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+VII
+</td>
+<td class="tdl">
+INSTRUMENTS
+</td>
+<td class="tdr">
+<a href="#CHAPTER_VII">78</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+VIII
+</td>
+<td class="tdl">
+SHIELDS AND SHIELDING
+</td>
+<td class="tdr">
+<a href="#CHAPTER_VIII">96</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+IX
+</td>
+<td class="tdl">
+LOCAL ANESTHESIA
+</td>
+<td class="tdr">
+<a href="#CHAPTER_IX">143</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+X
+</td>
+<td class="tdl">
+HELOMA
+</td>
+<td class="tdr">
+<a href="#CHAPTER_X">149</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XI
+</td>
+<td class="tdl">
+CALLOSITAS
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XI">182</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XII
+</td>
+<td class="tdl">
+VERRUCA
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XII">185</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XIII
+</td>
+<td class="tdl">
+CALLOUSED NAIL GROOVE
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XIII">205</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XIV
+</td>
+<td class="tdl">
+ONYCHOCRYPTOSIS OR INGROWN TOE NAIL
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XIV">210</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XV
+</td>
+<td class="tdl">
+DISEASES OF THE NAILS
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XV">237</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XVI
+</td>
+<td class="tdl">
+FISSURES, BLISTERS, AND BURNS
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XVI">248</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XVII
+</td>
+<td class="tdl">
+BURSITIS
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XVII">263</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XVIII
+</td>
+<td class="tdl">
+CHIMATLON
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XVIII">283</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XIX
+</td>
+<td class="tdl">
+DISEASES OF THE SWEAT GLANDS
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XIX">297</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XX
+</td>
+<td class="tdl">
+ULCERS
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XX">306</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XXI
+</td>
+<td class="tdl">
+CUTANEOUS MANIFESTATIONS OF SUPER-ACIDITY
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XXI">329</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XXII
+</td>
+<td class="tdl">
+VOCATIONAL FOOT DISORDERS
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XXII">339</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XXIII
+</td>
+<td class="tdl">
+LOCOMOTION AS AN AID IN DIAGNOSIS
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XXIII">343</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XXIV
+</td>
+<td class="tdl">
+MISCELLANEOUS FOOT LESIONS
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XXIV">357</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XXV
+</td>
+<td class="tdl">
+X-RAYS IN PODIATRY
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XXV">385</a>
+</td>
+</tr>
+<tr>
+<td class="tdr">
+XXVI
+</td>
+<td class="tdl">
+THE PODIATRIST’S OFFICE
+</td>
+<td class="tdr">
+<a href="#CHAPTER_XXVI">405</a>
+</td>
+</tr>
+
+<tr>
+<td class="tdr">
+</td>
+<td class="tdl">
+GLOSSARY
+</td>
+<td class="tdr">
+<a href="#GLOSSARY">411</a>
+</td>
+</tr>
+
+<tr>
+<td class="tdr">
+</td>
+<td class="tdl">
+INDEX
+</td>
+<td class="tdr">
+<a href="#CROSS_REFERENCE_INDEX">433</a>
+</td>
+</tr>
+
+</table>
+
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_ix">[Pg ix]</span></p>
+
+
+  <h2 class="nobreak" id="FOREWORD">
+    FOREWORD
+  </h2>
+</div>
+
+
+<p>This volume has been compiled by men who started out in life
+as chiropodists. They have lived to see the genesis of podiatry
+from the trade which was theirs, and each of them has
+taken active part in the efforts which marked the transition from
+the old to the new order of things. The period of evolution has
+been extremely brief. Five short years have sufficed to transform
+the corn-cutters’ trade to the podiatrists’ profession.</p>
+
+<p>One of the programmed features of the educational development
+of podiatry was the creation of a scientific literature bearing
+upon the practice of this branch of medicine. The earliest manifestation
+along the lines of this progress was the production of “The
+Text Book of Chiropody.” This ponderous tome (1183 pages)
+contained matter pertaining to the teaching of medical and other
+scientific subjects that led up to the study of chiropody and to
+practical chiropody itself. The chapters on this latter topic were
+the first attempts of a scientific nature to collect material relating
+to podiatry practice. In consequence, the articles were few and
+their contents were meagre. Nevertheless this pioneer attempt to
+array chiropodical facts and methods of treating foot lesions
+proved efficacious in stimulating members of the chiropody profession
+to the higher educational needs, and all over the english speaking
+globe this literature was hungrily masticated and digested
+by individual practitioners and by chiropody societies.</p>
+
+<p>Bright and intelligent members of the profession utilized the
+material thus furnished them by practically applying suggested
+treatments and methods. Aspiring to augment their own knowledge
+and to add to this literature, they wrote up their experiences
+and, from time to time, their matured deductions were given publicity
+through the columns of “The Pedic Items” and “The Podiatrist.”
+The instructors on the faculties of the various chiropody
+teaching institutions, utilized these chapters in their pedagogic work,
+and medical practitioners turned to them to gain their first concrete
+knowledge of the subjects which they treated. These initial
+chapters thus filled an acute want and so proved their worth.</p>
+
+<p><span class="pagenum" id="Page_x">[Pg x]</span></p>
+
+<p>In this volume, a more serious task has been undertaken. Each
+article will be found to have been prepared with a view to presenting
+the subject matter in its entirety, in scientific order and with
+accuracy. There has been no guessing as to cause and effect. Empiricism
+finds no place in these pages. The medical and surgical
+viewpoint is continuously in evidence and “Practical Podiatry”
+thus becomes the first medical work of its kind ever published, a
+sad commentary on the negligence of medical teachers and medical
+practitioners who have thus permitted non-medical graduates
+to compile the first facts relating to an important branch of medicine.
+The erstwhile tabooed “corn-cutter” thus becomes a leader
+in a collateral branch of medicine, and medical practitioners are
+compelled to glean their knowledge of this subject from laymen,
+who, without their material, moral or monied support—yes, often in
+spite of obstacles which medical practitioners have placed in their
+way—have succeeded in clearly and scientifically portraying features
+of essential medical practice which are to aid materially in
+creating a better species of the genus homo, and in relieving the
+woes of our race. Podiatrists may well feel a pride in this achievement
+and medical practitioners would do well to take home the
+lesson of indifference which this incident discloses.</p>
+
+<p>Podiatry has not alone enriched the scholastic literature of
+medicine, but has also augmented the language of science. New
+terms have had to be coined to properly designate conditions, diseases
+and instruments. In order that these may be understood by
+the readers of this volume, their purport is given in the general
+glossary which will be found in the book. The etymologic construction
+of these new words is not explained because their origin will be
+readily apparent from their definitions.</p>
+
+<p>“Surgery with special reference to Podiatry” was the first
+volume of this series to be published. In presenting “Practical
+Podiatry” to the profession and to the public, the second rung in
+the ladder of podiatry literature has been created and within two
+years it is hoped that the “System of Podiatry,” of which both of
+the above volumes are a part, will have been completed.</p>
+
+<p>Thus will be constituted a library for practitioners and
+students of podiatry which it is hoped will ever prove creditable
+to its sponsors, profitable to the profession and helpful to humankind.</p>
+
+<blockquote>
+<p class="right">
+  M. J. L.
+</p>
+</blockquote>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_1">[Pg 1]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_I">
+    <span class="chap">CHAPTER I</span>
+    <br>
+    THE RECENT HISTORY OF
+    PODIATRY
+  </h2>
+</div>
+
+
+<p>The first steps in the movement for the enactment of a
+law governing the practice of chiropody in the United
+States were made in the state of New York, when, in 1895
+C. S. Levy, H. Levy, L. B. Rosenberg, H. Mayer, E. Werther
+and M. M. Marks met at the residence of C. S. Levy to discuss
+this matter. As a result of this meeting, a bill drafted
+by Maurice Marks, a well known New York lawyer, was
+subsequently presented to the New York State legislature.
+John B. Stanchfield, leader of the assembly, spoke at length
+on the question of “feet” and amid mirth and laughter (the
+question was considered somewhat of a joke), the bill was
+passed by the lower house. Shortly thereafter, the senate
+took similar action on the bill, whereupon Governor Morton
+promptly signed it.</p>
+
+<p>In accordance with the provisions of the law, the Pedic
+Society of the State of New York was organized on the 3rd
+of June, 1895, and R. H. Westervelt was elected president,
+George Erff, treasurer and Louise Hartogensis, secretary.
+Wm. D. Gaige, Jonas M. Heimerdinger and L. B. Rosenberg
+were selected as the first board of examiners.</p>
+
+<p>R. H. Westervelt served as president of the society for
+a period of two years, when he was succeeded by Elliott W.
+Johnson, who acted as chief executive officer for fifteen
+years. George Erff was the next president and he in turn
+was succeeded by Alfred Joseph, J. P. Solomon and Ernest
+Graff.</p>
+
+<p>The affairs of the society improved with each succeeding
+<span class="pagenum" id="Page_2">[Pg 2]</span>year, and much of the credit of its success should go to
+Maurice M. Marks, who acted as attorney for the society,
+and in addition, assisted wherever he could.</p>
+
+
+<h3 id="BIRTH_OF_THE_PEDIC_ITEMS">
+  BIRTH OF “THE PEDIC ITEMS”
+</h3>
+
+<p>“The Pedic Items,” which has done so much to advance
+the calling of podiatry, is the child of Alfred Joseph. In
+1906 he outlined a plan to the members of the Pedic Society
+of the State of New York, whereby a journal could be
+created and conducted profitably. On January 1st, 1907, a
+leaflet called the “Pedic Society Items” was sent to the
+members. On April 1st, 1907, a four page paper was published,
+and after that Alfred Joseph was offered the position
+of editor. The “Items” appeared every four months for
+the first few years of its existence, and finally became a
+monthly paper which has grown to a sixty-four page book,
+and even this is inadequate to convey all that is new and of
+interest to the members of the profession. This book is now
+current podiatry literature in every english speaking country
+in the world. A number of chiropody publications have
+appeared from time to time, most of them, of no scientific
+value, and they died an early death. The newest paper,
+“The Podiatrist,” is a thoroughly scientific journal, that
+has already found a place in the profession; it is edited and
+published by E. K. Burnett, one of the progressive members
+of the podiatry profession, and appears once each month.</p>
+
+
+<h3 id="FIRST_SCHOOL_OF_CHIROPODY">
+  FIRST SCHOOL OF CHIROPODY
+</h3>
+
+<p>At the March, 1911 meeting of the Pedic Society of the
+State of New York, Alfred Joseph, as chairman of a committee
+appointed to take the matter under advisement, read
+a report on the question of organizing a school, and asked
+that moneys be subscribed for the purposes of incorporating
+such an institution. In a short time, over $1,200.00 was subscribed
+and the corporation known as “The Chiropodists of
+<span class="pagenum" id="Page_3">[Pg 3]</span>America” came into existence, with George Erff, president
+and Alfred Joseph, secretary.</p>
+
+<p>This school was conducted along commercial lines, and
+although its purposes were good, it did not meet the standards
+which its promoters were hopeful of establishing for
+it and which it later secured through the action of the
+Regents of the University of the State of New York.</p>
+
+
+<h3 id="THE_NATIONAL_ASSOCIATION_OF_CHIROPODISTS">
+  THE NATIONAL ASSOCIATION OF CHIROPODISTS
+</h3>
+
+<p>The October, 1911, issue of “The Pedic Items” contained
+the first announcement of a proposed plan to organize
+a national association of chiropodists. All chiropodists
+were invited to become members, and after a mail vote,
+Chicago was selected as the first convention city. On July
+1st, 2nd, and 3rd, after the usual preliminaries, the organization
+was completed, and Alfred Joseph, who was the organizer
+of the association, was elected president. Ernest
+Graff was elected secretary-treasurer. This organization
+has grown from 225 members at its first meeting, to the
+present large society of over 1,000 members. The influence
+of the N. A. C. is and has been decidedly salutory, and its
+organizers can well be proud of the work they have accomplished.</p>
+
+
+<h3 id="CHANGE_IN_THE_CHIROPODY_LAW_OF_NEW_YORK">
+  CHANGE IN THE CHIROPODY LAW OF NEW YORK
+</h3>
+
+<p>The members of the Pedic Society of the State of New
+York, after a brief experience, realized the shortcomings of
+the original law which governed the practice of chiropody.
+They sought to advance their calling and to provide so that
+those entering the profession should be properly equipped.</p>
+
+<p>A committee of the Pedic Society of the State of New
+York composed of George Erff, Maurice Marks and Alfred
+Joseph, called upon Edward Milton Foote, M. D., a prominent
+surgeon, for advice as to procedure. Dr. Foote, in
+turn, advised that the secretary of the N. Y. State Board
+<span class="pagenum" id="Page_4">[Pg 4]</span>of Medical Examiners be consulted. Thus it came to pass
+that these gentlemen met Maurice J. Lewi, M. D.</p>
+
+<p>Dr. Lewi listened attentively to the request of the committee
+that he devise ways and means for improving the
+then inefficient chiropody law, fell in heartily with their
+objects and after outlining a plan of procedure, drafted a
+bill which, after receiving the sanction of the State education
+authorities, was introduced in the legislature. The bill
+was unanimously passed and became a law September 1st,
+1912. Thereupon the State Education Department delegated
+Dr. Lewi to outline a standard for chiropody schools
+which they promptly adopted. Much to the surprise of the
+officials of the New York School of Chiropody, these standards
+were so high that they feared it would be impossible for
+them to carry them into effect.</p>
+
+<p>Conducting a school along the lines set by the State
+made it necessary to engage as its head one who was a
+medical practitioner, an educator, an executive and a man
+of character. Where was such a man to be found? After
+much deliberation and numerous consultations, the committee
+of the Pedic Society decided that there was but one man
+known to them who combined all of these attributes and he
+was the very individual who had guided them in seeking to
+advance their profession, Dr. Lewi. When the proposition
+was put to Dr. Lewi, he declined with thanks on the ground
+that his position as Secretary of the State Board of Medical
+Examiners was to his liking. The committee was insistent
+and pleaded with him to reconsider his determination. For
+three months the committee and their friends labored with
+Dr. Lewi and finally, after making certain stipulations which
+placed the management of the school in his sole charge, he
+capitulated, and on January 1st, 1913, he assumed the presidency
+of the reorganized School of Chiropody of New York.
+With meagre funds, but with earnest zeal he commenced his
+task and soon surrounded himself with a splendid faculty
+and with a modest but sufficient equipment. The school has
+flourished. It behooves every member of the profession of
+<span class="pagenum" id="Page_5">[Pg 5]</span>podiatry to remember that had it not been for the broad-mindedness
+and the foresight of Dr. Lewi, this calling which
+is gradually taking its place as a legitimate branch of
+medicine, would still be the trade it was, and the podiatrists
+of today would still be the “corn-cutters” of yesterday.</p>
+
+<p>On September 27th, 1917, the Regents of the University
+of the State of New York granted a provisional charter to
+The First Institute of Podiatry and henceforth the School
+of Chiropody of New York will be known by that title.</p>
+
+
+<h3 id="THE_DEVELOPMENT_OF_OTHER_SCHOOLS">
+  THE DEVELOPMENT OF OTHER SCHOOLS
+</h3>
+
+<p>After the organization of the new regime in podiatry
+education, the old system of conducting schools for gain
+only, was gradually eliminated and the need for schools to
+teach foot ills in a scientific manner, became apparent.
+Since the organization of The First Institute of Podiatry,
+several other institutions have come into existence whose
+purpose is to equip their students to be true podiatrists.
+The California College of Chiropody, situated in San
+Francisco, is the only institution west of Chicago, imparting
+knowledge of this character. In the middle west, the City
+of Chicago boasts of two schools, viz.: the Illinois College
+of Chiropody and the Chicago School of Chiropody. The
+State of Ohio is well represented by the Ohio College of
+Chiropody in the City of Cleveland. Temple University of
+Philadelphia, Pa., has a Department of Chiropody and is
+educating specialists in conjunction with its medical course.
+The latest addition to chiropody teaching institutions is
+the University of Massachusetts in East Cambridge,
+Mass.</p>
+
+<p>All of these institutions are endeavoring to educate
+their students along ethical and scientific lines, and it is
+but a question of time when they will have attained the
+status and educational influence of The First Institute of
+Podiatry.</p>
+
+<p><span class="pagenum" id="Page_6">[Pg 6]</span></p>
+
+
+<h3 id="ORGANIZATION_OF_PEDIC_SOCIETIES">
+  ORGANIZATION OF PEDIC SOCIETIES
+</h3>
+
+<p>After the Pedic Society of the State of New York had
+been conducting its affairs for several years, podiatrists
+throughout the country, recognizing the advantages to be
+derived from a conjunction of individual interests into
+groups, created organizations in thirty-seven States of the
+Union. It is safe to predict that within the next five years,
+there will be a podiatry organization in each of the remaining
+States not now so organized.</p>
+
+<p>Activities along these lines have not been limited to the
+United States alone. In England, the Incorporated Society
+of Chiropodists is a flourishing body, boasting a large membership.
+Ernest G. V. Runting is president of that organization
+and he and many others in the British Isles are
+helping to make podiatry a real profession. The other
+European countries are not progressive in podiatry work
+(possibly due to the war situation), but as the United States
+and Great Britain advance, so will the other nations follow.
+It is unfortunate that the people of many of these European
+countries do not fully appreciate the value of scientific foot
+treatment, but, as in other educational branches, it is only
+a question of time when every government in the civilized
+world will recognize the necessity for a full study of this
+important branch of medical science, and will also pass laws
+regulating podiatry practice.</p>
+
+<p>In the United States, one of the first states to follow the
+example of New York, was California. In July, 1901,
+George Koenigstein called a meeting of the chiropodists
+in San Francisco, and an organization known as the San
+Francisco Chiropodists Association was formed. This
+society had for its prime purpose, the passing of a law
+governing the practice of chiropody in the State of California;
+the organization elected no regular set of officers
+but held desultory meetings once or twice a month at the
+office of Charles L. Scharff.</p>
+
+<p>The bill that this society formulated was presented to
+<span class="pagenum" id="Page_7">[Pg 7]</span>the legislature at Sacramento and Drs. Scharff and Koenigstein
+were delegated to press it to passage. They worked
+like Trojans but to no avail. The bill was pigeon-holed and
+nothing more was heard of it. Subsequently the Society
+died a peaceful death.</p>
+
+<p>In 1907, following the great fire in San Francisco, a
+few chiropodists again attempted to pass legislation in California,
+but this endeavor was also fruitless. In the latter
+part of 1911 and in the early part of 1912, stimulated by an
+article relating to the subject which appeared in “The Pedic
+Items,” and fully realizing the benefits of chiropody organization,
+if properly conducted, several California practitioners
+were elected to membership in the National Association.
+Among these were Oscar L. Gruggel, S. Rutherford
+Levy, and Charles L. Scharff. These men became N. A. C.
+propagandists, and secured the applications of others in
+California for membership in the National Association. On
+January 12th, 1912, The Pedic Society of the State of California
+was permanently organized and chartered. Its first
+officers were, S. Rutherford Levy, President; William F.
+Leck, First Vice-President, Oscar L. Gruggel, Second Vice-President;
+H. H. Katz, Third Vice-President; Charles L.
+Scharff, Secretary-Treasurer; Z. L. Comet, Sergeant-at-arms,
+and F. Schilling, Counsel for the Society.</p>
+
+<p>This society attempted to pass a State law regulating
+the practice of chiropody (in 1913) and a bill drafted for the
+purpose by Mr. Schilling, was presented to the legislature.
+By almost superhuman effort on the part of every member
+of the society, the bill passed both houses of the legislature,
+but the Governor vetoed it on the ground that he was
+opposed to the creation of new State Commissions.</p>
+
+<p>Dismayed, but not disheartened, the legislative committee
+immediately made arrangements to carry on the fight at
+the next session of the legislature. The new bill introduced,
+instead of creating a separate commission, placed the supervision
+of chiropody practice in the hands of the existing
+State Board of Medical Examiners. Changes agreeable to
+<span class="pagenum" id="Page_8">[Pg 8]</span>all concerned were made, and in the 1915 session of the
+legislature, the Benson Medical Act, 443, to regulate the
+practice of podiatry in California, was passed by both
+houses. On June 8th, the bill was signed by the Governor
+and the law became effective August 8th, 1915.</p>
+
+<p>In the State of Illinois, the first organization was effected
+in September, 1904. A charter was applied for and
+granted to Charles Kenison, Nicholas Von Schill, Frank
+Johnson and Ignace J. Reis. The officers elected were,
+Charles Kenison, President; Leonard Lower, Vice-President;
+C. G. Sims, Treasurer and Ignace J. Reis, Secretary.</p>
+
+<p>On September 18th, 1912, the temporary organization of
+The Illinois Pedic Association was effected. The organization
+was made permanent on October 2nd, 1912, and the
+following were elected as the first officers:</p>
+
+<p>President, Ignace J. Reis; Vice-President, Maximilian
+Pincus, M. D.; Secretary, Henry Schmidt; Treasurer, John
+Kenison; Trustees, Leonard A. Lower; Henry J. Riegelhaupt;
+Charles Kenison; Counsellors, Frank S. Lower,
+M.D., H. P. Kenison, M. Pincus, M.D.</p>
+
+<p>In the year 1906, S. L. Lawton of Fall River, Mass.,
+consulted with F. J. Coughlin of Boston as to the advisability
+of forming a state chiropody association. Harry
+P. Kenison of Boston was advised with and readily fell in
+with the plans. As a result, a meeting was called at the
+office of the latter and the Massachusetts Association was
+created. The first officers were J. P. Buntin, Boston, President;
+S. D. Lawton, Fall River, Vice-President; F. J.
+Coughlin, Boston, Secretary-Treasurer, and the following
+Directors: H. P. Kenison, F. E. Davis, C. R. Watkins, A.
+M. Brackett, W. E. Lee and G. M. Pettingill. This society
+has flourished and, due to the efforts of several of its members,
+including the present president of the N. A. C., H. P.
+Kenison, the present law governing the practice of
+chiropody in Massachusetts was passed. This was accomplished
+in spite of strenuous opposition on the part of
+<span class="pagenum" id="Page_9">[Pg 9]</span>medical practitioners and a few disgruntled chiropodists
+within and out of the organization.</p>
+
+<p>In the West, there is gradually springing up a progressive
+spirit in all that pertains to podiatry. Much of this
+spirit has been created through the efforts of a few practitioners
+in the State of Colorado who have been extremely
+active in the past few years. In 1914, Bertha De Wolfe,
+having taken a course at the School of Chiropody of New
+York, located in the City of Denver. Realizing the necessity
+of organization, she immediately set to the task, and in
+December of that year, the Colorado Pedic Society held its
+first meeting. It was incorporated, January, 1915. Its first
+officers were, C. S. Rees, President; A. M. Parker, first Vice-President;
+Lucy Ballou, second Vice-President;
+Bertha De Wolfe, Secretary-Treasurer.</p>
+
+<p>The late Benjamin Oelsner of Bridgeport, Conn., was
+always an active member of the profession, and through his
+efforts, the Connecticut Pedic Society was organized, in the
+city of New Haven, March 23rd, 1910. This organization
+has grown rapidly, and because of its activities, Connecticut
+now has a chiropody law on its statute books.</p>
+
+<p>The Rhode Island Chiropodists Society was organized
+November 8th, 1914, largely through the efforts of Alfred
+C. Moran, who represented the National Association of
+Chiropodists in that section of the country. This organization
+is gradually growing, and since the convention of the
+N. A. C. which was held in Providence, R. I., many practitioners
+who previously showed no interest in the union of
+podiatry forces, have become active workers in the interests
+of the profession. The officers of The Rhode Island Chiropodists
+Society are Charles T. Heilborn, President; Henry S.
+Batchelder, first Vice-President; F. S. Sargent, second
+Vice-President; Alfred C. Moran, Secretary-Treasurer.</p>
+
+
+<h3 id="LAWS_GOVERNING_PODIATRY_PRACTICE">
+  LAWS GOVERNING PODIATRY PRACTICE
+</h3>
+
+<p>Since the first law governing the practice of podiatry
+passed in the State of New York, eighteen other
+<span class="pagenum" id="Page_10">[Pg 10]</span>states have taken similar action. The National Association
+of Chiropodists has been largely responsible
+for most of the success along these lines. The committee
+in charge of legislation has been a most active one, and its
+usefulness may be realized, when it is recorded that during
+the period from August, 1916, to July, 1917, six states in
+the union passed laws regulating the practice of podiatry.
+As the profession advances, and the academic requirements
+are increased, the laws are so changed as to create a greater
+scope of endeavor for our practitioners. Thus in some
+states the law permits the podiatrist to perform operations
+of a major nature, while in others the practice is limited
+to structures involving the true skin only. It is safe to
+predict that in a few years, every state in the union will have
+enacted legislation regulating the practice of podiatry. The
+states now governed by such laws (New Jersey was the
+first) are Colorado, California, Connecticut, Illinois, Louisiana,
+Maryland, Massachusetts, Michigan, Minnesota, New
+Jersey, New York, Ohio, Pennsylvania, Rhode Island, Vermont,
+Virginia, Washington, West Virginia and Wisconsin.&#x2060;<a id="FNanchor_1_1" href="#Footnote_1_1" class="fnanchor">[1]</a>&#x2060;</p>
+
+<p>Educators and the public generally throughout the entire
+country are beginning to realize the value of scientific
+foot care, and where the chiropodist was derided and scoffed
+at years ago, the podiatrist of today is gradually taking
+the place he so rightly deserves, at the side of the members
+of the other professions, honored and respected as a well
+trained, educated man who is proving a benefactor to the
+human race. So it is, that the schools of chiropody are
+being developed, and in a few years when the academic
+requirements will have become the same as for the other
+professions, the courses of study at these schools will run
+on all fours with the schedules of study maintained at
+medical schools.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_11">[Pg 11]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_II">
+    <span class="chap">CHAPTER II</span>
+    <br>
+    THE SKIN
+  </h2>
+</div>
+
+
+<p>Podiatry deals largely with ailments involving the skin
+or its appendages and it is deemed advisable to describe
+briefly the anatomy and physiology of that organ, so as to
+refresh the memories of those who study this work.</p>
+
+<p>It is not the intention of the authors to enter deeply
+into this subject and the reader is referred to the works in
+this series which deal exclusively with anatomy and physiology,
+for a more intimate knowledge of the skin. It is an
+accepted fact that no one can intelligently comprehend
+<span class="pagenum" id="Page_12">[Pg 12]</span>pathology without knowing the normal structure and functions
+of the tissues of the body to be considered, and it is
+for that reason that the pages to follow have been written.</p>
+
+<figure class="figcenter illowe30" id="i_p011">
+  <img class="w100" src="images/i_p011.jpg" alt="diagram showing components of the skin">
+  <figcaption class="hang1">
+    1. Stratum Corneum; 2. Stratum Lucidum; 3. Stratum Granulosum;
+    4. Stratum Mucosum; 5. Papillary Layer; 6. Reticular Layer; 7.
+    Subcutaneous Tissue; 8. Hairs; 9. Fat Cells; 10. Sudoriferous Glands;
+    11. Sebaceous Glands; 12. Pacinian Body or Touch Corpuscle; 13.
+    Connective Tissue Cells; 14. Nerve Endings 15. Vascular Papillæ and
+    Capillary Loops
+  </figcaption>
+</figure>
+
+
+<h3 id="ANATOMY_OF_THE_SKIN">
+  ANATOMY OF THE SKIN
+</h3>
+
+<p>The skin as a whole is composed of two distinct layers
+resting upon a third structure, the subcutaneous tissue.
+The outer portion is called the epidermis, cuticle or scarf
+skin, and is without blood and nerve supply, while the inner
+portion is called the corium, derma or cutis vera, and contains
+the capillary loops and nerve endings.</p>
+
+
+<h3 id="THE_EPIDERMIS">
+  THE EPIDERMIS
+</h3>
+
+<p><b>The Epidermis</b> is divided into four layers, named from
+without inward, the stratum corneum, the stratum lucidum,
+the stratum granulosum and the stratum mucosum or rete
+Malpighii.</p>
+
+<p><b>The Stratum Corneum</b>, or horny layer of the skin, is
+composed of many layers of horny, non-nucleated scales
+which are being continuously displaced by exposure to
+weather, water, etc., and are being as continuously renewed
+by the deeper layers. This layer of the skin is involved in
+the simpler foot lesions such as heloma and callositas.</p>
+
+<p><b>The Stratum Lucidum</b>, or clear layer of the skin, is composed
+of a few rows of transparent cells, without distinct
+boundary, and, except on the palms and soles, is considered
+a part of the stratum corneum. It is composed of from two
+to four layers of cells, which are like the cells of the horny
+layer except that they are brighter and more homogeneous.
+This layer is not often clearly defined and is of no importance.</p>
+
+<p><b>The Stratum Granulosum</b>, or granular layer of the skin
+is composed of several rows of polygonal shaped cells which
+are well marked on the soles of the feet. The nuclei of the
+cells are not well defined and the cell itself refracts light.
+<span class="pagenum" id="Page_13">[Pg 13]</span>The granules found in this layer are varied in shape and
+contain a fluid called eleidin and a peculiar solid substance
+called keratohyalin. This substance is derived from the
+cytoplasm of the cells and represents the first process in
+the cornification of the cells in the outer layers of the
+epidermis.</p>
+
+<p><b>The Stratum Mucosum</b>, or mucous layer of the skin,
+usually called the rete, or rete Malpighii, is the deepest and
+most important layer of the epidermis. The basal layers
+of cells are separated from the corium by a basement membrane
+or membrana propria, and these layers, which are
+made up of columnar cells, contain the pigment of the skin.
+The next few layers show elongated, oval or rounded shaped
+cells, the form varying with the locality, the tendency being
+to a rounded shape, owing to the more even pressure on the
+cells from above and below. The cells are irregularly
+formed and are made up of a soft substance with large oval
+or rounded nuclei. In the intercellular spaces is found a
+fluid which is nutrient in character. In the stratum
+mucosum are found the prickle cells. These cells have hairlike
+processes on them which serve to hold the cells together.</p>
+
+
+<h3 id="THE_DERMA">
+  THE DERMA
+</h3>
+
+<p><b>The Derma, or Corium</b>, is divided into two layers, the
+outer, called the papillary layer, or pars papillaris, and the
+inner, called the reticular layer, or pars reticularis. It is
+composed of bundles of fibrous tissue, yellow elastic tissue
+and connective tissue cells, the reticular layer being more
+compact than the papillary layer. The derma contains blood
+vessels, nerves, lymphatics, touch corpuscles, hairs, sweat
+glands and sebaceous glands.</p>
+
+<p><b>The Papillary Layer</b> of the skin is composed of small
+conical elevations called papillæ, which blend with the prolongations
+of the rete above. The best developed papillæ
+are found on the under or flexor surfaces of the fingers and
+toes and attain their greatest length at this point. They are
+<span class="pagenum" id="Page_14">[Pg 14]</span>placed in double rows that underlie the cutaneous ridges on
+the fingers and toes. These cutaneous ridges remain unchanged
+throughout life and are so characteristic of each
+individual, that they are used as a means of detecting and
+identifying criminals and others. Papillæ of two kinds are
+noticed, the one being very well supplied with blood vessels,
+and are called vascular, the others being only scantily supplied
+with blood, containing medullated nerves, and are
+called sensory papillæ.</p>
+
+<p><b>The Reticular Layer</b> of the derma is composed of loosely
+arranged bundles of connective tissue which merge with the
+papillary layer without a distinct line of demarcation. In
+these bundles of connective tissue are found the sweat
+glands, the sebaceous glands, the hair follicles and the
+deeper lymphatics. This layer of the derma is made up of
+fasciculi of connective tissue which blend into each other
+obliquely and give it a plexiform appearance. As the
+bundles ascend towards the surface they divide into smaller
+and finer bundles, and when the papillary layer is reached,
+they have a close, felt-like appearance.</p>
+
+<p><b>The Subcutaneous Areolar Tissue</b>, or tela subcutanea,
+connects the skin with the deeper structures and should be
+considered a part of the true skin. It is made up of loosely
+arranged bundles of connective tissue which cross each
+other repeatedly and form well defined spaces. These
+spaces contain fat, and where there are large quantities
+of this fat, as on the soles of the feet, the tissue is designated
+as adipose. The subcutaneous areolar tissue also contains
+the deeper hair follicles and the deeper sweat glands.</p>
+
+<p><b>Blood Supply.</b> The layers of the epidermis are without
+vascular supply, but the derma and the subcutaneous tissue
+are well supplied with blood vessels. There are two plexuses,
+one superficial in the upper layer of the derma, and
+the other deep, in the subcutaneous tissue. The vessels of
+the upper layer arise from the deeper plexus and give off
+branches in all directions supplying the hair follicles, sweat
+and sebaceous glands. The papillary layer is richly supplied
+<span class="pagenum" id="Page_15">[Pg 15]</span>with delicate capillaries, which terminate in the
+papillæ, and are called capillary loops.</p>
+
+<p><b>Lymphatics.</b> The lymphatics follow the vessels in a
+general way, there being two plexuses, viz.: deep and superficial.
+Lymph spaces are found in the rete Malpighii, which
+connect with the channels of those in the derma. The
+papillæ and the glands also have lymph channels.</p>
+
+<p><b>Nerve Supply.</b> The skin contains both medullated and
+non-medullated nerve fibres; these fibres are especially
+abundant in the soles of the feet and at the ends of the toes.
+They enter the skin with the more important ascending
+blood vessels. The non-medullated nerves terminate in the
+rete as fine filaments, and the medullated nerves end in the
+corium and subcutaneous tissue in special terminals called
+corpuscles. Examples of these are Pacinian corpuscles,
+tactile corpuscles and the end bulbs of Krause.</p>
+
+<p>In addition to the sensory nerves, the skin also contains
+vasomotor nerves. These nerves are found on the smooth
+muscles of the skin and on all glands having such muscles,
+and have a direct action on these glands.</p>
+
+<p><b>Muscles.</b> Both striated and non-striated or smooth
+muscles are found in the skin. Those of the latter variety
+are most common, while the former are sparingly found.
+The smooth muscle fibres are found in connection with
+the hair follicles, the sebaceous and the sudoriferous glands,
+and they act upon these organisms.</p>
+
+<p><b>Sudoriferous Glands.</b> The sudoriferous glands, or
+sweat glands, are found in the reticular layer of the corium
+and in the subcutaneous tissue. They are simple tubular
+glands which are coiled into globular shape. The tubule of
+the gland empties into a gland duct which passes through
+the corium and the epidermis and opens on the surface of
+the skin in a funnel-shaped sweat pore. The sweat glands
+are very numerous, particularly on the soles of the feet.
+It is estimated that there are 2,000,000 sweat glands in the
+adult human body.</p>
+
+<p><b>Sebaceous Glands.</b> The sebaceous glands, or oil glands,
+<span class="pagenum" id="Page_16">[Pg 16]</span>are found in the reticular layer of the derma, usually
+associated with or in close proximity to a hair follicle. They
+may occur independent of the hairs however, as is the case
+in the lips. They vary in size from a simple pouch to a
+many pouched or multilobular gland. These pouches empty
+into a common duct, which in turn empties between the
+hair and the inner sheath. The ducts secrete sebum, which
+consists of fatty degenerated cells, in which is found epithelial
+waste matter. The sebum keeps the skin and the hair
+soft and oily.</p>
+
+
+<h3 id="NAILS">
+  NAILS
+</h3>
+
+<p><b>The Nails</b> are a specialized form of epidermis, and are
+considered by many to correspond to the stratum lucidum
+of that structure. They are horny, elastic, transparent,
+quadrilateral plates, and are found at the distal ends of the
+fingers and toes, on their dorsal surfaces. The nails are
+convex on the outer surface and concave within. The nail
+itself is called the body and rests upon the nail bed. It has
+a free edge distally and two lateral and a proximal or short
+edge which latter lie in a groove called the nail or ungual
+fold. The ungual wall overlies the lateral and proximal
+portions. The nail is embedded into the derma at its
+proximal end by a root. This part of the nail is found
+beneath the ungual wall and is composed of cells which have
+not yet become horny.</p>
+
+<p>The thin layer of skin, which extends forward from
+the nail groove at the beginning of the body of the nail, is
+called the eponychium or nail skin. The lunula is the little
+whitish, crescentic spot, a portion of the nail bed, which is
+found in front of the nail fold, and extends to the lateral
+edges of the nail.</p>
+
+<p>The matrix of the nail is situated beneath the
+root of the nail, and is so-called because it is from this
+structure that the nail is produced. The matrix is thick,
+and raised in a series of longitudinal ridges, which are
+readily seen through the transparent nail tissue. It corresponds
+<span class="pagenum" id="Page_17">[Pg 17]</span>to the mucous layer of the epidermis, and is
+essentially of the same structure. The matrix is highly
+vascular, which accounts for the pink color seen through
+the nail, except at the lunula.</p>
+
+
+<h3 id="PHYSIOLOGY_OF_THE_SKIN">
+  PHYSIOLOGY OF THE SKIN
+</h3>
+
+<p>The functions of the skin may be subdivided as follows:</p>
+
+<blockquote>
+<p>
+  Touch Organ<br>
+  Protective Covering<br>
+  Excretory and Secretory Organ<br>
+  Temperature Regulator<br>
+  Organ of Respiration
+</p>
+</blockquote>
+
+<p>The skin acts as a touch organ or as an organ of tactile
+sensibility; this power is supplied by special bodies found
+in the papillæ. The degrees of consistency, of size, of form
+and of other qualities are recognized by this function.
+Other sensations are conveyed by these special nerve endings,
+such as heat and cold, burning, itching, tingling, etc.
+The sense of touch is well developed, particularly in the
+skin at the ends of the fingers, and this sense may be
+farther increased, as is the case with blind persons.</p>
+
+<p>The skin acts as a protective organ to the body within,
+by excluding harmful agents such as bacteria, chemicals,
+heat, cold, etc. It is elastic and thick and is without sensation
+and thus protects the delicate structures beneath it
+from injury from various causes.</p>
+
+<p>The functions of excretion and of secretion are performed
+by the glands. The sudoriferous, or sweat glands,
+excrete the perspiration, and in this way also act as elimination
+organs, accessory to the kidneys. The body is continuously
+sweating. When there is no indication of this
+function, when the skin seems dry, the name “insensible
+perspiration” is applied; when the function is apparent, by
+the formation of drops of moisture on the surface, it is
+called “sensible perspiration.”</p>
+
+<p>The sebaceous glands are organs of secretion. They
+<span class="pagenum" id="Page_18">[Pg 18]</span>give off an oily substance called sebum, which lubricates
+the hairs, and gives an oily, soft appearance to the skin.
+This tends to keep the outer layers elastic and pliable;
+where this function is absent, the skin becomes dry and is
+likely to form cracks or fissures.</p>
+
+<p>The skin acts as a regulator of the body heat, by controlling
+the radiation of the heat as brought to the surface
+from within, and by regulating evaporation. The normal
+tension of the skin on the various parts of the body has an
+influence in the regulation of body temperature.</p>
+
+<p>The function of respiration is, to some extent, duplicated
+by the skin, the process being analogous to the respiration
+that takes place in the lungs. The amount of oxygen
+absorbed is small, but water and carbon dioxide are freely
+given off.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_19">[Pg 19]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_III">
+    <span class="chap">CHAPTER III</span>
+    <br>
+    ASEPSIS AND ANTISEPSIS
+  </h2>
+</div>
+
+
+<p>To understand thoroughly and rationally to practise
+asepsis and antisepsis, it is necessary for the operator to
+realize the difference between the two terms. There is a
+general belief among the laity—and, unfortunately, among
+some chiropodists—that these two words are synonymous,
+and that asepsis and antisepsis comprehend the same
+system of treatment. This is a fallacy.</p>
+
+<p><b>Asepsis</b> is a condition in which living pyogenic organisms
+are absent. Aseptic surgery comprehends the performance
+of an operation in a field free from pyogenic or
+septic germs, with sterilized hands, instruments, etc., preventing
+the introduction of germs from without.</p>
+
+<p><b>Antisepsis</b> is the process whereby germs causing disease,
+fermentation, or putrefaction are destroyed. Antiseptic
+treatment comprehends the use of certain drugs or a
+group of drugs which prevent the action of germs, which
+inhibit their growth, or which destroy them.</p>
+
+<p>In the comparison of these two foregoing definitions
+the distinction between the two words is clearly brought
+out. We speak of a drug—mercuric chloride, for instance,
+as having an antiseptic action. We speak of a piece of
+sterile gauze—sterilized, we will say, by heat—as being
+aseptic. The mercuric chloride is an active substance which,
+applied to a septic area, will proceed energetically to its
+work of germ inhibition or destruction. The sterile gauze,
+placed over a similar area, has no power to prevent or even
+retard the action of the invading bacteria, let alone destroy
+them, but once having been rendered free from such germ
+life by an antiseptic, the aseptic gauze will keep the area
+<span class="pagenum" id="Page_20">[Pg 20]</span>in a germ free condition for a greater or lesser length of
+time.</p>
+
+<p>To sum up, then, the term “antiseptic” is applied to a
+drug or group of drugs from whose actions bacteria are
+rendered innocuous or are destroyed; and “aseptic” is
+applied to a condition in which no germ life exists, having
+previously been freed from such contamination by the use
+of an antiseptic agent.</p>
+
+<p>Some years ago the term “germicide” was used in contradistinction
+to that of “antiseptic.” This usage was
+brought about through the belief that some antiseptics
+would not destroy all forms of germ life. Germicide, at
+that time, was used to distinguish a drug which would
+energetically attack and destroy all bacteria. Inasmuch as,
+on close survey, it was found that the antiseptics which
+would not destroy all germs were, in a great measure,
+weaker solutions, and that, if used in greater strength, they
+would be efficient as purifying agents, this distinction, today,
+has been done away with, and the terms germicide and
+antiseptic are used synonymously and will be similarly
+employed in this chapter.</p>
+
+
+<h3 id="ANTISEPSIS">
+  ANTISEPSIS
+</h3>
+
+<p>Antiseptics to be actually efficient must be brought in
+direct contact with the septic area. There is an erroneous
+belief that all of the official germicidal agents and a
+majority of the proprietary preparations, the advertising
+matter of which latter claims for them great antiseptic
+proprieties, are efficient in deep-seated, septic processes by
+mere surface application. This is wrong, and it is for this
+reason that in all septic inflammations, free drainage must
+be obtained and maintained, and the actual surface upon
+which the bacterial action is in evidence must be exposed
+before the beneficial action of antiseptic agents can be
+exerted or prove beneficial.</p>
+
+<p>The skin unquestionably does, at times, absorb a drug
+applied to its surfaces; but where an active infective process
+<span class="pagenum" id="Page_21">[Pg 21]</span>is present, the antiseptic action of a germicidal agent is
+practically nil unless the drug is brought into direct contact
+with the septic surface.</p>
+
+<p>The present success of Dakin’s solution, for instance,
+is not so much on account of the great efficacy of the solution
+itself—although it has potent germicidal properties—as it is
+due to the Carrel method of irrigation whereby this solution
+is carried to the most obscure recesses in which the
+infective process is present. Applied superficially, as must
+needs be done in chiropodial practice, we find that Dakin’s
+solution is of no greater value than many other antiseptic
+agents, except perhaps that, on account of its being non-toxic,
+it can be used in cases where germicides with strong
+toxic properties are contra-indicated.</p>
+
+
+<h3 id="HISTORY_OF_ANTISEPTICS">
+  HISTORY OF ANTISEPTICS
+</h3>
+
+<p>The story of antiseptics is one of the most interesting
+in all the pages of medicine and surgery.</p>
+
+<p>Antiseptics were employed as remedial agents long
+before the exact causes of putrefaction or fermentation
+were known. The Egyptians preserved the human body
+against the attacks of putrefactive organisms, without any
+knowledge of the character of the organisms causing decay.
+The wonderful state of preservation in which we, today,
+find the bodies of their kings, was brought about by means
+of balsams containing, probably, such antiseptics as benzoic
+and cinnamic acids.</p>
+
+<p>In the sixteenth century the surgeons treated gunshot
+wounds with boiling oil. They knew that if these wounds
+were left untreated, putrefaction would ensue accompanied
+by great suffering, and the ultimate death of the patient.
+They also knew, empirically, to be sure, that boiling oil
+applied to the wound prevented the development of this
+putrefactive process, but they did not know why such was
+the case, nor did they realize that, by this use of superheated
+oil they were merely cauterizing the wound.</p>
+
+<p>Ambrose Pare (1510-1590), who started life as an apprentice
+<span class="pagenum" id="Page_22">[Pg 22]</span>barber-surgeon in Paris, became a military surgeon
+in the army of Francis I, in Piedmont; and he, more from a
+humane feeling, as his writings tell us, than from any particular
+scientific knowledge, had the temerity to dispense
+with this oil boiling technic and to trust to a simple bandage
+saturated with a concoction of herbs. Pare, however, has
+no particular place in the development of antisepsis, his
+principal contribution to surgery being in the development
+of the use of the ligature for large arteries, which made
+amputation on a large scale possible for the first time.</p>
+
+<p>Antiseptic surgery dates from the last few years of the
+nineteenth century, and among the names of its sponsors
+which will ever remain foremost, are Pasteur and Lister.</p>
+
+<p>Lister’s use of local antiseptics in surgery, however,
+should not, perhaps, be spoken of as a discovery. Without
+detracting in any way from the credit due him, it should be
+referred to, more correctly, as a practical application, in
+particular of the theories of Pasteur, and of several previous
+investigators.</p>
+
+<p>Prior to Lister’s use of phenol, the substance had already
+been described by Reichenbach in 1832, and by
+Runge in 1834, as one which would prevent putrefaction.
+Long before these, tar and a number of similar products
+were advocated and used for foul ulcers, but the fact remains
+that Joseph Lister placed the use of antisepsis in
+connection with surgical procedures on a sound and practical
+basis.</p>
+
+<p>Taking as a working basis the experimental researches
+of Louis Pasteur (Communications on the Theory of Fermentation
+1853, 1858; The Germ Theory, read before the
+French Academy of Sciences on April 29th, 1878, and The
+Extension of the Germ Theory, which appeared in 1880),
+Joseph Lister, an English surgeon, developed his theory
+of antiseptic wound treatment. His first experiments were
+made public in 1860. At that time he stated that the evils
+observed in open wounds were due to the admission into
+them of organisms which “exist in the air, in water, on
+<span class="pagenum" id="Page_23">[Pg 23]</span>instruments, on sponges, and on the hands of the surgeon
+or the skin of the patient.” Having accepted the germ
+theory of putrefaction, Lister applied himself to discover
+the best way of preventing harmful organisms from reaching
+the wound from the moment it was made until it was
+healed, or, if this could not be done, of using some agent
+to destroy the organism, either before it reached the wound
+or after it had lodged there.</p>
+
+<p>Acting on the advice of Lemaire, who had already experimented
+with several substances which were known to be
+antagonistic to putrefaction, Lister chose carbolic acid,
+which he used first in the crude form.</p>
+
+<p>His experiments extended over a number of years
+during which period he surmounted many obstacles, until
+in the early 80’s he finally perfected his antiseptic treatment
+of wounds by means of carbolized sprays for the air of the
+room, carbolized solutions for irrigation, for instruments
+and for surgeons’ hands, and carbolized dressings with
+mackintosh protection, as post-operative procedures. Today
+we smile at the idea of a dressing of phenol in any
+strength, covered with mackintosh protection; but in advocating
+this procedure, Lister had in mind, as nearly as
+possible, to cover the wound so that no external agencies
+might come in contact with it.</p>
+
+<p>From this beginning, our present day antiseptic surgical
+technic has been gradually developed. Mercuric chloride
+gradually replaced phenol, and the use of the carbolic spray
+was discontinued on account of its chilling influences on
+exposed surfaces, which tended to lower their vitality.</p>
+
+<p>Aseptic surgery owes its origin primarily to antiseptic
+surgery. Not long after Lister’s rules for antiseptic
+procedure were generally observed, the realization came to
+many that the success of Listerian surgery did not depend
+so much upon the spray or the carbolized gauge, as it did
+upon cleanliness; the surgeon’s hands, the instruments, the
+area to be operated upon, and the dressings must be clean—surgically
+clean.</p>
+
+<p><span class="pagenum" id="Page_24">[Pg 24]</span></p>
+
+<p>Today we have the rule of “the soap and nail brush,”
+the sterilized instruments, the aseptic rubber gloves for the
+operator’s hands, and the sterile dressing. The modern
+surgeon uses no antiseptics during operations; he uses instruments
+which are positively germless and the dressings
+of aseptic gauze are not impregnated with medications.</p>
+
+
+<h3 id="ANTISEPTICS">
+  ANTISEPTICS
+</h3>
+
+<p>The important subject of antisepsis embraces such a
+variety of agents which may be employed in the numberless
+conditions arising, that it is usually divided into three
+groups. (1) general antiseptics; (2) local antiseptics; (3)
+internal antiseptics. For the purposes of the podiatrist,
+some knowledge of the first group is desirable, but his principal
+thought on this subject should be given to a thorough
+knowledge and understanding of the second group, those for
+local application. Inasmuch as the podiatrist is not
+allowed to prescribe internal medicines, no discussion of the
+third group, comprising internal antiseptics, will be included
+in this chapter.</p>
+
+<p><b>General Antiseptics</b>, or disinfectants, play so great a
+part today in preventive medicine that the podiatrist
+should at least inform himself on the general principles
+involved.</p>
+
+<p>Under this group we find a number of agents which are
+employed for purposes of general disinfection. First on the
+list comes:</p>
+
+<p><b>Sunlight.</b> The bright, direct rays of the sun, coming
+into direct or immediate contact with germ life, are the best
+of all disinfectants. This does not mean their merely shining
+on one side of a carpet, or on small masses of blood,
+pus or sputum, but their penetrating each individual microorganism.
+When this can be accomplished, all germ life is
+destroyed in a few hours. But this cannot be accomplished
+in all conditions, and, unless the penetration of sunlight is
+thorough it is not dependable. For this reason we are
+<span class="pagenum" id="Page_25">[Pg 25]</span>forced to rely on other agents (thermal and chemical) to
+accomplish our purpose.</p>
+
+<p><b>Heat.</b> A direct flame will, of course, instantly destroy
+all forms of microscopic life; dry air heated to 160° C.
+(320°F.) will destroy all disease germs—but not all spores—in
+one hour. Moist heat, water or air saturated with
+aqueous vapor, heated to 75°C. (167°F.) will destroy most
+germs.</p>
+
+<p>Boiling water will even kill spores in ten minutes, if
+they are not in small masses. To break up such masses the
+addition of a small amount of baking soda will serve, not
+alone to dissolve these albuminous collections, but will also
+keep instruments from rusting (see Sterilization). Steam,
+or air which is supersaturated with steam, is fatal to pathogenic
+organisms, and at a much lower temperature than
+dry hot air.</p>
+
+<p>Chemicals which may be included under this group of
+general disinfectants are: formaldehyde, lime, sublimed sulphur
+and chlorinated lime.</p>
+
+<p><b>Formaldehyde</b>, formalin or formic aldehyde, is widely
+used as a general disinfectant. It is exceedingly powerful,
+one part of the gas rendering fifty thousand parts of air
+irrespirable. The action of formaldehyde is increased by
+moist heat, it does not actively corrode metallic instruments
+nor does it injure fabrics. The formaldehyde cabinet is used
+generally by podiatrists. (See Sterilization).</p>
+
+<p>The official preparation of formaldehyde is a 37% solution
+known as liquor formaldehydi, U. S. P. For the disinfection
+of rooms, the solution may be applied directly by
+washing or spraying, or it may be used in vapor form.
+When the latter is employed, the windows and doors are
+tightly closed and all the crevices are plugged with paper.</p>
+
+<p><b>Lime</b>, calx, or calcium oxide, is extensively used but
+must be freshly prepared to be effective. Unslacked lime
+is a cheap, and an efficient means of destroying animal matter,
+but the milk of lime, freshly slaked, is by far the most
+desirable form.</p>
+
+<p><span class="pagenum" id="Page_26">[Pg 26]</span></p>
+
+<p><b>Sublimed Sulphur</b>, or flowers of sulphur, is not so generally
+used today as is formaldehyde. It should be used
+only in places where nothing can be injured by the corrosive
+action of the resulting sulphurous acid. As with formaldehyde
+disinfection, the vapor must come into actual
+contact with the microorganisms and the atmosphere should
+be moist.</p>
+
+<p><b>Chlorinated Lime</b>, improperly called chloride of lime, is
+a ready source of chlorine, and is a convenient and inexpensive
+agent for general disinfection purposes. It has a
+corrosive action, however, and therefore should not be used
+in places where this action will do damage.</p>
+
+<p>There are a number of drugs which may be more or less
+successfully employed as general antiseptics and disinfectants.
+Phenol, cresol, potassium permanganate, mercuric
+chloride and copper sulphate are on this list, but as the
+podiatrist is principally concerned with the second group,
+local antiseptics, these drugs, which are included usually
+under that group, will now be discussed.</p>
+
+<p>It is deemed wise before passing on to the subject of
+local antiseptics, to bring one important point to the attention
+of the student. Under no circumstances must the term
+deodorant be confused with disinfectant. A deodorant is
+an agent which merely destroys or conceals an offensive
+odor and has no power whatsoever to actually destroy or
+inhibit the growth or action of bacteria. Many disinfectants
+are also deodorants, but a deodorant may not always have
+germicidal properties.</p>
+
+<p><b>Local Antiseptics</b> are agents which are applied locally
+and externally for the purpose of arresting putrefaction.
+In podiatry there are a number of drugs belonging to this
+class which may be safely employed and whose beneficent
+action may be depended upon.</p>
+
+<p>There has been a marked tendency in podiatry in the
+past toward the use of a number of proprietary drugs for
+germicidal purposes. Happily this practice is dying out,
+<span class="pagenum" id="Page_27">[Pg 27]</span>and a few years will find the therapeutics of podiatry established
+on a sound, rational basis.</p>
+
+<p>The following local antiseptics can be safely employed
+in podiatry operations:</p>
+
+<p><b>Alcohol</b> is used generally in practice to render fields
+of operation surgically clean. The pure grain alcohol is
+used for the immersion of instruments prior to operation,
+but a 60% solution is found more efficient for antiseptic
+action upon the body surfaces. A pledget of sterile cotton,
+saturated with alcohol and placed over a part, insures absolute
+asepsis in a short time. Alcohol alone cannot be practically
+used as a wet dressing. In this connection it is combined
+with boric acid, equal parts, and is efficient as an
+antiseptic.</p>
+
+<p><b>Liquor Alumini Acetatis</b>, an 8% aqueous solution of
+acetate of aluminum, is used almost entirely as a wet dressing
+in infective inflammations. It is non-toxic and, while
+it is irritant to extensive denuded surfaces, it is usually employed
+for its astringent action.</p>
+
+<p><b>Balsam of Peru</b> is used chiefly in podiatry as a stimulating
+agent; its antiseptic properties, however, are well
+known and are probably due to the benzoic and cinnamic
+acid which it contains. It is used either alone, in ointment
+form, 3% to 10%, or in combination with collodion, 10%.</p>
+
+<p><b>Boric Acid</b> is employed principally as a wet dressing in
+cases of inflammations. It is quite free from toxicity and
+is but slowly absorbed. It is also used in powder form as
+an antiseptic.</p>
+
+<p><b>Boroglycerine</b>, U. S. P., contains 30% of boric acid. It
+is found particularly effective in the treatment of indolent
+ulcers where a mild antiseptic lotion is desired.</p>
+
+<p><b>Borate of Sodium</b> (Sodii boras, U. S. P.), borax, has
+an alkaline reaction and for this reason is sometimes substituted
+for boric acid. It is soluble in 16 parts of water.</p>
+
+<p><b>Dakin’s Solution</b> is a solution of hypochlorite of soda,
+¹⁄₂%. The preparation of the original solution is so difficult
+that large quantities of the drug are not easily obtainable.
+<span class="pagenum" id="Page_28">[Pg 28]</span>Chlorazene, an American product which is recommended
+by both Dakin and Carrel, is obtainable in tablet
+and in ointment form. One tablet dissolved in 8 ounces
+of water makes a solution, ¹⁄₂ of 1%. The solution is unstable,
+necessitating its being constantly made fresh, and
+for this reason the use of the drug is not practical in
+podiatry practice today. When used, the solution must be
+changed within twenty-four hours; if this is not done it
+becomes irritant, setting up an acute dermatitis. The drug
+is used as a wet dressing, but never with rubber or oiled
+silk covering.</p>
+
+<p><b>Di-Chloramin-T</b>, the newer form in which Dakin’s solution
+is used, is a 5% or 10% hypochlorite of soda solution
+in oil of eucalyptus. This combination is found to be less
+irritating than the original solution. It is used as an antiseptic
+dressing.</p>
+
+<p><b>Glycerinum</b>, U. S. P., is not alone useful as a mild
+antiseptic but is also extensively used as a vehicle for many
+other substances in the treatment of skin lesions.</p>
+
+<p><b>Hydrogen Dioxide</b>, peroxide of hydrogen, is used principally
+in podiatry to decompose pus in which bacteria are
+protected from the action of other antiseptics. As the
+antiseptic action of hydrogen dioxide is dependent solely
+upon the liberation of its component oxygen, it is easily
+seen that once the ebullition occurring on its contact with
+albuminous surfaces ceases, it becomes inert. “Peroxide”
+is used as a pus germ destroying agent, and to loosen
+dressings which have become adherent from copious discharge.</p>
+
+<p><b>Iodine</b>, Tinct. Iodii, U. S. P., is 7% of iodine in alcohol,
+and presents the best agent known at the present time by
+which surface sterilization can be obtained. It is highly
+germicidal, but continued applications are decidedly corrosive
+and not alone inhibit the development of new granules,
+but also cause severe dermatitis, and at times symptoms of
+iodine poisoning. The one feature which prevents its use
+in some chiropodial procedures is the discoloration of the
+<span class="pagenum" id="Page_29">[Pg 29]</span>tissues produced by its application. It may be used full
+strength or diluted with water, as weak as a 1% solution.</p>
+
+<p><b>Iodoform</b>, despite its unpleasant and suggestive odor, is
+an efficient antiseptic and is used in powder form. Its
+antiseptic action is principally derived by the slow liberation
+of its component iodine.</p>
+
+<p>Several forms of mercury are used in podiatry.</p>
+
+<p><b>Bichloride of Mercury</b>, or mercuric chloride, is used,
+¹⁄₂₀₀₀, to prepare fields for operation, and from ¹⁄₅₀₀₀
+to ¹⁄₁₀₀₀₀ as a wet dressing in infective inflammations. It
+is highly toxic and should never be used for any great
+length of time, or on a denuded surface of any size, as it
+is rapidly absorbed into the general system, and its corrosive
+action tends to inhibit the development of new granules.
+There are also systemic effects to be feared from its
+absorption.</p>
+
+<p><b>Mercurous Chloride</b>, calomel, can be used as an antiseptic
+dusting powder on many chiropodical lesions. It is
+combined generally with bismuth, equal parts, as an antiseptic
+and astringent application for blisters and burns.</p>
+
+<p><b>Unguentum Hydrargyri</b>, U. S. P., is a 50% ointment,
+used principally in chiropody in the treatment of parasitic
+diseases of the nails.</p>
+
+<p><b>Unguentum Hydrargyri Ammoniatum</b>, 10%, is an antiseptic
+ointment used safely in any case where such action
+is desired.</p>
+
+<p><b>Phenol Liquefactum</b>, U. S. P., carbolic acid, is used as
+an antiseptic in solution, 2¹⁄₂%. It is highly toxic and is
+never used as a wet dressing under any circumstances.
+Phenol, besides its toxic properties, has an anesthetic action
+on the peripheral nerves, and due to this action, many cases
+of carbolic gangrene have been reported.</p>
+
+<p><b>Liquor Cresolis Compositas</b>, U. S. P., also a coal tar
+product, can be advantageously used in a general spray for
+the foot, or for the special field of operation. It is antiseptic,
+and its saponaceous properties (it is a solution of
+<span class="pagenum" id="Page_30">[Pg 30]</span>cresol and soap) aid in softening the tissues as well as in
+cleansing them. It is used in 2% strength.</p>
+
+<p><b>Lysol</b>, an unofficial phenol derivative, is also used as a
+general spray, 2%, in water. Its odor is very strong and it
+is therefore objectionable to many persons.</p>
+
+<p><b>Thymol</b> is a phenol occurring in a volatile oil. It
+possesses strong antiseptic properties, but its comparative
+insolubility in water has prevented its more general use.
+The only official combination of thymol is</p>
+
+<p><b>Thermolis Iodidum</b>, U. S. P. Thymol iodide, or more correctly
+dithymoldiiodid, has been better known for years
+under its trade name “aristol.” It is used as a dusting
+powder, is actively antiseptic by the liberation of iodine, and
+has become popular as an iodoform substitute.</p>
+
+<p><b>Potassium Permanganate</b>, U. S. P., has its greatest usefulness
+as a local antiseptic application where deodorant
+action is also desired. In the treatment of indolent, foul
+ulcerations it is very efficacious.</p>
+
+<p><b>Sulphur</b> is used principally in podiatry in the form of
+<b>Unguentum Sulphuris</b>, U. S. P. It is composed of 15% of
+washed sulphur, usually in a lanolin base, and has a mildly
+stimulating and antiseptic action.</p>
+
+<p>There are any number of additional drugs, both official
+and unofficial, which can be and are used in podiatry practice,
+but it is deemed sufficient to name the foregoing which
+constitute a complete armamentarium for all antiseptic procedures.</p>
+
+
+<h3 id="THE_FIELD_OF_OPERATION">
+  THE FIELD OF OPERATION
+</h3>
+
+<p>For rendering the field of operation aseptic the following
+technic will be found efficient:</p>
+
+<p>In addition to preparing the immediate field it is found
+advantageous to treat the surrounding areas to prevent the
+washing in of bacteria. To accomplish this the use of an
+antiseptic spray is to be advocated.</p>
+
+<p>Equipped as the podiatrist is with modern air compressing
+<span class="pagenum" id="Page_31">[Pg 31]</span>devices, this is a simple matter, the principal question
+being the selection of a proper spray.</p>
+
+<p>An aqueous solution of alcohol is exceptionably suited
+for purposes of this kind and where a lesion is already
+present this drug should be used to the exclusion of all
+others.</p>
+
+<p>Most cases the podiatrist is called upon to treat,
+however, present no lesion, yet asepsis must be procured in
+the event of a lesion being made during his operative procedures.
+In cases of this nature a spray of liq. cresolis
+compositus, U. S. P., 2¹⁄₂%, will be found to be an agreeable
+and efficient application. This solution has but a slightly
+disagreeable odor and has marked softening as well as
+antiseptic properties.</p>
+
+<p>After the whole foot has been thoroughly sprayed and
+dried with a sterile towel, the immediate field of operation
+may be coated with tr. iodine, 3¹⁄₂%. This is one-half the
+strength of the official tincture and is advocated to obviate
+the deep stain occasioned by the use of the 7% tincture.
+In many cases, however, no stain whatsoever can be countenanced
+for fear of obliterating some diagnostic point, and
+it may be found advisable to dispense entirely with iodine,
+substituting alcohol, 60%, in its stead.</p>
+
+<p>A pledget of sterile cotton saturated in this solution
+of alcohol and placed over the area under treatment, will
+produce asepsis in a short time. The penetrating qualities
+of alcohol are, however, found to be increased, if application
+is made by means of a cotton wound applicator, the
+mixture being rubbed vigorously into the parts.</p>
+
+<p>The use of either of these two methods will procure a
+sterile field upon which any chiropodial operation may be
+commenced and completed in safety.</p>
+
+<p>Should hemorrhage be caused during operation, it may
+be arrested in a number of ways: (1) Bichloride of mercury,
+¹⁄₁₀₀₀, may be applied on a pledget of sterile cotton.
+This will serve to check the blood flow by hastening coagulation,
+and at the same time will procure asepsis. (2) Tr.
+<span class="pagenum" id="Page_32">[Pg 32]</span>iodine may be painted over the lesion and digital or tourniquet
+pressure applied until coagulation is complete. (3)
+Astringent and antiseptic dusting powders may be applied.
+(4) Styptics (Monsel’s solution is efficient and the least
+irritating) may be used, but it must be remembered that
+these drugs combine no antiseptic qualities and therefore it
+is good surgery to apply tr. iodine before their use.</p>
+
+<p>A hemorrhage arrested by any of the foregoing methods
+should be dressed antiseptically, as well. For this form of
+dressing, antiseptic ointments or dusting powders are found
+to be most effective.</p>
+
+
+<h3 id="ASEPSIS">
+  ASEPSIS
+</h3>
+
+<p>The topic of asepsis will be found more thoroughly, discussed
+under the chapter “Sterilization.”</p>
+
+<p>Aseptic procedure comprehends the employment of all
+instruments and materials which have by some means been
+previously rendered free from germ life. Instruments are
+to be thoroughly sterilized by boiling in water for at least
+fifteen minutes, the hands of the operator are to be thoroughly
+cleansed, or are made as nearly germ free as is possible;
+the dressings used are to be surgically cleansed
+(usually by moist or dry heat) before application; and no
+antiseptic solutions are included in the treatment.</p>
+
+<p>It is doubtful if aseptic procedures can be practised in
+podiatry to the exclusion of antisepsis. It must be remembered
+that after most chiropodical surgical procedures, the
+foot surfaces (again encased in a shoe) teem with septic
+matter which present the mediums best suited for the propagation
+of bacterial life,—heat, moisture and darkness.</p>
+
+<p>An aseptic dressing having been employed, the length of
+time it will remain germ free is problematic; so it is found
+advisable in most instances where there is danger of infection,
+to resort to an antiseptic method of treatment rather
+than to rely solely upon the aseptic.</p>
+
+<p>Dr. Edward Adams, Professor of Surgery at The First
+<span class="pagenum" id="Page_33">[Pg 33]</span>Institute of Podiatry, lecturing to the students on “The
+Newer Antiseptics in the War,” spoke as follows:</p>
+
+<p>“The immense number and variety of wounds encountered
+in the present war, necessitating the care of many
+thousands of men at one time, and the entirely new situations
+created by modern warfare, have led to an amount of
+research heretofore unknown. True to its traditions, the
+medical profession has endeavored to discover the best
+methods in treatment and to render the best service in its
+power to bestow. Never has the surgeon had to face greater
+difficulties and never has he recorded more brilliant success.</p>
+
+<p>“Where practically every wound is infected, antisepsis
+has necessarily received unusual attention, and the merits
+of different substances having antiseptic properties have
+been thoroughly discussed and have narrowed down to a
+very few. The fact is emphasized that those which are
+strong enough to be antiseptic must be used with great care,
+especially in cases where drainage is not free.</p>
+
+<p>“After many trials and many discussions the tendency
+of men of the greatest experience, however, is to reduce the
+problem to very simple terms which may be expressed thus:
+(1) How to secure a clean wound. (2) How to give nature a
+chance with a minimum of interference, since, after all, she
+must do the healing.</p>
+
+<p>“The early part of the war demonstrated the fact that
+both antisepsis and asepsis, as heretofore practised, have
+been vanquished by Mars. By some it was even considered
+that Lister’s work went for naught. Now, however, antisepsis
+and asepsis, each in its proper place, have come into
+their own again and Lister is still the apostle of good
+tidings.</p>
+
+<p>“The reasons are plain: first, at the beginning of
+the war we did not possess sufficiently effective antiseptics
+such as have now been given us; second, we were not masters
+of an efficient technic. We owe these innovations especially
+to two men, Dakin and Carrel, who have wrought a
+marvelous change. Lister taught us above all how to prevent
+<span class="pagenum" id="Page_34">[Pg 34]</span>infection; Dakin and Carrel, following his principles,
+have taught us how to conquer even the most virulent infections.
+For nearly half a century surgeons have been
+fighting strenuously against infection, but it required the
+stimulus of war to enable us to win a victory. Prevention
+and cure both are ours now.</p>
+
+<p>“The newer antiseptics that have been discovered and
+used since the war are chiefly: Dakin’s solution of hypochlorite
+of soda, di-chloramin-T, eusol and eupad, both
+preparations of hypochlorous acid, flavin, acriflavin, and
+proflavin, and a mercurial preparation known as mercurophen.</p>
+
+<p>“These newer antiseptics, especially the flavin group,
+have pronounced bactericidal qualities, but it is too recent
+as yet for them to have been tested on a sufficiently large
+scale to permit of positive conclusions as to their value.
+Flavin is described in detail as to its process of manufacture
+and its action in an article by C. H. Browning and his colleagues
+in the Bland-Sutton Institute of Pathology of Middlesex,
+London (<i>British Medical Journal</i>, January 20, 1917,
+page 73). For technical reasons flavin as one of the acridin
+group is now called acriflavin, and a more potent preparation
+is called proflavin, which is described in the <i>British
+Medical Journal</i>, June 9, 1917. Dakin, in the same journal,
+June 23, 1917, endorses Browning’s method of treatment
+with acriflavin. Its antiseptic action, instead of being diminished
+by blood serum, is increased thereby, even up to
+five times its potency. Moreover, as used by Browning, it is
+harmless to the tissues and does not interfere with the activity
+of the leucocytes nor with phagocytosis.</p>
+
+<p>“The most important paper yet published on these
+newer antiseptics is by Browning Culbranson and L. H. D.
+Thornton in the <i>British Medical Journal</i>, July 21, 1917.
+The principal points brought out by their experiments with
+the use of acriflavin and proflavin are as follows: first, that
+the bactericidal power of acriflavin and proflavin, instead
+of being diminished and even destroyed by the contact of
+<span class="pagenum" id="Page_35">[Pg 35]</span>blood serum (as is the case with hypochlorite of soda,
+bichloride of mercury, etc.), is greatly increased from 10
+to 40 fold. Second, as a result, these two antiseptics, though
+acting at first merely by inhibiting bacterial growth, later
+become increasingly powerful and actively destroy the bacteria.
+After two hours’ contact in the presence of serum,
+mercuric chloride is practically equal to acriflavin in its lethal
+effect on the streptococcus and bacillus coli, but by this time
+the effective action of the mercury salt on the bacteria has
+come to an end, and a concentration which has then failed
+to kill the organisms, exerts little or no inhibiting effect
+on the proliferation of the survivors. On the other hand,
+concentrations of the flavins, which at this period have
+merely inhibited multiplication, later on prove bactericidal,
+so that finally the flavin compound is ten to twenty times
+more lethal than corrosive sublimate. Therefore, instead
+of renewing the solution every two hours, only one or two
+daily dressings are required. Moreover, they are apparently
+harmless to the tissues. Experiments show that such
+concentrations of flavin as will effectively control the bacteria
+do not interfere with phagocytosis.</p>
+
+<p>“Brilliant green, like the hypochlorites, in the presence
+of serum, soon loses its value as a bactericide; hence, if used
+it must be renewed at frequent intervals. On the other
+hand, it possesses the advantage of being an extremely potent
+bactericide, far exceeding the flavins in watery solutions,
+while at the same time it is comparatively harmless
+to phagocytosis, as well as to the tissues locally, and when
+applied to a wound it is devoid of general toxic action on the
+body. Its use by two hourly flushings after the Carrel
+method, has proved most encouraging.</p>
+
+<p>“The Dakin Solution. The value of this antiseptic has
+been demonstrated by Drs. Carrel and Dakin. It is a carefully
+standardized solution of sodium hypochlorite and is
+usually prepared from chlorinated lime (bleaching powder),
+but may be prepared directly from chlorine gas. The formula
+has been varied from time to time. Some surgeons
+<span class="pagenum" id="Page_36">[Pg 36]</span>use an acid solution (anærobes do not live in an acid medium),
+others an alkaline solution, while Drs. Dakin and
+Carrel in their method, avoid an excess of either quality. In
+the solution now used by them which is made according
+to the formula of Dufresne, the chlorinated
+lime is combined accurately with both sodium carbonate
+and sodium bicarbonate, making a nearly neutral
+product which contains from 0.45 to 0.5 per
+cent. of sodium hypochlorite, because less is too weak
+and more is too strong. The advantages of this solution
+are as follows: (1) It is antiseptic and does not damage the
+tissues. (2) It is non-toxic and no danger is to be apprehended
+from its absorption. (3) It is hypertonic, that is,
+the concentration of the solution is greater than that of
+blood serum and tissue fluids, and therefore, it produces an
+outflow of lymph. (4) If used as an acid solution it is available
+against anærobic bacteria which require an alkaline
+medium.</p>
+
+<p>“The fact that nearly all wounds of the present war are
+infected, in connection with the serious and often fatal nature
+of the infection, has stimulated an unusual amount of
+research with the hope that a reliable and safe disinfectant
+may be discovered—especially one that will not injure the
+tissues of the body, since these are more easily affected by
+the disinfectant than the bacteria themselves. This object
+has been realized in large part by the Dakin-Carrel solution,
+which, however, to be effective, must be frequently renewed
+according to the Carrel technique. It is also frequently
+very irritating to the skin, although this may be avoided
+by the use of petrolatum.</p>
+
+<p>“According to the investigation of Dakin, a chemical
+action takes place between the hypochlorite in the solution
+and the proteins in the wound exudate with the formation of
+the new substances called chloramines. One of these chloramines
+has been prepared synthetically and introduced under
+the name of chlorazene, which is said to possess a germicidal
+power four times greater than the Carrel-Dakin solution
+<span class="pagenum" id="Page_37">[Pg 37]</span>itself and is unirritating to the skin but, like the latter, must
+be frequently renewed. By dissolving one of these chloramines
+in an oily medium, however, it is possible to keep it in
+contact with the wound surfaces for a much longer time than
+can be done with a watery solution. The advantage of this
+is evident.</p>
+
+<p>“The solution which is used at present has been named
+di-chloramin-T, the medium being chlorinated eucalyptus
+oil or paraffin oil. A ten per cent. solution of di-chloramin-T
+and eucalyptol may be kept in a colored bottle for at least
+one month with only slight change. It is applied to the
+wound surface in the form of a spray after the removal of
+infection foci and devitalized tissues. Deep cavities are
+filled with the liquid and drainage afterwards provided for.
+The high percentage of disinfectant contained in this preparation
+renders it active for a period of twenty-four hours
+because of the slow liberation of the germicide. It would
+appear that when applied with strict attention to detail it is
+not only less expensive than the Dakin-Carrel method, but
+will secure healing of a wound in a much shorter time. The
+gradual elaboration of the remedy makes it particularly applicable
+in cases that cannot be frequently dressed during
+transportation. Di-chloramin-T, hypochlorites and hypertonic
+salt solutions all have the power of dissolving dead tissue.
+A precaution to be remembered, however, is that if
+used near a blood vessel hemorrhage may occur.</p>
+
+<p>“For a detailed report of the use of di-chloramin-T
+in the treatment of infected wounds, read Dr. H. T. Dakin’s
+article in the <i>Journal of the American Medical Association</i>,
+July 7, 1917. For a still later description of the Dakin-Carrel
+treatment of wounds, see the report of the Surgical Commission
+to the Directors General of the British Army Medical
+Service reprinted from the <i>British Medical Journal</i>,
+November 3, 1917.</p>
+
+<p>“To my mind the best preparations that can be easily
+used are: (1) Chlorazene (Abbott), in tablet form; (2) in
+form of a non-irritating surgical powder containing 1 per
+<span class="pagenum" id="Page_38">[Pg 38]</span>cent. chlorazene; (3) in form of a cream containing 1 per
+cent. of chlorazene in a sodium stearate base. These I can
+recommend.”</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_39">[Pg 39]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_IV">
+    <span class="chap">CHAPTER IV</span>
+    <br>
+    STERILIZATION
+  </h2>
+</div>
+
+
+<p>In the practice of medicine and its allied branches, it is
+recognized that no unsterilized object is clean; it is therefore
+necessary for every such object to be sterilized before
+being brought in contact with, or near to a wounded surface,
+or to a surface about to be wounded.</p>
+
+<p>Previous to the time of Lister, who was the first one
+to practise and to advocate asepsis and antisepsis, it was
+considered normal for a wound to suppurate and the consequent
+appalling results were accepted as being in order.
+Today, however, asepsis and antisepsis have been proven to
+be absolute essentials to intelligent treatment, and it is accordingly
+necessary that every practitioner treating the
+human body, should exercise the greatest care so as to prevent
+the invasion of hostile bacteria.</p>
+
+<p>Sterilization may be defined as the act of rendering an
+object sterile (clean), by the destruction of microorganisms,
+preferably by means of heat. To perform any operative
+work, so that there is perfect asepsis, or freedom from bacteria,
+depends entirely upon the care exercised in practising
+such asepsis. The instruments, the dressings, the field of
+operation and the hands of the operator are all media for
+contamination and the infection of wounds, and the sterilization
+of all these is necessary, as infection might come from
+lack of care in the preparation of any one of these details
+before an operation.</p>
+
+<p><b>Instruments.</b> The most efficient way of rendering instruments
+sterile, is by immersing them in boiling water for
+fifteen minutes. To each quart of water used in the sterilizer,
+is added one-half an ounce of sodium carbonate (washing
+<span class="pagenum" id="Page_40">[Pg 40]</span>soda). This prevents rusting and also acts as a solvent
+for any fatty substance that may be on the instruments.</p>
+
+<p>Superheated steam is used for sterilizing instruments,
+but this requires especially large and expensive apparatus
+which is not at the command of most practitioners. Dry
+heat will destroy bacteria, but it is not as effective as moist
+heat (steam). To procure absolute results requires a high
+temperature, which effects the temper of the steel in the instruments.</p>
+
+<p>Instruments with sharp cutting edges, such as are used
+in the removal of helomata, are blunted by boiling. They
+are therefore best sterilized by immersing them in pure carbolic
+acid for a few minutes, followed by dipping in grain
+alcohol, the instruments being handled with a pair of
+forceps.</p>
+
+<p><b>Dressings.</b> Dressings such as gauze, bandages, absorbent
+cotton and other cloth materials are best sterilized by
+steam which is allowed to circulate through the material
+for fifteen minutes, and they may then be placed in dry heat
+for a short time, thus allowing the moisture to evaporate.
+If a steam sterilizer is not available, the dressings may be
+boiled, or they may be baked for ten minutes in a temperature
+not lower than that of the boiling point of water. Care
+should be taken that the heat is not great enough to scorch
+or burn the materials.</p>
+
+<p>Sterilized dressings of all kinds may be purchased in
+convenient, hermetically sealed packages, and may be safely
+used without preparation. Once such a package has been
+opened and used, the contents do not remain sterile; the
+materials left over from an operation should not be used
+at another operation unless they have been again thoroughly
+sterilized.</p>
+
+<p><b>Field of Operation.</b> The skin of the foot is much
+thicker than that on the other parts of the body and in addition
+it usually does not receive the same hygienic care as
+does the rest of the skin surface. It is therefore highly essential
+<span class="pagenum" id="Page_41">[Pg 41]</span>that additional precautions be taken in preparing
+the foot for operation.</p>
+
+<p>The entire foot should be scrubbed with soap and warm
+water so as to remove as much of the exfoliated skin and
+dirt as possible. It is then immersed in a solution of bichloride
+of mercury (¹⁄₂₀₀₀) and wrapped in a sterile towel
+until ready for operation. The foot may also be prepared
+by first scrubbing with soap and water, washing with alcohol,
+60%, and finally painting the part to be operated upon
+with tincture of iodine. Iodine has proven to be the best
+antiseptic in use today, but very often it interferes with
+chiropodical operations due to the stain it produces. This
+may be overcome to a certain extent by washing the part
+with alcohol after the iodine has been applied.</p>
+
+<p>Alcohol in a sixty per cent. solution is a very efficient
+antiseptic and wherever iodine cannot be used, it may be
+substituted. A piece of absorbent cotton, dipped into the
+alcohol, is placed in contact with the part to be treated and
+is allowed to remain for a few minutes. Like iodine, alcohol
+penetrates the layers of the epidermis and so destroys
+the bacteria that lurk between the outer layers.</p>
+
+<p><b>Hands of the Operator.</b> There are several ways of
+cleaning the operator’s hands, but each such procedure is
+preceded by thoroughly scrubbing them with green soap
+and a nail brush for at least ten minutes, in warm water.
+Alcohol or ether should then be rubbed over the hands to
+dissolve fats, and they should then be dipped in a solution
+of bichloride of mercury (¹⁄₂₀₀₀) for a few minutes. A
+most efficient way of sterilizing the hands consists of the
+following: after scrubbing the hands as before described,
+take equal parts of chloride of lime and carbonate of soda
+(about one-half teaspoonful of each) and add enough water
+to make a paste. This is thoroughly rubbed into the hands
+and when the sensation of warmth has disappeared they
+are rinsed in sterile water.</p>
+
+<p>The use of rubber gloves to protect the hands is of
+some advantage in that they may be thoroughly boiled before
+<span class="pagenum" id="Page_42">[Pg 42]</span>they are used; but unless the hands are sore or the skin
+is tender, they should not be employed, as they decrease the
+sense of touch so necessary in chiropodial procedures.</p>
+
+
+<h3 id="STERILIZING_APPARATUS">
+  STERILIZING APPARATUS
+</h3>
+
+<p>There are many kinds of apparatus for each form of
+sterilization, and the podiatrist, in selecting a sterilizer,
+must be guided by the size of his purse as well as the amount
+of space he can afford for such an apparatus.</p>
+
+<p>The steam sterilizer is unquestionably the best for general
+purposes, and the dual compartment arrangement is
+better than a single chamber outfit. Steam sterilizers for
+office purposes vary in size from the small single chamber,
+measuring four inches wide, eight inches long and four
+inches deep, to the larger double chamber which measures
+twelve inches wide, twenty-four inches long, the upper chamber
+twelve inches deep and the lower chamber six inches
+deep. The latter sterilizers are the best possible for the
+podiatrist’s work, in that they allow for the sterilization
+of towels, dressings and instruments at the same time, and
+there is no direct contact between the instruments and the
+boiling water. The apparatus may be heated by gas or by
+electricity, gas being the most desirable as it is more easily
+controlled and regulated. The cost of the instrument
+equipped for gas heating is very much cheaper, and the
+operating expense is less than when electricity is similarly
+used.</p>
+
+<p>As its name implies, the double compartment sterilizer
+is composed of two distinct sections which are easily separated,
+and when put together look as if they were one section.
+The lower compartment is more shallow than the
+upper and contains the water which is boiled for the manufacture
+of the steam to be utilized in the sterilization. The
+upper compartment has an inner jacket which is so arranged
+that the steam passing from below is collected in
+it, and is admitted into the compartment proper through a
+<span class="pagenum" id="Page_43">[Pg 43]</span>small opening at one end. This causes the steam to be
+forced in under a slight pressure, which increases the heat
+and adds to its power as a germ destroying agent. The
+opening is controlled by an inlet valve which may be adjusted
+so as to prevent the steam from entering the compartment.
+The steam then circulates around it in the
+jacket and in this way
+dry heat is generated in
+sufficient quantity to allow
+for dry heat sterilization.
+If space permits, it
+is advisable to have two
+such sterilizers, one for
+steam sterilization and
+the other for dry heat
+sterilization. The instruments,
+towels and dressings
+may thus be dried
+which prevents the rusting
+of the steel, and
+makes the linen more easy to handle. These sterilizers
+are as well, an ornament to any office.</p>
+
+<figure class="figcenter illowe15" id="i_p043">
+  <img class="w100" src="images/i_p043.jpg" alt="">
+  <figcaption>
+    ELECTRIC STERILIZER
+  </figcaption>
+</figure>
+
+<p>Where space is limited, the smaller electric sterilizers
+may be substituted for the larger outfits. There are many
+styles and shapes of this kind of instrument, but the principle
+is the same in all of them. There must be ample space
+for the reception of the instruments, and the cover must
+be closed when the water is boiling. The electric current is
+passed into a metallic disc, situated beneath the bottom of
+the water receptacle. As the current passes through this
+disc, it becomes hot, and the water in the compartment is
+gradually heated until the boiling point is reached. The
+current must never be left on when the machine is not in
+use, for when the water has evaporated, the heat will cause
+the solder holding the joints of the sterilizer to melt and
+cause a separation of the seams. This molten solder might
+even drip on something combustible and set it alight. There
+<span class="pagenum" id="Page_44">[Pg 44]</span>are some electric sterilizers which are equipped with safety
+devices which prevent this possible accident. The device
+provides so that when this heat is great enough, it melts a
+small piece of an alloy with a very low melting point. This
+metal is held in position by a clamp which is attached to the
+current flow and when this melts, the current is cut off and
+further heating is impossible.
+This is a very
+valuable attachment,
+particularly when one is
+inclined to be careless.</p>
+
+<p>Another form of
+smaller electric sterilizer
+consists of a glass
+compartment into
+which is placed the
+heating apparatus.
+This latter is composed
+of coils enclosed in a
+metal protector. The
+protector is attached to a handle, through which pass the
+electric wires. This coil and handle is placed into the glass
+bowl and is held fixed by a small clamp. A cover is then
+placed over the bowl, which is so arranged as to allow the
+wires to pass through it.</p>
+
+<p>For sterilization with pure phenol and alcohol, it is
+necessary to have two wide mouth, glass stoppered, two-ounce
+bottles. When the instruments are being sterilized
+they may be left standing in either bottle until ready for
+use. A piece of felt, cut to fit the inside bottom of each of
+the bottles, should be placed in situ, so that when sharp
+edged instruments are placed in the bottles, their points
+will not be broken, by coming in contact with the hard glass.</p>
+
+<figure class="figcenter illowe15" id="i_p044">
+  <img class="w100" src="images/i_p044.jpg" alt="">
+  <figcaption>
+    FORMALDEHYDE STERILIZER
+  </figcaption>
+</figure>
+
+<p>Formaldehyde gas is an agent which has germicidal
+properties, and is used to a great extent where steam sterilizers
+are not available. Formalin, a concentrated solution
+of the formaldehyde gas, readily gives up its gaseous constituent
+<span class="pagenum" id="Page_45">[Pg 45]</span>so that when the liquid is placed on a flat tray, the
+gas will penetrate objects around it. Cabinets have been
+constructed which are so arranged that the lower shelf
+contains the solution, and the upper shelves may be used
+for instruments, dressings, towels, etc. When the cabinets,
+which vary greatly in size, are tightly closed, the gas will
+penetrate every object contained therein, thus destroying
+any microorganisms which might be present.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_46">[Pg 46]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_V">
+    <span class="chap">CHAPTER V</span>
+    <br>
+    THE CARE OF THE FOOT
+  </h2>
+</div>
+
+
+<p><b>The Naked Foot.</b> For many centuries the human foot
+was allowed to go naked, and our aboriginal ancestors never
+knew what foot clothing of any type meant. Much the same
+as with the rest of his body, unaided nature was allowed to
+minister to the needs of his pedal extremities. Research
+has shown that primitive man was very strong and able to
+withstand the abuses of the elements to a marked degree.
+The body adapted itself to nature and the elements, so that
+it could bear extreme heat or cold, wind or rain, or any
+condition of the weather, without giving way before these
+nature forces.</p>
+
+<p>So it was with the foot of man during this period. The
+skin of the soles became thickened so that even the roughest
+surfaces caused no discomfort when borne upon by his bare
+feet. Even to this day, savage tribes that still go barefoot
+have skin on the soles of the feet that is tough and hardened.
+The author has seen natives of Central America, who are of
+this class, step on objects such as glass, lighted cigars, etc.,
+without experiencing any appreciable discomfort.</p>
+
+<p>In aboriginal man, muscular action of the entire foot
+was developed to its maximum. The muscles of the toes
+were under perfect control so that objects could be felt and
+lifted with them, much the same as with the fingers of man
+today. The leg muscles were well developed so that the
+position of the body in walking could be altered quickly and
+the body weight could be rapidly changed from one foot to
+another, so as to avoid contact with sharp pointed objects,
+such as burrs, sharp twigs, pointed stones, etc.</p>
+
+<p>Nature was primitive man’s physician. Being continuously
+<span class="pagenum" id="Page_47">[Pg 47]</span>exposed to the air, skin exfoliation, evaporation of
+moisture and other normal functions were never interfered
+with. The objects with which the body came in contact in
+wading through small streams, or in walking through the
+wet grass and dewy underbrush, acted much the same as
+the bath brush of modern times. Further, man of that
+period, living on nature’s foods, was never subject to the
+various conditions brought about by improper diet and
+which in turn manifest themselves in the feet as well as in
+other parts of the body.</p>
+
+<p><b>Advent of Foot Clothing.</b> As time went on and man
+became more and more civilized, clothing for the foot was
+gradually adopted, and from that time to the present the
+foot has undergone changes that make it necessary for the
+human race to resort to treatment for lesions that could not
+have developed if nature had had her way, and man had
+never adopted covering for the foot.</p>
+
+<p>The first style of foot covering was the sandal. This
+caused no special trouble, but when man began to depend
+upon them for protection for the soles of the feet, nature
+consequently no longer required the tough, protecting, heavy
+skin, and gradually the integument of that region became
+thinner. The result has been, that today, slight trauma or
+irritation causes many disturbances on the soles, among
+which are the common helomata dura and verrucæ.</p>
+
+<p>An evolution of footgear followed the use of the sandal,
+and with civilization came vanity in foot dress and finally
+the modern shoe, completely at variance with nature’s demands
+and causing so many disturbances that specialists
+in treating foot lesions became requisite to care for them.</p>
+
+<p><b>Modern Footgear.</b> The modern shoe, as compared to
+the normal foot, is worthy of special consideration. As a
+rule, the men who build shoes have from time immemorial
+been pure commercialists. Their purpose in engaging in
+the manufacture of footwear always has been and is to do
+business. They have attempted to create styles that would
+sell. They have produced wares that would be popular and
+<span class="pagenum" id="Page_48">[Pg 48]</span>therefore saleable. The question of the niceties of the anatomy
+and physiology of the foot and leg played no part in
+their calculations because they knew nothing about these
+features as factors in gaining results. The foot was treated
+as a whole, much as the hat manufacturer considers the
+human head when building a head covering. No consideration
+was given the natural beauties of the foot, so much
+appreciated by the ancient Greeks. The need for conserving
+the functions of the small bones of the foot so that their
+articulations would not be disturbed, caused them no pause.
+The necessity for allowing free play to all of the muscles
+which abduct, adduct, evert, invert, flex and extend the foot
+was and is a negligible quantity with the shoe-builder.
+There are few exceptions to this rule.</p>
+
+<p>Suppose the dentist were to make sets of teeth to
+be fitted to the jaws of those who had become toothless,
+basing their manufacture of these dental adjuvants
+on the prevailing needs of groups of these tooth-defectives,
+and tooth-shops were to be instituted to
+fit these sufferers from wares in stock! The public would
+deride such an innovation. And still it is almost as ridiculous
+to suppose that our shoe-shops can properly clothe the
+feet of the public as they should be clothed from a stock of
+shoes which are made without careful relevancy to the anatomy
+and physiology of the foot. Let us take one feature
+of the modern shoe as a sample of this pandering to style:
+the high heel, so common on women’s shoes, is a pure conceit.
+It is responsible for many of the foot lesions of today,
+and in addition causes systemic disturbances of a serious
+nature. When the body in standing is erect, the foot should
+be at right angles to the leg. When the heels are raised,
+however, it would be necessary to tilt the body forward to
+still maintain the right angular posture. It therefore becomes
+necessary in maintaining the erect position to allow
+for the malalignment of the body, due to the high heels,
+and this is accomplished in the knees, hips and spine. The
+knees are flexed, the hips rotated and the abdomen thrust
+<span class="pagenum" id="Page_49">[Pg 49]</span>forward. This latter interferes with the normal position
+of the abdominal organs, and thus arise many diseases
+common to women. The high heel is the etiologic factor.
+Locally, the calf muscles become contracted and an inward
+lateral displacement of some of the tarsal bones results.
+Gradually the other bones of the foot are displaced,
+and weak and flat foot result. Further, the high heel
+causes the foot to slip forward in the shoe and the toes
+are thus crowded. When the body weight is brought to bear
+upon the ball of the foot in walking, this crowding prevents
+the normal spreading of the metatarsal bones, and there is
+distortion of the bones, causing anterior displacement, or
+dropping of the anterior arch with resulting metatarsalgia.</p>
+
+<p>Another illustration: the function of the sudoriferous
+glands, namely, the elimination of liquid waste, in the form
+of sweat or perspiration, is going on continuously. As the
+fluids are brought to the surface by the gland ducts, evaporation
+takes place immediately, except under unusual
+circumstances, such as mental excitement, increased temperature,
+etc., in which instances the production may be very
+rapid or may be retarded. When the foot is encased in a
+shoe, or in a stocking that does not absorb moisture, such
+as silk or lisle, this evaporation is retarded to a greater or
+lesser degree, depending upon the leather of which the shoe
+is made. Such interference with normal functions is productive
+of many foot ills elsewhere noted in these pages.
+In this connection the podiatrist should be familiar with
+these facts: Vici kid is the most porous of all the leathers
+used in shoe manufacture, so that most if not all of the
+moisture excreted by the glands evaporates. Calf skin is
+not so efficient for foot covering, in that evaporation is limited;
+both of these leathers are far superior to either patent
+leather or colt skin, which latter are absolutely air and
+water tight, and should never be used as a foot covering.
+The stocking should be of a material that will absorb moisture,
+and cotton or woolen hose are best for this purpose and
+will assist in keeping the feet dry and normal.</p>
+
+<p><span class="pagenum" id="Page_50">[Pg 50]</span></p>
+
+<p>Again, the nails of the toes are often unfavorably
+affected by the modern shoe, especially the nails of the great
+toes. The toe box of the average shoe is made of stiff, unyielding
+material so that if the shoe is narrow or short,
+irritation or undue pressure is brought to bear upon the
+nail or the surrounding tissues, causing disease. It is especially
+necessary to obviate the possibility of pressure of the
+soft tissue of the nail groove against the hard nail substance,
+because if such a condition arises and is allowed to
+persist, calloused nail grooves, helomata and often ingrown
+toe nails result. In the same manner, pressure on the
+various parts of the nail may cause club nail, onychia
+or paronychia. Simple packing of the nail grooves with
+absorbent cotton, if properly done, is often the means
+of avoiding serious nail lesions, which, as a rule, are
+very painful.</p>
+
+<p>In this connection it would be well to remember that it
+is most important that the nails be cut properly. The corners
+of the nails should never be removed, unless there is
+some trouble beneath the part. Removal of the corners of
+the nails changes the position of the surrounding soft tissues,
+which depend upon the hard nail substance for support,
+and thereby causes them to collapse. This is one of
+the primary etiologic factors of ingrown toe nail.</p>
+
+<p>The bony structures of the foot have suffered extensively
+since the advent of modern footgear, and the treatment
+of the lesions in which the osseous tissue is involved is
+of importance to the podiatrist as well as to the surgeon or
+orthopedist. Many deformities of the foot are such that
+only the surgeon is qualified to successfully treat them, but
+the more common lesions properly come under the care of
+the podiatrist, and should be treated by him.</p>
+
+<p>Pointed shoes cause displacement of the metatarsal
+bones, with subsequent nerve compression; hallux valgus is
+a common deformity due to misfitting shoes. These latter
+conditions are the result of improper footgear, as also of
+incorrect posture and of faulty locomotion.</p>
+
+<p><span class="pagenum" id="Page_51">[Pg 51]</span></p>
+
+<p>The soft tissues of the foot have suffered to a great
+extent because of the modern shoe, especially the muscles
+that arise in the leg and are inserted in the foot. Upon
+these muscles principally depend the motions of the foot,
+especially those of flexion, extension, adduction and abduction.
+The calf muscles, as previously stated, become shortened,
+due to the high heels. Additionally the muscles on the
+outer side of the leg are shortened while those on the inner
+side are lengthened. The long extensors of the toe are also
+shortened.</p>
+
+<p>When it is remembered that there are twenty muscles
+in addition to the twelve muscles of the leg inserted into
+the foot, the limited motion of this area, as compared to
+other parts of the body, is apparent. Take for instance,
+the movements of the toes in the average adult. The action
+of the great toe is markedly limited and that of the lesser
+toes is almost lost. This loss of action is brought about by
+a lack of use of the digits of the feet. The hands and fingers
+being used continuously, the movements of these digits are
+active and numerous. The toes have a like muscular supply,
+but are far less efficient. The ability of the barefoot races
+to use their toes as accessory fingers, is proof that lack of
+development is due to lack of motion because of the toes
+being encased for most of the time in footgear.</p>
+
+<p><b>Hygiene of the Foot.</b> The many perverted functions
+of the foot that have been brought about by the use of modern
+footgear have made it essential that this part of the body
+be given special attention both by the specialist and by the
+individual himself. There are several essentials for proper
+foot care with which everybody should be familiar, and it is
+the duty of the podiatrist to instruct his patients in these
+essentials. The general hygiene of the foot is little understood
+by the average layman, and the fact that a patient
+takes a daily bath is no indication that the feet are being
+properly cleansed. To accomplish this the foot should be
+washed with soap and water, care being taken that any excrementitious
+matter which may have accumulated between
+<span class="pagenum" id="Page_52">[Pg 52]</span>the toes is thoroughly removed. It is best to use warm
+water for this purpose, and when the feet have been thoroughly
+cleansed they should be rinsed in cold water. This
+closes the glands which have become dilated by the heat; if
+allowed to remain open, they will over-functionate. The
+foot must be dried well, especially between the toes, and
+after this has been done, alcohol may be applied to assist
+in this purpose. Alcohol is both astringent and dehydrating.
+In cases of a normally dry skin, alcohol may be dispensed
+with; instead, a small quantity of an animal oil
+should be rubbed into the skin; lanolin is very efficient for
+this purpose.</p>
+
+<p>Water, as a therapeutic agent, is used extensively and
+has many advantages that are lacking in other remedial
+measures. It is one of the most ancient of remedies, and its
+value has been recognized to such an extent that there are
+large institutes in this and other countries devoted exclusively
+to hydrotherapy.</p>
+
+<p>No other agent is capable of producing so great a variety
+of physiologic effects as water; it is easily obtained and
+is also readily adaptable for the various conditions in which
+it is of benefit. Pastor Kneipp obtained excellent results
+with his water cure in Europe, and although his methods
+are not original creations, and their application was largely
+empiric, they attracted international attention. The entire
+system of treatment as practised by him was based upon
+some hygienic principle, and most of the results achieved
+were due to the application of common sense.</p>
+
+<p>Water has three properties to which its value as a
+therapeutic agent are due; first, its power to absorb and
+communicate heat; second, its solvent properties; third, the
+ease with which it changes its physical state from the liquid
+to the solid or gaseous form. These three properties, either
+alone or combined, are to be considered when water is
+applied to the body as a therapeutic agent.</p>
+
+<p>A given quantity of water by weight can absorb more
+heat than any other substance. The readiness with which
+<span class="pagenum" id="Page_53">[Pg 53]</span>this heat is absorbed makes it possible to apply either heat
+or cold to the body. Thus, ice applied to the body will melt,
+and in doing so will extract a large amount of heat from the
+tissues. It is valuable therefore in conditions such as local
+infections, in which the heat of the body is above normal.</p>
+
+<p>Every substance is more or less soluble in water.
+Water is therefore called the universal solvent. Water is
+the medium by which foods are dissolved and absorbed in
+digestion; water also dissolves and carries off the waste
+products to the various organs of elimination.</p>
+
+<p>For therapeutic application, the temperature of water
+varies from 32 degrees, F. to 120 degrees, F., depending
+upon the condition in which it is used and also the purpose
+of its use. Foot baths are of special interest to the podiatrist,
+so that it is necessary to be familiar with the particular
+type of foot bath that is valuable in the treatment of foot
+lesions.</p>
+
+<p>The <i>alternate foot bath</i> is used for stimulating the
+cutaneous circulation, and acts as a general tonic for the
+nerves and other tissues. The bath is given as follows: the
+feet are placed in hot water for two minutes and then
+plunged into cold water and kept there for 30 seconds.
+They are then returned to the hot water for two minutes
+and back into the cold water for 30 seconds. This is repeated
+a number of times, always starting with the hot
+water and finishing with immersion in cold water. This
+bath affords great relief to those suffering with tired feet
+after having worn shoes for a long period. As a general
+hygienic adjunct, the alternate foot bath is of great benefit,
+and should be employed at night before retiring.</p>
+
+<p><b>Foot Care of Infants and Adolescents.</b> About eighty
+per cent. of the civilized, shoe wearing people, are foot
+afflicted to a greater or lesser degree, and most of this can
+be traced to neglect of the feet in infancy and youth. Many
+of the most common diseases found in adults might have
+been avoided if proper care had been taken and the causative
+factors removed in proper time.</p>
+
+<p><span class="pagenum" id="Page_54">[Pg 54]</span></p>
+
+<p>The foot of an infant, which has never worn a shoe, is
+really a perfect foot, and it is the only stage in life in which
+the perfect foot is commonly found. The toes are spread
+and the forefoot is slightly adducted. When the first footgear
+is selected for the infant (it must be borne in mind that
+the foot grows rapidly at this age) the shoe should be of
+sufficient length and width to allow for this growth. The
+softest materials should be used for the first shoes of the
+infant, for as the feet are not used in walking at this age,
+the necessary support to locomotion received from the
+material in the shoe, is a negative factor.</p>
+
+<p>When the child commences to walk, the shoes should be
+changed, and a sole should be provided. The upper should
+be of kid, and should extend slightly above the ankle. Laced
+shoes should be used, and continued throughout the entire
+period of infancy and youth. The normal adduction of the
+forefoot should be considered and the outer border should
+curve inward in a gradual line. The foot should be measured
+for shoes with the child bearing its weight on the foot.
+This allows for the spread of the foot in weight bearing,
+and measurements taken under these conditions give assurance
+of a proper fit.</p>
+
+<p>As the infant grows, the muscular strength of the legs
+is increased, and eventually the limbs are strong enough to
+support and carry the body weight. It is at this time that
+the child will commence to walk by natural impulse or
+instinct. From the short, jerky, uncertain step, there is a
+gradual improvement and, with time, the infant gains confidence
+and strength and the step soon becomes firm and
+steady. The question is often asked of physicians and
+podiatrists by anxious mothers: “why is it that my baby
+does not walk?” It seems to be a source of worry to them,
+for as these mothers watch other children walking, they
+become envious and attempt to teach their children to walk.
+Walking is a natural function and it is foolhardy to insist
+upon infants attempting this foray until the bones to
+which the muscles are attached are sufficiently unyielding
+<span class="pagenum" id="Page_55">[Pg 55]</span>and the muscles involved can coordinate for that purpose.
+The use of artificial means of assistance for the child, viz.,
+the various contrivances on the market that support the
+child under the arms and allow the feet to drag on the
+ground, should be discouraged.</p>
+
+<p>Premature locomotion causes an unnatural strain upon
+the legs and feet and is often the cause of malformations
+which continue on in later life. Many foot and leg lesions
+can be attributed to an over-anxious mother who insisted
+upon her child walking before the time was ripe for it to do
+so. Therefore it behooves every mother to allow nature to
+have its way, and to wait until the legs are strong enough.
+In cases where walking is unsteady, it may be advisable to
+assist the strengthening of the muscles by massage and
+passive motion.</p>
+
+<p>The use of appliances to assist a child which already
+walks should be guarded, and only when there is something
+pathologically wrong should they be employed. Weak-ankle
+shoes, or weak-ankle braces or supports, although
+they apparently help the child’s gait, really retard the
+normal motions at the ankle joint, and there is little possibility
+of a compensatory increase in strength of the parts
+as a result of their use. When the ankle is continuously
+supported by some outside agent, the normal support, i.e.,
+the muscles of the leg, become weaker. This is because they
+are not used, and atrophy is the result. When conditions
+are such that assistance must be sought, the part should be
+exercised by massage, exercises and passive motion. It is
+often a difficult matter to prescribe exercises for a child,
+but if given in a cheery way, so that the child thinks it is
+playing a new game or is having heaps of fun, the results
+are often remarkable. The First Institute of Podiatry is
+now planning an exercise room for children of the poor
+whose locomotion is impaired and the experiment will be
+watched with interest.</p>
+
+<p>As the child grows into adolescence, the shoes should be
+changed often enough to allow for the normal growth of
+<span class="pagenum" id="Page_56">[Pg 56]</span>the foot. It is better to buy shoes oftener, than to attempt
+economy at the expense of health. The parents should
+acquaint themselves with an orthopedist or a podiatrist to
+advise and a competent shoe man, under the direction of the
+advisor, should fit the shoes of the growing child. Thus,
+caring for the same foot over a protracted period, such a
+specialist is better able to judge the size and shape best
+adapted for the individual. Walking and other forms of
+exercise should be encouraged, especially those exercises
+that develop the muscles of the foot and leg. It must be
+borne in mind that the flat foot and weak foot of later life
+are caused by deficient muscular action of certain groups of
+muscles.</p>
+
+<p><b>Foot Care of Adults.</b> After the foot has attained its
+full growth, and the bones have become calcified, correction
+of the lesions involving the bony tissue is difficult. Young
+persons who have been accustomed to wearing shoes with a
+straight inner line, and with broad toes, will pass into middle
+age without much, if any foot trouble. Slight friction
+or pressure may produce small helomata, but these are of
+little consequence and are easily relieved by intelligent care
+and treatment.</p>
+
+<p>As previously stated, pointed and narrow shoes with
+high heels are responsible for many of the local foot lesions,
+and corrective treatment should be begun at as early a
+period as possible. When a person reaches middle age, the
+bones of the foot have become set. Attempts at correction,
+such as the prescribing of shoes with a straight inner line
+for such persons, cause the foot to be put into an entirely
+new position, and because the bones have become firmly
+set, such a new departure is frequently fraught with discomfort,
+and at times causes other bone and muscle troubles
+which are painful.</p>
+
+<p>In younger adults, correction should be gradual. It is
+inadvisable to adopt radical measures for those who have
+been wearing incorrect shoes, or who have been walking
+and standing incorrectly for a long period of time. A
+<span class="pagenum" id="Page_57">[Pg 57]</span>woman who has been wearing high-heeled shoes for a few
+years, has a shortening of the calf muscles which should
+be corrected, but to change from a two-inch heel to one a
+half-inch high, without gradually reducing the height, will
+cause extreme discomfort. Appropriate exercises should be
+advised and the style of the footgear should be gradually
+and not abruptly changed as the foot responds to treatment.</p>
+
+<p>Walking is one form of exercise in which every able-bodied
+person can indulge, and is a means of maintaining
+body health as well as of keeping the muscles of the foot
+and legs strong. Like every other form of exercise, it
+should be practised with caution. The individual who walks
+long distances is placing an undue strain upon the muscles
+of the lower extremity, and instead of being benefited, he
+is being harmed. The position of the foot is important in
+walking. The foot should point forward, and the forefoot
+should swing slightly inward with each step. In this way
+all of the muscles of the leg receive their proper share of
+work. The pace should be brisk and steady, yet not fast
+enough to cause the person to suffer in breathing. Slow,
+leisurely strolls are useless as a medium for muscular improvement,
+and are simply a waste of time.</p>
+
+<p><b>The Care of the Soldier’s Foot.</b> The foot of the soldier
+is subjected to unusual strain, both on the march and while
+in the trenches, and special care is necessary if the maximum
+of efficiency is to be maintained. Hygiene should be
+practised to a greater extent than under ordinary circumstances,
+and immediate attention should be given to minor
+troubles that might pass unnoticed in civil life.</p>
+
+<p>The feet should be washed daily, and if long marches
+are contemplated, they should receive this attention both
+before and after the march. The feet should be thoroughly
+dried after each washing, and dusted with some foot powder
+that will absorb moisture. Lycopodium is the best base to
+use in foot powders. Socks should be examined and if
+found torn or badly mended, should be discarded because
+the pressure of the spots that have been darned may result
+<span class="pagenum" id="Page_58">[Pg 58]</span>in painful troubles. Shoes should be large enough to accommodate
+the spreading of the anterior arch in walking, yet
+should be snug in the heel to prevent the foot from sliding
+and creating friction. When soldiers are to serve in the
+trenches their feet should be given special attention, to
+prevent the possibilities of trench foot and other foot
+lesions that are the result of trench life. It has been proven
+by those who have gone thoroughly into the matter that the
+water and mud which is found in the trenches is responsible
+for these lesions, therefore it is necessary to guard against
+it reaching the feet of the men. In addition to wearing rubber
+boots, the feet should be thoroughly rubbed with some
+greasy substance immediately before entering the trenches.
+Mineral oils are best, and although the process of rubbing
+the feet and legs with oil is repulsive to the men, it should be
+compulsory, as it is the means of preventing loss of limbs.
+Cloths dipped in melted paraffin and then wrapped around
+the feet will suffice to keep the water from the skin.</p>
+
+<p>Immediately after a siege in the trenches, the feet
+should be thoroughly washed with soap and warm water,
+carefully dried, and dusted with an antiseptic foot powder.
+One containing boracic acid and talcum will answer ordinary
+purposes. If abnormal lesions develop, these should
+be treated in keeping with the requirements.</p>
+
+<p>The men should receive instructions at regular intervals,
+and lectures on the care of the foot should be given by
+the officer in charge of that particular branch of the medical
+department. Foot inspections should be made at prescribed
+times, and during these inspections, the podiatrist can
+easily determine whether or not the men are in need of foot
+attention beyond that which comes with self-care. The feet
+should also be examined before a march of ten miles or
+more, and should be re-examined immediately after the
+march. This procedure will save the men from developing
+any serious trouble, as the beginning of any such trouble
+is thus detected, and proper preventive treatment can be
+applied, sufficiently timely.</p>
+
+<p><span class="pagenum" id="Page_59">[Pg 59]</span></p>
+
+<p>One or two podiatrists should be attached to each
+ambulance train while the troops are on the march, so that
+they are available at short notice. The immediate application
+of a shield or pad over some part of the foot that is
+being irritated will often save the individual from foot infection
+that may be serious. Too much care cannot be given
+the feet of the soldiery as their efficiency is based upon their
+powers of locomotion. It was the opinion of the first
+Napoleon that an army moved upon its stomach. By that
+he meant that plenty of proper food was essential to every
+fighting force. In these times, it is conceded that the foot-whole
+alone can be counted as competent soldiers, important
+as may be the food question. It behooves us, therefore, to
+give to the men who are willing to offer up their lives for
+their country’s weal, the very best possible care, and although
+the foot of the soldier has received no special attention
+in the past, the time is now ripe for the recognition of
+the podiatrist as an integral part of every officered unit
+in the Medical Corps of the Army and of the Navy. From
+a national economic standpoint alone, this recognition
+should be accorded because it must be clear that unless
+proper precautions are taken to note the condition of the
+soldier’s feet before he goes overseas, thousands will be
+found unavailable for first line work and will thus constitute
+themselves an incubus rather than an aid to the fighting
+force of our country.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_60">[Pg 60]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_VI">
+    <span class="chap">CHAPTER VI</span>
+    <br>
+    DRESSINGS AND BANDAGING
+  </h2>
+</div>
+
+
+<h3>DRESSINGS.</h3>
+
+<p><b>Definition.</b> A dressing is the material applied to a
+wound for the purpose of excluding the air, stimulating repair
+and protecting the affected areas from irritation and
+from other untoward conditions.</p>
+
+<p>Four classes of dressings are used in podiatry, viz.:
+the moist dressing, the dry dressing, the ointment dressing
+and the occlusive dressing.</p>
+
+<p><b>The Moist Dressing.</b> The moist dressing is generally
+composed of several thicknesses of gauze applied to a part
+and moistened with some germicidal, antiseptic, astringent,
+antiphlogistic or sedative solution.</p>
+
+<p>There are two forms of moist dressing: the evaporating
+and the non-evaporating.</p>
+
+<p><b>The Evaporating Moist Dressing</b>, generally known as
+the wet dressing, is an application of several thicknesses of
+gauze saturated with a solution and allowed to remain uncovered
+so that evaporation of the solution takes place.
+The gauze is remoistened from time to time so that it is
+kept continually wet. The action of this form of dressing,
+independent of the specific action of the solution employed,
+is heat reducing and causes localized anemia. It may be
+employed wherever infection or inflammation is present.</p>
+
+<p><b>The Non-Evaporating Moist Dressing</b> is composed of
+several thicknesses of gauze saturated in a solution and
+covered with some impervious covering such as gutta percha
+tissue, oiled silk or fish skin. This form of dressing, independent
+of the action of the solution employed, is heat producing
+<span class="pagenum" id="Page_61">[Pg 61]</span>and locally hyperemic. It is contra-indicated in the
+presence of pus, as the warmth and moisture produced by
+its use is congenial to the growth of bacteria. It should
+only be used when the skin is unbroken, in such cases as
+sprains and bruises, or where the action of a poultice is
+not contra-indicated.</p>
+
+<p><b>The Dry Dressing.</b> The dry dressing is composed of
+several thicknesses of sterile gauze applied to a part and
+allowed to remain dry. There are two forms of dry dressing,
+(1) that in which the gauze itself is alone applied, and,
+(2) one composed of dry sterile gauze or cotton used for
+the purpose of applying a dusting powder, having either
+antiseptic, astringent or stimulative qualities or in some
+instances, all three. The plain gauze dressing is used where
+asepsis and drainage alone are desired in a wound, all
+symptoms demanding the treatment by means of drugs having
+been eliminated. The gauze is used either as a “wick”
+and packed into a cavity as a drain, or in a series of thicknesses
+covering the whole affected area.</p>
+
+<p>The dusting powder dressing consists in applying a
+powder to the affected surfaces and covering the same with
+several thicknesses of sterile gauze, or with a pledget of
+sterile cotton. The dusting powder is used when astringency
+is desired, as from bismuth subgallate (dermatol);
+or where stimulative and antiseptic action is desired, as
+from thymol iodide (aristol).</p>
+
+<p><b>The Ointment Dressing.</b> The ointment dressing is one
+in which an ointment, held in place either by lint, gauze or
+cotton, plays a conspicuous part in the repair of the lesion.
+The ointment is either spread upon the fabric used, or is
+applied directly to the affected areas by means of a spatula.
+This form of dressing can be used in the treatment of
+superficial inflammations, blisters, pernio, etc., but is contra-indicated
+in the presence of a discharge, as the fatty or oily
+base of the ointment interferes with the absorption of such
+a discharge and so prevents proper drainage of the part.</p>
+
+<p><b>The Occlusive Dressing.</b> The occlusive dressing is one
+<span class="pagenum" id="Page_62">[Pg 62]</span>employed for the purpose of excluding the air and of completely
+sealing the parts. In podiatry this occlusion is obtained
+by the use of collodion, either plain or medicated, by
+a combination of collodion and cotton, or by the application
+of compound tincture of benzoin.</p>
+
+
+<h3 id="FABRICS">
+  FABRICS.
+</h3>
+
+<p>There are a number of fabrics which may be used for
+dressing materials in podiatry. The three most important
+are gauze, cotton and lint.</p>
+
+<p><b>Gauze</b> is a thin meshed, loosely woven cloth employed
+in the manufacture of bandages and used for wound dressings;
+such gauze should be sterilized or impregnated with
+antiseptics.</p>
+
+<p>The varieties of gauze which are of practical use in the
+practice of chiropody are:</p>
+
+<blockquote>
+<p>(1) <i>Plain aseptic gauze</i>, either dry or moist; a gauze
+sterilized either by dry heat, so that the fabric remains dry,
+or subjected to moist heat (steam) sterilization from which
+the gauze retains a certain amount of moisture. The dry
+gauze is put up commercially in pasteboard boxes, and can
+be thus obtained in quantities of one square yard and upwards.
+The moist aseptic gauze is obtainable in as small a
+quantity as the former, but comes in sealed glass jars which
+may be kept upon the operating stand or cabinet.</p>
+
+<p>(2) <i>Corrosive sublimate gauze</i> is put up in glass jars
+in quantities of one square yard and upwards. The gauze
+is saturated in a solution of mercury bichloride and may
+be obtained in strengths from ¹⁄₂₀₀₀ to ¹⁄₁₀₀₀₀.</p>
+
+<p>(3) <i>Iodoform gauze</i> is put up for surgical use in the
+same manner and quantity as No. 2. The medication impregnates
+the whole fabric and constitutes an excellent
+method of applying the drug. On account of the suggestive
+odor of iodoform, however, this gauze has lost favor with
+the podiatrist.</p>
+
+<p><span class="pagenum" id="Page_63">[Pg 63]</span></p>
+
+<p>(4) <i>Borated gauze</i>, or gauze impregnated with boric
+acid in 10% strength, is used in podiatry where a mild antiseptic
+dressing is desired. It comes in glass jars in
+quantities similar to the two foregoing varieties.</p>
+</blockquote>
+
+<p>The forms in which gauze are used in podiatry practice
+are numerous. The following are the most important:</p>
+
+<blockquote>
+<p>(1) <i>Bandage.</i>
+Gauze, in varying
+widths, makes a highly
+practical bandaging
+material. Cotton bandages
+are used, but cannot
+compare with even
+the poorer grades of
+linten gauze for durability.
+The reader is
+referred to the sub-heading,
+“Bandaging,”
+at the end of
+this article.</p>
+
+<figure class="figcenter illowe24" id="i_p063">
+  <img class="w100" src="images/i_p063.jpg" alt="">
+  <figcaption>
+    LARGE GAUZE SQUARE FOR DRESSING
+    INGROWN NAIL
+  </figcaption>
+</figure>
+
+<p>(2) <i>Large gauze
+squares.</i> It is a common
+practice among
+podiatrists to cut large
+quantities of gauze
+into pieces about three
+inches square. These
+have two uses: (a), to
+dry off instruments
+dripping with alcohol
+or whatever germicidal
+solution has been used, before operation, and (b),
+as a dressing applied over the affected area. In the latter
+instance this size square is practical where the whole
+distal end of the toe is to be covered, as in applying a moist
+dressing in the treatment of ingrown nail, or where there
+<span class="pagenum" id="Page_64">[Pg 64]</span>is a large area to be covered on the dorsum, plantar or
+lateral sides of the foot or upon the lower leg. As a “wipe”
+for instruments, one thickness, and as a dressing, three or
+four thicknesses are used.</p>
+
+<p>(3) <i>Small gauze squares.</i> These are about an inch-and-a-half
+square and have their principal use as a dressing to
+cover one side of a toe nail, or to cover a small area of the
+integument, or as a “wick” in the drainage of a large sinus
+or deep ulcerative condition. Both the large and small
+squares, cut to size, are sterilized by heat and are then
+placed in a formaldehyde sterilizer until used; this assures
+their absolute asepsis.</p>
+
+<p>(4) <i>Nail Groove and Sinus Pledgets.</i> For the more
+confined areas of the nail groove or for a small sinus, gauze
+is cut into small pieces measuring about one-half inch long
+and one-eighth inch wide. Several thicknesses of the fabric
+are cut together so that even from a small amount of gauze
+many small pledgets or “wicks” are obtainable. These
+small gauze pieces are very practical for packing a nail
+groove, and, as the fibre is looser and the pledgets do not
+harden, they make a much softer and more yielding pad for
+the nail than does cotton.</p>
+
+<p>In the drainage of a small sinus, these small pieces of
+gauze offer a very practical material for use as a “wick.”
+Three or four strands of the fabric may be inserted at the
+mouth of the sinus to prevent surface granulation, while
+the repair in the deeper tissue is still incomplete.</p>
+</blockquote>
+
+<p><b>Cotton.</b> Cotton is the white, fluffy, fibrous covering of
+the seeds of the cotton plant which, when ginned and refined
+to a uniform smoothness, furnishes a medium which
+is used extensively in surgical dressings.</p>
+
+<p>Aseptic absorbent cotton is manufactured by a number
+of firms and, except in the cheaper grades, no irregularities
+or foreign matter are found in the fabric.</p>
+
+<p>Cotton is used in podiatry practice by winding it on
+the end of a wooden or metal applicator. The fabric, thus
+<span class="pagenum" id="Page_65">[Pg 65]</span>fashioned about the applicator, is used either dry or dipped
+in some medication for applying solutions to the foot. It
+is also used to dry parts or to wipe instruments; as a dressing,
+it is used principally in combination with collodion to
+make the cocoon dressing. This name is derived from
+its resemblance to the cocoon of the silkworm or the butterfly.</p>
+
+<p>A cocoon dressing is a pledget of cotton, the fibre of
+which is smoothed and is placed in one direction, while the
+edges of the pledget are thinned out or “feathered.” The
+cotton is applied over the part and collodion (preferably
+flexible collodion) is painted over it by means of a brush or
+a glass rod in such a manner as to bind the edges of the
+cotton firmly to the skin. The collodion when applied is
+semi-liquid, and as its constituents, ether and alcohol,
+evaporate upon contact with the air, the pyroxylin remaining
+becomes an integral part of the cotton, joining intimately
+with its fibres and with the surface of the skin.
+After the edges are bound down in place, the collodion may
+be painted once along the length and once across the fibre
+at the centre of the dressing, so as to bind the dressing into
+one cohesive whole; it is not wise, generally, to saturate the
+whole pledget with collodion, as when dried, the dressing
+will be hard and unyielding. In the procedure first described
+the dressing is semi-occlusive; in the latter, occlusive.
+The cocoon dressing is used principally as a covering
+for a part when an ointment has been applied and, as
+in these cases the parts beneath are tender, it is wise to
+have the dressing as soft and pliable as possible.</p>
+
+<p>This form of dressing may be used alone or it may
+be applied as a covering and protection over the aperture
+of a shield after an ointment has been applied to the part.
+It is found very practical when applied over a nail fold and
+groove in which an ointment has been used. The dressing
+will confine the unguent to the proper areas and prevent it
+from running over that side of the digit. In dressing a
+blister or other irritated area, due to ill-fitting shoes or
+<span class="pagenum" id="Page_66">[Pg 66]</span>mended hosiery, the cocoon is also very practical. The
+cotton not alone serves to hold the medication in place, but
+acts as a padding so that the part may not be subjected to
+further irritation.</p>
+
+<p>Cotton is also used in the form of a small pledget for
+packing a nail groove. The pledget or roll should be small
+and thin and is used to hold a medication in place; at the
+same time it constitutes a soft pad upon which the edge of
+the nail rests.</p>
+
+<p><b>Lint.</b> Lint is a flocculent material procured by ravelling
+or scraping linen.</p>
+
+<p>Surgeon’s absorbent lint as a dressing and shielding
+material, is continuously coming more into vogue. Otto
+Sjogren of New York is a great believer in its efficacy and
+in his demonstrations at The First Institute of Podiatry
+strongly advocates its use. The late W. A. Kennedy of Philadelphia
+was also strong in his advocacy of lint as a dressing
+and is on record as follows: “The essentially favorable
+feature in utilizing lint for shielding purposes is that, when
+properly adjusted, there is no pressure on the parts which
+it serves to protect. Most, if not all, of the material of which
+shields are ordinarily made, is of an unyielding character,
+and, in consequence, the capillary circulation of the compressed
+part is disturbed. If such a condition exists, absorption
+is prevented and the treatment is in most instances
+harmful rather than helpful. Because lint is a
+loosely woven cotton fibre, it does not pack in a hard mass,
+but always remains soft and yielding; nor is it necessary
+to apply it excepting in thin layers.</p>
+
+<p>“The method of use should be as follows:</p>
+
+<p>“Select a perfect sheet of lint and cut off a square or
+oblong piece slightly larger than the lesion and round off
+the corners so that they will not bulge when plaster strips
+or bandages are applied. Then cut a round opening in the
+lint, slightly larger than the lesion. Spread such medicament
+as is desired on the part requiring it, and then place
+the fluffy side of the lint next the skin, in situ, with the
+<span class="pagenum" id="Page_67">[Pg 67]</span>edges of the opening surrounding the part under treatment.
+Over this dressing, place a piece of lint so as to
+cover the existing dressing in its entirety and apply ordinary
+adhesive plaster to retain the whole in place. The
+thickness of the dressing represented in layers of lint will
+depend upon the necessities of each individual case, but
+in the experience of the writer, the most
+satisfactory results are obtainable where
+the dressing is least bulky. At times,
+when several layers of the lint are requisite
+to the patient’s comfort, it will be
+found advisable to cut out the sides of one
+of the under layers
+for the purpose of
+making a half-moon
+dressing; then apply
+the top covering.</p>
+
+<p>“In the accompanying
+illustrations
+most of the required
+dressings shown are
+of two thicknesses
+only, the under layer
+having the round
+opening and the upper layer acting as
+a protective as well as an absorbing
+medium. This method will be found
+useful, in that drainage may take place
+properly where there is a suppurating
+surface, and even though the patient
+does not return for treatment at the
+time suggested, there will be no danger
+of septic infection because of a damming
+in the flow of exudate, a menace
+which is so common in some forms of dressing. Patients
+will rarely complain that the plaster ‘draws’ offensively if
+the above dressing is properly applied.</p>
+
+<figure class="figcenter illowe24" id="i_p067right">
+  <img class="w100" src="images/i_p067right.jpg" alt="">
+  <figcaption>
+    DORSAL LINT
+    DRESSING
+  </figcaption>
+</figure>
+
+<figure class="figcenter illowe24" id="i_p067left">
+  <img class="w100" src="images/i_p067left.jpg" alt="">
+  <figcaption>
+    PLANTAR LINT
+    DRESSING
+  </figcaption>
+</figure>
+
+<p><span class="pagenum" id="Page_68">[Pg 68]</span></p>
+
+<p>“The plantar aspect of the foot exhibits four full dressings
+and half of another.</p>
+
+<p>“The dressing covering the great toe may be utilized
+for any lesion from a callous to a perforating ulcer; the
+one on the distal end of the middle toe, for heloma or for
+any other condition usually met with in this region.</p>
+
+<p>“The dressing covering the fifth metatarsophalangeal
+articulation can be applied for perforating ulcer, for callous
+or for vascular heloma and can be placed anywhere
+after treating this lesion. The dressing covering the os
+calcis region is of a single thickness and can be used in
+varying sizes for any lesion found on the plantar surface.</p>
+
+<p>“The partial dressing, covering the first metatarsophalangeal
+articulation is used from one to any required
+number of layers for covering bunions, enlarged joints, etc.;
+the other section of this dressing is shown on the dorsal
+aspect of the foot in the other illustration.</p>
+
+<p>“The dressing covering the dorsal aspect of the great
+toe is used after any ingrown nail treatment and the dressings
+on the third and fifth toes are applied after the removal
+of helomata.</p>
+
+<p>“The dressing covering the fifth tarsometatarsal articulation
+is very useful in combating the calloused and oft-times
+inflamed area produced by the side seam of shoes,
+especially of the low-cut type.</p>
+
+<p>“Lastly, the dressing covering the tarsal aspect is a
+comfortable arrangement to apply after removing the minute
+helomata produced by the eyelets of a shoe or for any
+other lesion found on the dorsal surface.</p>
+
+<p>“In case of extensive ulceration or of profuse discharge
+from a lesion, it is advisable to use several layers of
+sterile or medicated gauze before applying the absorbent
+lint to the surface.”</p>
+
+<p><b>Collodion.</b> Plain flexible collodion is used extensively
+in podiatry as an agent to bind cotton into place upon a
+part or as a vehicle of application for a number of drugs,
+or whenever an occlusive dressing is applied. Flexible collodion
+<span class="pagenum" id="Page_69">[Pg 69]</span>is ordinary collodion to which is added castor oil and
+turpentine. These drugs serve to reduce the contraction of
+the film during evaporation. Plain collodion, as evaporation
+takes place, contracts in area and when applied is liable
+to draw or “pucker” the skin about the part. Flexible
+collodion has practically no contractile tendencies during
+evaporation.</p>
+
+<p>Flexible collodion, unmedicated, is used as an application
+over chilblains or in other conditions where occlusion
+is desired.</p>
+
+<p><b>Medicated Collodions.</b> Flexible collodion, medicated
+with various drugs, is also used extensively in podiatry.
+The four named and described below are the most important,
+and are most generally used.</p>
+
+<p><b>Iodized Collodion</b> (C. Iodatum, N. F.). Iodized collodion
+is a five per cent. solution of iodine in flexible collodion.</p>
+
+<p>It is used in podiatry as a covering for the exposed
+tender tissues after removal of a callositas or an heloma.
+The film formed by the collodion serves as a protection
+against friction to the part and the iodine contained in
+the mixture acts as an antiseptic and counter-irritant.
+This combination may also be used where any counter-irritant
+action is desired and wherever the tincture may be
+used.</p>
+
+<p><b>Ichthyolated Collodion</b>, 5 to 15% of ichthyol in collodion,
+is used for the same purposes as the iodized collodion
+in the protection of a previously pared callous, and as an
+antiphlogistic and stimulant in erythematous chilblain, this
+form of medication is used extensively and with good results.
+It forms an occlusive film over the chilled parts,
+and by the action of its constituent, ichthyol, serves to
+stimulate the deranged functions and to promote absorption
+in the congested parts.</p>
+
+<p><b>Benzoated Collodion</b>, 5 to 10% of tinctura benzoini composita
+in flexible collodion, may be applied in post-operative
+procedures in heloma, etc., as described in preceding
+paragraphs, and is also efficient as a stimulant in the treatment
+<span class="pagenum" id="Page_70">[Pg 70]</span>of pernio and as a covering for blisters and other
+superficial lesions where no discharge is present.</p>
+
+<p><b>Salicylated Collodion</b> is a medicated collodion with the
+following formula:</p>
+
+<blockquote>
+<p>
+  Salicylic acid, 30 parts;<br>
+  Ext. of cannabis Indica, 5 parts;<br>
+  Collodion, 240 parts.
+</p>
+</blockquote>
+
+<p>It is extensively used in the medical treatment of heloma
+or callositas. This combination is disintegrative in its
+action and should not be applied on sound or normal integument.</p>
+
+<p>Collodion, either plain or medicated, is contra-indicated
+in the presence of a discharging surface. By sealing the
+lesion, no drainage is possible, and the waste materials
+thrown off are kept confined to the detriment of the healing
+process.</p>
+
+<p><b>Paraffin Preparations.</b> Barth de Sandfort, a French
+naval surgeon, in experimenting for drugs to treat the cases
+of burns developing from the liquid fire and burning oil
+attacks of the Great War, discovered and perfected a substance
+known as “ambrine.” The exact composition of
+this paraffin is a secret, and for this reason it has been received
+coldly in this country, but a number of similar paraffin
+preparations have been developed and are in general
+use today. The four most popular of these are known commercially
+as paraffin No. 7, paraffin No. 7-11, parresine and
+redintol.</p>
+
+<p>Paraffin No. 7 (Dr. Hull) consists of paraffin (hard),
+67%; paraffin (soft), 25%; olive oil, 5%; oil of eucalyptol,
+2%, and resorcin, 1%. To prepare paraffin 7, first melt the
+hard paraffin, then add in the order named the soft paraffin,
+olive oil, oil of eucalyptol and resorcin.</p>
+
+<p>Paraffin No. 7-11 (Dr. Adams) consists of paraffin
+(hard), 69%; paraffin (soft), 25%; olive oil, 3%, and thymol
+iodide, 3%. The preparation of paraffin 7-11 is similar to
+that described for the preceding combination.</p>
+
+<p><span class="pagenum" id="Page_71">[Pg 71]</span></p>
+
+<p>Parresine (officially adopted by the United States
+Army and Navy) is a wax-like substance, containing about
+95% of paraffin; this is treated by the addition of a vegetable
+wax and mineral and vegetable resins so as to modify its
+physical character, especially as regards plasticity, ductility,
+pliability and adhesiveness. It also contains eucalyptol, a
+valuable antiseptic, which is added to cover the characteristically
+disagreeable odor developing from burned surfaces
+and other large abrasions during the process of healing.</p>
+
+<p>Redintol is a mixture of paraffin and resins, having
+similar melting points. The firm manufacturing it have
+prepared a special form of sheet cotton for use in connection
+with the application of this product.</p>
+
+<p><i>Technic.</i> The technic of the application of these
+paraffin preparations is similar and is described in detail
+in the chapter on “Burns.” The advantages of the wax
+treatment are numerous.</p>
+
+<p>(1) It is an inexpensive dressing (a pound of wax and
+a pint of liquid petrolatum, together costing about sixty
+cents, will dress many burns).</p>
+
+<p>(2) It is a comfortable dressing because it is smooth,
+and the granulating surface does not grow through it as with
+the gauze. The paraffin is hard enough to make the dressing
+somewhat rigid and to act as a splint.</p>
+
+<p>(3) It is a cleaner dressing, because the wound discharge
+is not permitted to soak through the impermeable
+wax covering, soiling all the linens that come in contact
+with the patient.</p>
+
+<p>(4) Superficial burns heal more readily under this
+treatment than with any other previously used method.</p>
+
+<p>(5) It is a most comfortable dressing, for the reason
+that the granulations do not grow through it, and the dressing
+is lifted off painlessly.</p>
+
+<p>(6) The resulting scars are not as pronounced.</p>
+
+<p>(7) It is a stimulant of granulations.</p>
+
+<p><i>Disadvantages.</i> The disadvantages of the wax treatment
+are:</p>
+
+<p><span class="pagenum" id="Page_72">[Pg 72]</span></p>
+
+<p>(1) Some patients refuse to be treated with the wax
+(it is applied hot directly to the injured area) because of
+the pain.</p>
+
+<p>(2) So many extravagant claims have been made for
+it, that the one who uses it for the first time will probably
+be disappointed.</p>
+
+<p>(3) An infected wound is covered with a sealed dressing.</p>
+
+<p>(4) We have no way of controlling the temperature of
+the wax. Taken from the boiling water at 212 degrees Fahr.,
+it is too hot. Cooling at 114 degrees Fahr., it is too cold.
+The degree of pain caused the patient is the only means
+one has of knowing if it is too hot, unless one tries it first
+on the back of the hand.</p>
+
+<p>(5) Around the skin edges it is painful.</p>
+
+
+<h3 id="IMPERVIOUS_COVERINGS">
+  IMPERVIOUS COVERINGS.
+</h3>
+
+<p>In connection with moist dressings, several varieties of
+impervious covering may be used.</p>
+
+<p><b>Oiled Silk</b> is a rubberized material of great strength,
+usually yellow in color and soft and smooth to the touch.
+The use of this material is quite general in podiatry for all
+moist, non-evaporating dressings. The technic of application
+consists in cutting a square of the fabric of sufficient
+size to cover the whole of the gauze dressing, also all
+sides of the toe (if this be the location of use) and a considerable
+amount of the surrounding healthy tissue. It is
+held in place either by a roller bandage, or by means of
+adhesive strips fastening down its edges to the adjacent
+surfaces. Dressings covered by oiled silk are apt to be
+bulky and for this reason, when the shoe is to be worn, it
+is not generally used.</p>
+
+<p><b>Gutta Percha Tissue</b> is a thin perishable material placed
+on the market by several firms. It is not to be compared
+with oiled silk for durability, but the dressing covered by
+gutta percha is not nearly so bulky, and for this reason it
+<span class="pagenum" id="Page_73">[Pg 73]</span>is popular and practical for use in podiatry. It is generally
+applied over the gauze by vulcanizing its edges to
+the surrounding integument. This is accomplished by
+means of heat, and, when completed, presents a neat dressing
+which is absolutely occlusive, and from which none of
+the solution used on the gauze underneath can escape. A
+square of the rubber tissue of sufficient size to more than
+cover the dressing is cut and held in place with the hand.
+A match is then applied to the edges of the square and
+while they are still melted they are lightly adhered to the
+surrounding skin. The tissue will adhere to the skin and
+will remain intact for a considerable period of time. The
+gutta percha is then covered by several turns of a roller
+bandage to protect the thin tissue from the rubbing of the
+shoe. Gutta percha tissue may also be held in place by
+means of adhesive strips as with oiled silk, but the vulcanizing
+process is by far the most popular and, insofar
+as confining the solution is concerned, it is also far more
+practical.</p>
+
+<p><b>Fish Skin</b> is a manufactured material of tissue paper
+thinness and has proven very popular for use as an impervious
+covering. The technic of application is similar to
+that described for oiled silk and it is held in place by the
+same means. It does not make a bulky dressing and for
+this reason its popularity has probably exceeded that of
+oiled silk.</p>
+
+
+<h3 id="BANDAGING">
+  BANDAGING.
+</h3>
+
+<p>A bandage is a strip of gauze, muslin, flannel or other
+material of varying widths and lengths, used in the various
+branches of medicine for retaining dressings, applications
+and splints and to produce compression. Occasionally they
+are applied to retain heat. Bandages also help keep a
+wound clean by preventing the ingress of foreign matter.</p>
+
+<p>Bandages are made of different materials, chief among
+which is gauze. This is made of lint, woven into a soft
+material, which is easily applied to all parts of the body.
+<span class="pagenum" id="Page_74">[Pg 74]</span>Muslin is a heavier cotton material and is made of cotton
+or silk or of a mixture of both (lisle) with rubber. Flannel
+is wool woven into a soft, firm, semi-elastic material. Rubber
+bandages are used to induce excretion and for compression.</p>
+
+<p>Bandages vary in width and length, depending on the
+size of the parts for which they are intended. For convenience,
+bandages are usually manufactured in widths
+varying from one-half inch to six inches, and in length from
+one to ten yards or more. Those which are used in podiatry
+vary in width from one-half inch to three inches. The
+standard length of bandages is five yards and ten yards.
+These may be cut and the unused piece preserved. A table
+of the widths of the various materials used in podiatry
+practice, showing the parts for which they are best adapted,
+follows:</p>
+
+
+<table class="autotable3">
+<tr class="xsm">
+<td class="tdc">
+</td>
+<td class="tdc">
+LESSER<br>
+TOES
+</td>
+<td class="tdc">
+GREAT TOE<br>
+FINGERS
+</td>
+<td class="tdc">
+ANKLE<br>
+WRIST
+</td>
+<td class="tdc">
+ANKLE WRIST<br>
+LEG FOREARM
+</td>
+<td class="tdc">
+LEG<br>
+FOREARM
+</td>
+<td class="tdc">
+LEG
+</td>
+</tr>
+
+<tr>
+<td class="tdl">
+Gauze
+</td>
+<td class="tdc">
+¹⁄₂″
+</td>
+<td class="tdc">
+1″
+</td>
+<td class="tdc">
+1¹⁄₂″
+</td>
+<td class="tdc">
+2″
+</td>
+<td class="tdc">
+2¹⁄₂″
+</td>
+<td class="tdc">
+3″
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Muslin
+</td>
+<td class="tdc">
+
+</td>
+<td class="tdc">
+1″
+</td>
+<td class="tdc">
+1¹⁄₂″
+</td>
+<td class="tdc">
+2″
+</td>
+<td class="tdc">
+2¹⁄₂″
+</td>
+<td class="tdc">
+3″
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Flannel
+</td>
+<td class="tdc">
+
+</td>
+<td class="tdc">
+
+</td>
+<td class="tdc">
+
+</td>
+<td class="tdc">
+2″
+</td>
+<td class="tdc">
+2¹⁄₂″
+</td>
+<td class="tdc">
+3″
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Elastic
+</td>
+<td class="tdc">
+
+</td>
+<td class="tdc">
+
+</td>
+<td class="tdc">
+
+</td>
+<td class="tdc">
+2″
+</td>
+<td class="tdc">
+2¹⁄₂″
+</td>
+<td class="tdc">
+3″
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Rubber
+</td>
+<td class="tdc">
+
+</td>
+<td class="tdc">
+
+</td>
+<td class="tdc">
+
+</td>
+<td class="tdc">
+2″
+</td>
+<td class="tdc">
+2¹⁄₂″
+</td>
+<td class="tdc">
+3″
+</td>
+</tr>
+</table>
+
+
+<p><i>A roller bandage</i> consists of one piece of material
+rolled in the shape of a cylinder, having a core and a free
+end, and is the kind used in podiatry.</p>
+
+<p><i>A double roller bandage</i> consists of one piece of material,
+rolled from both ends, so that when it is completed
+there are two cylinders and no free end.</p>
+
+<p><i>A plaster of Paris bandage</i> is composed of a piece of
+gauze or crinoline into which is rubbed powdered plaster of
+Paris. This bandage is placed in water and then applied
+to a part; after a few moments the entire bandage becomes
+hard and solid. This form of bandage prevents mobility
+and is used for fractures and dislocations. In podiatry it
+is used for taking impressions of the foot for fitting mechanical
+<span class="pagenum" id="Page_75">[Pg 75]</span>appliances. Bandages are classified as follows:</p>
+
+<p><i>Circular</i>—being circular turns around a part.</p>
+
+<p><i>Figure of eight</i>—the turns crossing each other like the
+strokes of the figure 8.</p>
+
+<p><i>Oblique</i>—covering the part by oblique turns.</p>
+
+<p><i>Recurrent</i>—the turns returning to the point from
+which they originated.</p>
+
+<p><i>Spica</i>—the turns crossing and recrossing, resembling in
+arrangement the husks of an ear of corn.</p>
+
+<p><i>Spiral</i>—the turns ascending or descending, each turn
+covering about two-thirds to three-fourths of the preceding
+turn.</p>
+
+<p><i>Spiral reverse</i>—when the bandage is turned in reverse
+position so that the inner side becomes the outer and the
+outer side rests against the skin, in order to better adapt
+itself to the part.</p>
+
+<p>Bandages are designated by various names, according
+to the shape they assume when completed, and they are
+sometimes named after the men who first used them; for
+example, “Barton’s bandage” of the head.</p>
+
+<p>The bandages used in podiatry are designated by the
+shape they assume. The names of the various bandages of
+the foot follow in the order of their importance:</p>
+
+<blockquote>
+<p>
+  Spiral bandage of the toes.<br>
+  Spica bandage of the foot.<br>
+  Figure of eight bandage of the ankle.<br>
+  Spiral reverse bandage of the leg.
+</p>
+</blockquote>
+
+<p><i>The Spiral Bandage of the Toes.</i> This bandage is
+applied to the great toe more often than to the lesser toes.
+Gauze, one inch wide for the great toe and one-half inch
+wide for the lesser toes, is used.</p>
+
+<p>This bandage may be started by a few circular turns
+around the ankle, then diagonally across the dorsum of the
+foot to the base of the great toe; but this may be simplified
+by making a simple circular turn around the proximal end
+of the toe, with the free end towards the heel, which will
+<span class="pagenum" id="Page_76">[Pg 76]</span>firmly lock the bandage. If the distal end of the toes is to
+be covered, the bandage is now applied from the proximal
+end of the toe on its plantar surface, over the distal end to
+the proximal end on the dorsal surface. This is repeated
+back and forth as often as necessary to cover the parts by
+what are known as recurrent turns. The spiral turns are
+now started and as the bandage moves toward the distal end
+of the toe, each turn must cover about two-thirds or three-fourths
+of the preceding one. When the toe is covered, the
+spirals are continued back to its base, where the bandage is
+tied off. Many toes are not cylindrical but taper to a point;
+so that when the spirals reach the distal end of the toe, the
+bandage bulges on the inner side. This bulging may be
+avoided by making a reverse turn over the part instead of
+a simple spiral.</p>
+
+<p><i>The Spica Bandage of the Foot.</i> Bandage 1¹⁄₂ to 2
+inches wide is used, depending on the size of the foot. The
+free end of the bandage is placed on the dorsum of the foot
+at the ankle joint, and is locked by several circular turns
+around the ankle. The bandage is passed diagonally forward
+across the dorsum of the foot to a point opposite the
+head of the metatarsal bone, then across the plantar surface
+of the foot to the opposite metatarsal bone, and diagonally
+backward across the dorsum of the foot, crossing the first
+half of the turn, producing an X. The turn is finished by
+passing the roller back over the tendo Achillis. This is
+repeated, the second turn covering about two-thirds of the
+first and so on backward until the desired area is covered.
+The bandage is finished by a few circular turns around the
+ankle and is tied off in the usual manner.</p>
+
+<p><i>Figure of Eight Bandage of the Ankle.</i> This bandage
+resembles the spica bandage of the foot in every way except
+that the first turn extends to the base of the metatarsal bone
+instead of to the head and, instead of tying it off at the
+ankle, a few spiral reverse turns are made up the leg. It is
+tied off as are the other bandages.</p>
+
+<p><i>The Spiral Reverse Bandage of the Leg.</i> This bandage
+<span class="pagenum" id="Page_77">[Pg 77]</span>is considered by many to be the most difficult of all the
+bandages of the extremities to apply. A few figure of eight
+turns are made around the ankle and then the spiral turn
+is made; the bandage is reversed so that the inner side becomes
+the outer and the outer side rests against the skin.
+Each turn should cover about three-quarters of the preceding
+one, and care should be taken that at the point of
+reversing the bandage, no wrinkles or uneven folds are
+produced. The reverse turns should not be made over a
+wound or a part that may be irritated by additional pressure.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_78">[Pg 78]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_VII">
+    <span class="chap">CHAPTER VII</span>
+    <br>
+    INSTRUMENTS
+  </h2>
+</div>
+
+
+<h3>TYPES, VARIETIES, USES,
+THEIR SELECTION AND CARE</h3>
+
+<p>No comprehensive monograph has yet been written discussing
+at any length the instruments of the podiatrist, and
+in compiling the following data there must necessarily be
+omissions. Up to the present moment no great amount of
+standardization has been accomplished along this line, either
+in the general use of a given instrument or in its name. It is
+the object of the author of this chapter to at least build a
+foundation upon which a complete and standardized line of
+instruments may be developed.</p>
+
+<p>Many special instruments developed by practitioners
+who have refrained, for reasons best known to themselves,
+from giving their ideas and discoveries to the profession at
+large, must necessarily be omitted, and it is to be greatly desired
+that the next few years will be rich in the development
+and standardization of our instruments and appliances.</p>
+
+<p>The instruments in general use today and manufactured
+by several companies, are all made practically of the
+same material and in the same manner, the differences
+between them, being due principally, to the finish. All such
+instruments as chisels, scalpels, spatulas, curettes, etc., are
+made from Sheffield steel, and are hand forged. The handles
+of these instruments are made of a silver or aluminum composite.
+Scissors, nail clips, thumb forceps, etc., are made
+also of Sheffield steel, but are drop forged.</p>
+
+<p>Most instrument makers today have discarded the older
+method of finishing, known generally as the “crocus” polish.
+<span class="pagenum" id="Page_79">[Pg 79]</span>This has come about principally for the reason that the application
+of the crocus polish or finish demands that the
+instrument be subjected to extreme heat. In accomplishing
+this, many instruments are rendered useless owing to the
+fact that the temper of the blade is ruined by the added heat.</p>
+
+<p>What is commonly known as a “satin” finish, accomplished
+by buffing, is now generally employed and does not
+tend in any way to injure the already highly tempered steel.</p>
+
+
+<h3 id="HISTORY_OF_INSTRUMENTS">
+  HISTORY OF INSTRUMENTS
+</h3>
+
+<p>With the exception of possibly two or three, it is doubtful,
+if chiropody has developed any really individual instruments.
+Our scalpels are similar to or are modifications of
+those of the surgeon; the nail chisels and excavators in general
+use have been borrowed from the realms of the dentist,
+as has the rotary drill; the nail clips, of course, are instruments
+which are purely for the purposes coming within the
+jurisdiction of the podiatrist; so, also are the various forms
+of the nail file.</p>
+
+<p>The chisel used by a great number of practitioners for
+the surgical removal of helomata, is one of the oldest of
+chiropody instruments and is one which was unquestionably
+developed by the chiropodist for his own needs. There is
+no instrument in use by the surgeon which bears any resemblance
+to the chisel, and for this reason we can safely
+say that it is a true chiropody instrument and may therefore
+safely be called the helotomon—the podiatry surgical instrument.
+This also, in a measure, can be said of the soft
+corn spoon. This is, to be sure, nothing but a very shallow
+curette, but nevertheless no instrument in use in general
+surgery can be rated as being similar to it; it is therefore
+properly styled the podiatrist’s curette.</p>
+
+<p>Prior to 1909, the chiropodist found it necessary to
+select his own manufacturer and have his instruments made
+according to his own ideas, or to select them from the catalog
+of the surgical supply house. This condition of affairs resulted
+<span class="pagenum" id="Page_80">[Pg 80]</span>in a wide diversity of styles. No two practitioners
+had similar instruments, and it seemed to furnish keen
+delight to one chiropodist to outdo his neighbor as to the
+size, finish and appearance of his instruments. Pearl handled
+scalpels were much in evidence and, when so, served to
+prove, without question, that the owner did no sterilization
+by boiling. Gold-plated
+blades and
+inlaid handles
+were frequently
+to be seen, proving
+nothing, unhappily,
+but the
+eccentricities of
+their owners.</p>
+
+<p>In the year
+1909, however,
+the manufacture
+of instruments as
+individual appliances
+for the chiropodist
+was
+started at the instigation of the late George Erff, by an instrument
+maker in Jersey City, N. J. His wares found such
+instant approval and the sales of his product so increased
+that it was not long before several other firms embarked in
+the business of manufacturing instruments solely for chiropodical
+work.</p>
+
+<p>This has done much to standardize instruments and
+today men and women in all parts of the world are beginning
+to use similar instruments made from standard
+patterns.</p>
+
+<figure class="figcenter illowe24" id="i_p080_fig01">
+  <img class="w100" src="images/i_p080_fig01.jpg" alt="">
+  <figcaption>
+    Fig. 1. SCALPELS
+  </figcaption>
+</figure>
+
+<p><b>The Scalpel.</b> Several varieties of scalpel are used in
+podiatry today. Some of them have been developed from
+an absolute need and some from the personal desire of the
+practitioner. The scalpel should be about five-and-one-half
+inches long, having a blade length of from one-and-one-half
+<span class="pagenum" id="Page_81">[Pg 81]</span>inches to one-and-three-quarters inches. Made from these
+dimensions, the instrument is practical as to size and has a
+working surface sufficient for any purpose.</p>
+
+<p><a href="#i_p080_fig01">Fig. 1</a> shows several varieties of scalpel. No. 2 in this
+group is a practically shaped blade to be used for work on
+callositas or heloma. This instrument will maintain a good
+shape with honing and is used by a great number of practitioners.</p>
+
+<p>This No. 2 is used for the removal of heavy callous and
+general work. Nos. 3 and 5 may be successfully used for the
+dissection and removal of helomata. These pointed scalpels
+are indicated whenever delicate work on small surfaces is
+demanded.</p>
+
+<figure class="figcenter illowe24" id="i_p081_fig02">
+  <img class="w100" src="images/i_p081_fig02.jpg" alt="">
+  <figcaption>
+    Fig. 2. CHISELS
+  </figcaption>
+</figure>
+
+<p><b>The Chisel.</b> The heloma and callosity chisels, Nos. 1, 2
+of <a href="#i_p081_fig02">Fig. 2</a>, are about five-and-one-half inches long with
+a blade length of one-and-one-quarter inches. Nos. 5 and
+6 are nail chisels and will be discussed under that
+heading.</p>
+
+<p>A series of chisels which are advocated by Harry P.
+Kenison, of Boston, differ from those shown in <a href="#i_p081_fig02">Fig. 2</a> only
+in that the handles are one-quarter of an inch in
+diameter and are round, being corrugated to prevent
+<span class="pagenum" id="Page_82">[Pg 82]</span>slipping. These instruments are five-and-one-quarter inches
+long.</p>
+
+<figure class="figcenter illowe24" id="i_p082_fig03">
+  <img class="w100" src="images/i_p082_fig03.jpg" alt="">
+  <figcaption>
+    Fig. 3. HELOMA AND CALLOSITY
+    CHISELS
+  </figcaption>
+</figure>
+
+<p><a href="#i_p082_fig03">Fig. 3</a> shows heloma and callous chisels (helotoma)
+recommended by E. C. Rice,
+M.D., of Washington, D. C.
+This variety of instrument is
+used principally for dissection
+work, but is also useful
+for shaving or paring
+methods. No. 1 of this group
+is used principally for large
+calloused areas on the plantar
+surfaces of the foot. The
+handles of these instruments
+are hexagonal and are five-and-one-quarter
+inches long.</p>
+
+<p><b>The Nail Chisel.</b> Varieties
+of straight chisels for the removal
+of ingrown portions of
+nail are shown in <a href="#i_p081_fig02">Fig. 2</a>,
+Nos. 5 and 6.</p>
+
+<p>Curved nail chisels are
+shown by Nos. 1 and 2 in
+<a href="#i_p083_fig04">Fig. 4</a>. Their use is described
+in the chapter on Ingrown
+Nails. Nos. 3, 5, 6, in
+this group, are nail packers
+used for packing gauze or
+cotton in the nail groove. No.
+4 in this figure is a curette
+excavator used for the removal
+of nail splinters or
+callous from the nail groove.</p>
+
+<p>There is a newer type of
+nail chisel with a guard
+along one edge. This is to
+prevent the instrument from
+<span class="pagenum" id="Page_83">[Pg 83]</span>penetrating the soft tissues of the nail bed while removing
+an imbedded portion of nail. This flange also aids in lifting
+the nail from its bed and in breaking up adhesions which
+may have formed in advanced cases.</p>
+
+<p>No. 2, <a href="#i_p083_fig05">Fig. 5</a>, is a nail groove gouge used for
+the removal of callous in that location.</p>
+
+<figure class="figcenter illowe24" id="i_p083_fig04">
+  <img class="w100" src="images/i_p083_fig04.jpg" alt="">
+  <figcaption>
+    Fig. 4. NAIL CHISELS
+  </figcaption>
+</figure>
+
+<figure class="figcenter illowe15" id="i_p083_fig05">
+  <img class="w100" src="images/i_p083_fig05.jpg" alt="">
+  <figcaption>
+    Fig. 5. MISCELLANEOUS
+    INSTRUMENTS
+  </figcaption>
+</figure>
+
+<figure class="figcenter illowe24" id="i_p083_fig06">
+  <img class="w100" src="images/i_p083_fig06.jpg" alt="">
+  <figcaption>
+    Fig. 6.
+    SOFT
+    CORN
+    SPOON
+  </figcaption>
+</figure>
+
+<p><b>Soft Corn Spoon.</b> (<i>Podiatrist Curette.</i>) The
+soft corn spoon, <a href="#i_p083_fig06">Fig. 6</a>, is in reality a shallow
+curette used for the purpose of dissecting an epithelial
+growth between
+the toes. The working
+edge of the instrument
+is sharp.</p>
+
+<p>A modification of this
+spoon is shown in <a href="#i_p083_fig05">Fig. 5</a>,
+No. 1. This instrument
+is commonly known as a
+“golf stick.” It is used
+for the same purpose as
+the soft corn spoon.
+These instruments are
+of the same length, in
+<span class="pagenum" id="Page_84">[Pg 84]</span>fact, are uniform in every way to the scalpel and nail chisel.</p>
+
+<p><b>The Spatula.</b> This is an instrument used almost entirely
+for the mixing of ointments and their application to
+a part. It is not sharp. (<a href="#i_p084_fig07">Fig. 7</a>, No. 1.)</p>
+
+<p><b>The Nail Scraper.</b> The scraper is used for cleaning
+around the nail, and for the removal of any callous which
+may be adherent to the nail body in or about the grooves.
+Two varieties are shown in <a href="#i_p084_fig07">Fig. 7</a>, Nos. 2 and 3.</p>
+
+<figure class="figcenter illowe24" id="i_p084_fig07">
+  <img class="w100" src="images/i_p084_fig07.jpg" alt="">
+  <figcaption>
+    Fig. 7. MISCELLANEOUS INSTRUMENTS
+  </figcaption>
+</figure>
+
+<figure class="figcenter illowe24" id="i_p084_fig08">
+  <img class="w100" src="images/i_p084_fig08.jpg" alt="">
+  <figcaption>
+    Fig. 8. EXCAVATORS WITH DETACHABLE HANDLE
+  </figcaption>
+</figure>
+
+<p><b>The Excavator.</b> Excavators for use in the nail grooves
+are of great service to the podiatrist. Probably the most
+practical variety of this instrument is that borrowed from
+<span class="pagenum" id="Page_85">[Pg 85]</span>the dentist. This form of excavator is composed of two
+parts, a handle, called commercially a cone socket handle,
+and an excavator point which screws into the hand piece.
+These points may be obtained in a great
+number of styles but the two shown in
+<a href="#i_p084_fig08">Fig. 8</a> are practical in all cases. No. 2
+has a small semi-sharp point, while No. 1
+has a larger point and is dull. These instruments
+can also be used as packers for
+placing gauze or cotton under the nail
+and in the grooves.</p>
+
+<p>Other forms of excavators are
+shown in <a href="#i_p085_fig09">Fig. 9</a>. No. 1 is a combination
+excavator and packer; No. 2, a packer;
+No. 3 an excavator; No. 4 a combination
+spatula and packer.</p>
+
+<figure class="figcenter illowe24" id="i_p085_fig09">
+  <img class="w100" src="images/i_p085_fig09.jpg" alt="">
+  <figcaption>
+    Fig. 9. EXCAVATORS
+  </figcaption>
+</figure>
+
+<figure class="figcenter illowe15" id="i_p085_fig10">
+  <img class="w100" src="images/i_p085_fig10.jpg" alt="">
+  <figcaption>
+    Fig. 10. INGROWING NAIL INSTRUMENTS
+  </figcaption>
+</figure>
+
+<p><b>Special Ingrown Nail Instruments.</b>
+A set of special instruments for use in
+surgical procedures in ingrown nail
+cases is shown in <a href="#i_p085_fig10">Fig. 10</a>. Nos. 1, 2, and
+3 are used for the removal of ragged
+edges of nail. No. 4 is a nail elevator,
+used for pre-operative examination, and
+No. 5 is a special oil stone used for
+sharpening Nos. 1, 2, and 3.</p>
+
+<p><b>Ingrown Nail Forceps.</b> Two types
+of forceps for the removal of the imbedded
+<span class="pagenum" id="Page_86">[Pg 86]</span>portion of the nail after it has been loosened from
+the nail body, are in general use. One is of a curved variety
+and is particularly practical; the other has a straight point
+and a locking device and is in reality a small artery forceps.
+<a href="#i_p086_fig11">Fig. 11</a> shows the
+straight point
+forceps.</p>
+
+<figure class="figcenter illowe15" id="i_p086_fig11">
+  <img class="w100" src="images/i_p086_fig11.jpg" alt="">
+  <figcaption>
+    Fig. 11.
+
+    STRAIGHT NAIL
+    FORCEPS
+  </figcaption>
+</figure>
+
+<figure class="figcenter illowe24" id="i_p086_fig12">
+  <img class="w100" src="images/i_p086_fig12.jpg" alt="">
+  <figcaption>
+    Fig. 12.
+
+    NAIL SPLITTER
+  </figcaption>
+</figure>
+
+<p><b>Ingrown Nail
+Clippers.</b> The
+clipper shown in
+<a href="#i_p086_fig12">Fig. 12</a> is used
+almost entirely in
+ingrown nail
+operations. It is
+extremely light
+and if used in the
+general cutting of
+nails will surely
+be sprung. The
+clipper illustrated
+is more correctly
+a nail “splitter.”
+These clippers
+may be obtained in two sizes, four and
+one-half and five inches.</p>
+
+<p><b>Nail Clippers.</b> The nail clipper
+should be of heavy stock so that all nails
+may be easily cut without injury to the
+instrument or pain to the patient. A
+heavy nail clip, even though it be dull,
+will do much more efficient work in general,
+than will a sharp light clipper.</p>
+
+<p>Two styles of nail clippers are shown here. <a href="#i_p087_fig13">Fig. 13</a> is
+a clip for general work while <a href="#i_p087_fig14">Fig. 14</a> finds its particular
+efficacy in club nail cases. Notice the angle of the blade in
+this type of instrument.</p>
+
+<figure class="figcenter illowe24" id="i_p087_fig13">
+  <img class="w100" src="images/i_p087_fig13.jpg" alt="">
+  <figcaption>
+    Fig. 13. NAIL CLIPPERS
+  </figcaption>
+</figure>
+
+<figure class="figcenter illowe24" id="i_p087_fig14">
+  <img class="w100" src="images/i_p087_fig14.jpg" alt="">
+  <figcaption>
+    Fig. 14. CLUB NAIL CLIPPERS
+  </figcaption>
+</figure>
+
+<p><b>Thumb Forceps.</b> Thumb forceps are used extensively
+<span class="pagenum" id="Page_87">[Pg 87]</span>in podiatry practice. All sterile dressings are handled with
+these instruments to insure immunity from the contamination
+of the hands.</p>
+
+<p>Three varieties of thumb forceps are shown in <a href="#i_p088_fig15">Fig. 15</a>.
+No. 1 has needle point corrugated jaws; No. 2 has curved,
+<span class="pagenum" id="Page_88">[Pg 88]</span>corrugated needle jaws; and No. 3 is a heavy pointed corrugated
+jawed instrument. These three styles are all four
+inches in length.</p>
+
+<p><b>Iris Tooth Forceps.</b> This instrument is used where the
+dissection method of treatment is employed. The sharp
+teeth at the end of the jaws, grasp the thickened mass
+as it is loosened from its bed. (<a href="#i_p082_fig03">Fig. 3</a>-A.) The ordinary
+thumb forceps may also be used in this connection but they
+are much more liable to slip than are those of the iris tooth
+variety.</p>
+
+<div class="col3container">
+<div class="col3"><figure class="figcenter illowe10" id="i_p088_fig15">
+  <img class="w100" src="images/i_p088_fig15.jpg" alt="">
+  <figcaption>
+    Fig. 15.
+    THUMB FORCEPS
+  </figcaption>
+</figure></div>
+
+<div class="col3"><figure class="figcenter illowe10" id="i_p088_fig16">
+  <img class="w100" src="images/i_p088_fig16.jpg" alt="">
+  <figcaption>
+    Fig. 16. HEAVY
+    STRAIGHT
+    SCISSORS
+  </figcaption>
+</figure></div>
+
+<div class="col3"><figure class="figcenter illowe10" id="i_p088_fig17">
+  <img class="w100" src="images/i_p088_fig17.jpg" alt="">
+  <figcaption>
+    Fig. 17. HEAVY
+    CURVED SCISSORS
+  </figcaption>
+</figure></div>
+</div>
+
+<p class="clear"><b>Scissors.</b> The podiatrist needs at least four styles of
+scissors in his general practice.</p>
+
+<p>For buckskin, felt and adhesive plaster a heavy scissors
+with straight blades is necessary. This scissors should be
+six or six and one-half inches in length and should preferably
+have round ends (<a href="#i_p088_fig16">Fig. 16</a>).</p>
+
+<p><span class="pagenum" id="Page_89">[Pg 89]</span></p>
+
+<p>A pair of heavy, curved scissors is also useful for
+shaping shields, cutting apertures and for other similar
+work. It is suggested that these be not too large for they
+are apt to be unwieldy. Four and one-half or five inches is
+ample size, and one point should be rounded, and one
+pointed (<a href="#i_p088_fig17">Fig. 17</a>).</p>
+
+<div class="col3container"><div class="col3"><figure class="figcenter illowe10" id="i_p089_fig18">
+  <img class="w100" src="images/i_p089_fig18.jpg" alt="">
+  <figcaption>
+    Fig. 18. CUTICLE
+    SCISSORS
+    (Curved Blades)
+  </figcaption>
+</figure></div>
+
+<div class="col3"><figure class="figcenter illowe10" id="i_p089_fig19">
+  <img class="w100" src="images/i_p089_fig19.jpg" alt="">
+  <figcaption>
+    Fig. 19.
+    CUTICLE
+    SCISSORS
+    (Straight Blades)
+  </figcaption>
+</figure></div>
+
+<div class="col3"><figure class="figcenter illowe10" id="i_p089_fig20">
+  <img class="w100" src="images/i_p089_fig20.jpg" alt="">
+  <figcaption>
+    Fig. 20. BANDAGE
+    SCISSORS
+  </figcaption>
+</figure></div></div>
+
+<p class="clear">Cuticle scissors are useful in many chiropodical procedures.
+<a href="#i_p089_fig18">Fig. 18</a> shows a four-inch, lance point curved
+scissors. <a href="#i_p089_fig19">Fig. 19</a> shows a four and three-quarters inches
+straight pointed cuticle scissors.</p>
+
+<p>A small bandage scissors, (<a href="#i_p089_fig20">Fig. 20</a>) should be included
+among the podiatrists’ instruments. It is not necessary to
+have a large pair, but one about four and one-half or five
+inches in size is very useful.</p>
+
+<p><span class="pagenum" id="Page_90">[Pg 90]</span></p>
+
+<p><b>The Hypodermic Syringe.</b> The choice of the hypodermic
+syringe is purely a matter of preference, but certainly
+an all-glass syringe (both barrel and piston) appears to be
+more practical from the standpoint of use and of sterilization.
+The metal barrel syringe is fast going out of use excepting
+of the type in which no washers are employed. A
+syringe having a capacity of 2 c.c. is ample for the use of
+the podiatrist (<a href="#i_p090_fig21">Fig. 21</a>).</p>
+
+<figure class="figcenter illowe24" id="i_p090_fig21">
+  <img class="w100" src="images/i_p090_fig21.jpg" alt="">
+  <figcaption>
+    Fig. 21. HYPODERMIC SYRINGE
+  </figcaption>
+</figure>
+
+<figure class="figcenter illowe24" id="i_p090_fig22">
+  <img class="w100" src="images/i_p090_fig22.jpg" alt="">
+  <figcaption>
+    Fig. 22. ROUGH CUTTING BURS
+  </figcaption>
+</figure>
+
+<p><b>The Rotary Drill.</b> One of the greatest boons to modern
+podiatry is the development of the rotary file or drill for
+their use. This instrument has become so all important in
+the treatment of many nail diseases, and, in fact, in the
+prophylactic treatment of the normal nail, that we may well
+wonder how any results were obtained before its advent.</p>
+
+<p>It is not the purpose of this chapter to go into the
+mechanism of the drill, but the selection of burrs is a subject
+which is of such importance as to merit mention.</p>
+
+<p><span class="pagenum" id="Page_91">[Pg 91]</span></p>
+
+<p><a href="#i_p090_fig22">Fig. 22</a> shows several varieties of rough or “cutting”
+burs for use in grinding down club nails. In this group
+“B,” “D” and “E” are particularly practical.</p>
+
+<p>Finishing burs are those used to smooth off the nail
+after the use of a cutting bur, for filing the edges of a
+normal nail, or for thinning the nail
+in prophylactic treatments (<a href="#i_p091_fig23">Fig. 23</a>).</p>
+
+<p><b>The Nail File.</b> The hand file, for
+smoothing the edge of a nail after clipping
+(<a href="#i_p091_fig24">Fig. 24</a>), should have a smooth
+and a rough side. The rough side is
+used in cases where the use of a drill
+is impossible.</p>
+
+<p><b>Toe Separators.</b> These are appliances
+used for the purpose of holding the toes apart while
+operating between them. The implement shown in <a href="#i_p091_fig25">Fig. 25</a>,
+depends upon the tension of the heavy wire for its efficacy.
+There is also an appliance used for similar purposes which
+is dependent upon a screw adjustment.</p>
+
+
+<div class="col2container"><div class="col2"><figure class="figcenter illowe10" id="i_p091_fig23">
+  <img class="w100" src="images/i_p091_fig23.jpg" alt="">
+  <figcaption>
+    Fig. 23.
+    FINISHING BURS
+  </figcaption>
+</figure></div>
+
+<div class="col2"><figure class="figcenter illowe10" id="i_p091_fig25">
+  <img class="w100" src="images/i_p091_fig25.jpg" alt="">
+  <figcaption>
+    Fig. 25. TOE SPREADER
+  </figcaption>
+</figure></div>
+
+<figure class="clear figcenter illowe24" id="i_p091_fig24">
+  <img class="w100" src="images/i_p091_fig24.jpg" alt="">
+  <figcaption>
+    Fig. 24. HAND FILE (SHOWING ROUGH SURFACE)
+  </figcaption>
+</figure></div>
+
+<p><b>Applicators.</b> Applicators, used for solutions, may be
+obtained in metal and in wood. Those of metal have a short
+hexagonal handle and are corrugated at the distal end so
+that cotton may be wound about
+them.</p>
+
+<p>The wooden applicator is a
+small round stick about six inches
+long. Such applicators are more
+practical than those of metal, for
+they may be thrown away after use.
+The metal applicators corrode after
+several applications of a corrosive
+drug and soon become useless.</p>
+
+<p><span class="pagenum" id="Page_92">[Pg 92]</span></p>
+
+<p><b>The Skiving Knife.</b> The choice of a knife for the manufacture
+of shields of felt or buckskin depends principally
+upon the fancy of the user. Some prefer an all-metal, flat-handled
+knife similar to those used by leather workers (Fig.
+26); others find it more practical to employ a blade set in a
+larger wooden handle, claiming that more purchase can be
+brought to bear upon the material to be cut,
+and consequently more accuracy is obtained.
+An instrument, known commercially as the
+“Murphy” knife, is a practical example of
+this latter variety. It has a wooden handle
+about four inches long, and a blade of similar
+length. The cutting edge is narrow toward
+the point and gives the operator a bias edge
+with which to do his cutting. The all-metal
+knife blade is similarly slanted. Skiving
+knives need not be made of the finest, highly
+tempered steel, and the edge placed upon
+them, when honed, need by no means be a
+“razor” edge.</p>
+
+<figure class="figcenter illowe24" id="i_p092_fig26">
+  <img class="w100" src="images/i_p092_fig26.jpg" alt="">
+  <figcaption>
+    Fig. 26.
+    SKIVING
+    KNIVES
+  </figcaption>
+</figure>
+
+
+<h3 id="CARE_OF_INSTRUMENTS">
+  CARE OF INSTRUMENTS
+</h3>
+
+<p>Instruments need care just as do any fine
+machine. Knives and other pieces of fine
+metal will rapidly lose their usefulness unless
+proper and unceasing care is taken of them.</p>
+
+<p><b>Honing.</b> Nearly every chiropodist at
+the present time hones his own knives or
+chisels. This is an art which comes naturally
+to some but usually is only developed through
+constant practice. The first important point that needs to
+be considered in this connection is the selection of a hone.
+A hone is a plane true block of fine compact stone for
+sharpening edged tools, and there are a number of these
+which may be used for podiatry instruments.</p>
+
+<p><b>The Belgian Hone</b> is in all probability the most popular
+of the sharpening stones and when genuine and of fine
+quality, they are superior to all other forms of stone. One
+<span class="pagenum" id="Page_93">[Pg 93]</span>of the principal drawbacks in the purchase of a hone of this
+variety is the fact that many are manufactured of a composite
+substance which is extremely hard and upon whose
+surface no impression can be made with the instrument. All
+hones should be fairly soft, so that the knife blade, as it is
+drawn across the surface, will take hold, and not “rough”
+or “gritty.” Any stone which has a tendency to roughness
+or coarseness will never put a real fine “razor” edge on a
+delicate instrument.</p>
+
+<p><b>The Swatty Hone</b> has been popular for years among
+barbers and others who are called upon to use razor-like
+blades. The one disadvantage in the use of this variety of
+stone is that they are hard, and considerable honing is
+needed to place a proper edge upon the instrument.</p>
+
+<p><b>The Oil Stone</b> is used more particularly for heavy instruments
+not demanding a fine surface for finishing. Skiving
+knives and the like may be successfully sharpened on
+stones of this kind. Some practitioners prefer to “rub
+down” an instrument on an oil stone or a “carborundum”
+stone and then smooth the edge or “finish” it on a genuine
+old rock Belgian hone. Carborundum hones cannot be obtained,
+as a rule, fine or smooth enough for real delicate
+work on podiatry instruments, but they are efficient for
+heavier instruments.</p>
+
+<p><b>Technic of Honing.</b> Having selected a stone the block is
+placed before you on a table. The knife is grasped firmly by
+the handle with the thumb and the third, fourth and fifth
+fingers. The second or index finger is placed at the junction
+of the blade with the handle on the upper surface. The
+blade of the knife is now laid upon the hone in such a manner
+that it is flat upon the stone’s surface, and, using the whole
+forearm, the fingers and wrist remaining stationary so that
+the angle of the blade remains unchanged, the blade is
+drawn in an oblique (right to left) direction toward the
+operator’s body. It must be remembered that the blade be
+drawn <i>obliquely</i> for if it be drawn straight no edge will be
+placed upon the instrument.</p>
+
+<p><span class="pagenum" id="Page_94">[Pg 94]</span></p>
+
+<p>Having completed this oblique stroke, the whole instrument
+is turned in the hand and laid upon the stone so that
+the other side of the blade is now upon its surface. An
+oblique (left to right) stroke is then made toward the
+operator using, as before, the whole forearm. This stroke
+having been completed the whole procedure is recommenced.</p>
+
+<p>The marks appearing on the blade of the knife caused
+by contact with the hone, plainly tell the operator whether or
+not he has the proper angle or whether he is holding the
+blade at the proper level through its long axis. Testing the
+sharpness of the blade on the finger-nail or skin, or judging
+from the appearance of the contact marks, tells the operator
+whether or not the instrument be sufficiently sharp.</p>
+
+<p>Do not overhone! This is a bad fault and will develop
+a “wire” edge on the instrument which may take hours to
+remove. An edge may be “wired” also by continued heavy
+pressure during the honing process. This should also be
+avoided. Usually several heavy strokes on either side of
+the blade, followed by a series of lighter ones, is sufficient
+to place an instrument in serviceable condition for a considerable
+period of time.</p>
+
+<p><b>Polishing.</b> Instruments which are subjected to boiling
+sterilization are bound to become discolored (not rusted)
+no matter what chemical may be put in the water to prevent
+this condition. For this reason it is found necessary, if the
+brightness of an instrument is to be retained, to clean or
+polish it from time to time.</p>
+
+<p>Scrubbing with sapolio or some similar substance, not
+too gritty, will serve to remove most of the stains but the
+labor occasioned by a procedure of this kind is considerable
+and is greatly lessened by the use of a motor buffer or
+polisher. In cases where rust stains are present, this
+machine is indispensable, for no amount of manual rubbing
+will remove these marks. The buffer wheel should be of
+some soft material, usually chamois, bound firmly. Machine
+buffing can never be used on delicate, sharp blades, as it will
+ruin whatever edge may be present. Handles may be
+<span class="pagenum" id="Page_95">[Pg 95]</span>cleaned efficiently as can scissors, thumb forceps, and similar
+instruments by this method.</p>
+
+<p><b>Wiping.</b> After an instrument is removed from boiling
+water it must be thoroughly dried if it is to be kept in good
+condition. The ideal sterilizer is one combining a superheated
+steam chamber, or a water boiling receptacle, and a
+dry hot air chamber for drying the instruments after sterilization.
+If such an apparatus is not included in the podiatrist’s
+equipment, the instruments must be thoroughly
+wiped until dry. This must be done with a sterile wipe to
+maintain surgical cleanliness and the process must be
+thorough.</p>
+
+<p>Care must be exercised in using superheated steam as a
+sterilizing agent that the instrument does not remain for
+too great a length of time in the vapor. Boiling water can
+only reach 212° F., and an instrument will stand subjection
+to this degree of heat for a considerable time, but steam is
+often heated to twice this degree and this terrific temperature
+is bound to untemper an instrument which is allowed
+to remain in the vapor over 30 or 40 seconds.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_96">[Pg 96]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_VIII">
+    <span class="chap">CHAPTER VIII</span>
+    <br>
+    SHIELDS AND SHIELDING
+  </h2>
+</div>
+
+
+<p>Shielding is one of the most important branches of
+practical podiatry. A great amount of study must be
+given to this work, and to afford his patient relief and comfort
+through the application of shields and strappings, the
+operator is continuously called upon to exercise his mechanical
+ingenuity or to develop this trait if it be not already
+existent.</p>
+
+<p>The surgical treatment of a condition may be faultless,
+and yet upon the application of an ill-fashioned or poorly-fitted
+shield, the patient will experience even a greater
+amount of discomfort or pain than before the treatment was
+commenced, and the operator’s previous good work is thus
+undone.</p>
+
+<p><b>Definition.</b> A shield is an appliance fashioned from
+some skin or fabric and used for the purpose of relieving
+pressure or friction, or to protect a tender part upon the
+foot. The nomenclature which is adhered to under this
+heading is comparatively a simple one. The various forms
+and varieties of shields mentioned and discussed are named
+either for their shape or for the particular parts of the foot
+to which they are applied. In some instances the two are
+combined. Thus a “lateral plantar half-moon or crescent
+shield” has a crescent shaped body and is used for the
+protection of an area on the lateral part of the plantar
+surface.</p>
+
+
+<h3 id="MATERIALS">
+  MATERIALS
+</h3>
+
+<p>Various materials are in general use today in the practice
+of podiatry for padding or shielding. The object is to
+<span class="pagenum" id="Page_97">[Pg 97]</span>give here a brief yet comprehensive description of each in
+its turn, together with a general survey of when, where and
+how they may be used.</p>
+
+<p><b>Chamois.</b> This skin presents a material which may be
+used in shielding parts where a pad of great thickness is not
+required. Chamois skin is quite thin and has not a great
+deal of stability or “body” in its make-up, and skins of a
+uniform thickness throughout are seldom obtainable. The
+hide thins out considerably toward the belly of the animal
+and for this reason there is a great amount of waste. However,
+in many cases chamois may be used with success in
+connection with helomata on the dorsal or outer lateral surfaces
+of the fifth toe, the dorsal surfaces of the intermediate,
+and the ends of all the toes. For heloma molle, shields of
+chamois may also be used to good advantage, as they are
+soft and pliable and when placed between the digits they
+readily take the shape of the toes without causing the irritation
+following the use of shields of a coarser or stiffer
+“body” in like positions.</p>
+
+<p><b>Buckskin.</b> Buckskin is probably the most generally
+used material for shielding in practice today. This hide
+has good “body” and even when skived to paper thinness
+retains a great amount of its stability. Buckskin can be
+obtained in thicknesses ranging from one-sixteenth to one-quarter
+or even three-eighths of an inch, but care should be
+exercised in its selection that no pieces of coarse-grained
+skin be chosen. This is noted because the coarse or
+“pebbled” skin does not skive readily, and when bevelled
+off, the edges remain ragged and uneven. There are several
+firms manufacturing excellent grades of buckskin.
+Shields of buckskin may be generally used in all conditions
+and locations, the thinner skins on the toes and dorsal surfaces
+and the thicker on the plantar surfaces and on the
+metatarsophalangeal joints of the great and fifth toes.</p>
+
+<p><b>Adhesive Moleskin.</b> A so-called moleskin having a prepared
+medicated adhesive substance on one side is becoming
+very popular with the profession. It may be obtained
+<span class="pagenum" id="Page_98">[Pg 98]</span>in rolls of from one to ten yards long, and from seven to
+twelve inches wide. It is very thin but has good “body,”
+and under the pressure to which it would be ordinarily subjected
+as a shielding material, does not stretch nor pull out
+of shape. Because of this thinness and its pliability and
+softness, no skiving of its edges is necessary, and it makes
+a neat, clean, practical material from which thin shields may
+be fashioned. Adhesive moleskin may be employed wherever
+chamois or the thinner grades of felt or buckskin are
+used.</p>
+
+<p><b>Sheep Skin.</b> Sheep skin is one of the lesser used but,
+nevertheless, practical shielding agents. Its one disadvantage
+is that the finished surface is smooth and shiny and
+an adhesive substance does not remain intact unless applied
+at the time the shield is to be used. This, however, does not
+present any serious objection to the use of the skin, as it is
+easily skived, has good “body” and presents a neat, clean
+appearance on the foot. It is employed wherever chamois
+may be used.</p>
+
+<p><b>Felt.</b> Plain white piano felting, of the softer and more
+pliable grades, is largely used at the present time. This
+felt can be obtained in thicknesses of from one-sixth to
+three-eighths or even one-half inch. The last mentioned
+thickness is very seldom used, and then only in cases where
+a slight support is needed for the longitudinal arch or as a
+pad in cases of painful heel. In both these instances the
+felt is pasted in the shoe rather than adhered to the foot.
+The one-sixteenth inch grade is used (1) between the toes
+(applied usually without adhesive); (2) as a substitute for
+chamois, kid or buckskin in all places where these latter may
+be used. The thicknesses ranging from one-eighth to three-eighth
+inch are used generally on the lateral surfaces of
+the first and fifth metatarsophalangeal articulations, on the
+plantar surface under the prominences of the same joints,
+and for protecting painful areas on the dorsum of the foot
+(its lateral borders), or in the region of the heel and the
+tendo Achillis. Felt shields may be applied with or without
+<span class="pagenum" id="Page_99">[Pg 99]</span>adhesive, and strapping should be done dependent upon the
+length of time the shields are required to remain.</p>
+
+<p>For badly inflamed or tender helomata, felt presents
+an ideal material for shielding. Shields of this material are
+softer and more yielding, and while they cannot be expected
+to stand the same amount of usage as those of buckskin
+they are, nevertheless, strongly recommended in the above
+named condition. After the aperture is cut to fit the part
+to be protected, its (the aperture’s) edges are nicked with
+scissors so that when applied they will expand and readily
+take the shape of the indurated areas. While they naturally
+pack down and become of denser consistency than at the
+time of application, felt shields never become as hard as
+those made of buckskin.</p>
+
+<p><b>Adhesive Felt.</b> This is the ordinary prepared felt
+manufactured by several firms, one side of which is covered
+with a preparation of dry gum arabic. Upon moistening
+this adhesive, the shield may be adhered to any part. Shields
+of adhesive felt are very handy to use when protection is
+desired for a short time and are very seldom strapped unless
+they are to be applied to the plantar surfaces. They have
+no specific use and may be applied wherever shields of other
+materials are used.</p>
+
+<p><b>Lamb’s Wool.</b> This material is used principally for
+insoles in shoes in cases of painful heel or severe callosities
+on the plantar surfaces, and in conditions where the integument
+of the foot is thin and the patient experiences pain or
+burning sensations when walking. The wool is left on the
+hide, so that there is ample body for the application of adhesive
+substances. This material, in the uses mentioned
+above, is seldom adhered to the foot itself, but is, rather,
+placed in the shoe.</p>
+
+
+<h3 id="PREPARATION_OR_MANUFACTURE_OF_SHIELDS">
+  PREPARATION OR MANUFACTURE OF SHIELDS.
+</h3>
+
+<p>The definite points to be considered in the making of
+a proper fitting are not many; these are important:</p>
+
+<p><span class="pagenum" id="Page_100">[Pg 100]</span></p>
+
+<p>1. Location of the part to be protected so that the size
+and shape of the shield may be determined.</p>
+
+<p>2. Thickness of the shield.</p>
+
+<p>3. Skiving.</p>
+
+<p>4. Aperture.</p>
+
+<p><b>Location of the Parts to Be Protected.</b> Extreme care
+should be exercised in deciding upon the size and shape of
+the shield. The location and size of the area to be protected
+should be taken into consideration and the shield should be
+so fashioned that no part of it extends on the tissue upon
+which its presence might cause irritation. For instance,
+a shield is to be applied on the dorsal surface of one of the
+intermediate toes; it should be wide enough to cover the
+surface of that toe, but should not be allowed to curl downward
+upon the digit’s lateral surfaces or to lap over or
+extend upon the adjoining toes. Again, a shield applied on
+the plantar surface should never be allowed to extend forward
+to a point where it might crowd under the toes and
+come in contact with their webs.</p>
+
+<p>No shield applied for the protection of one area should
+be allowed to extend over and press upon another area
+which is not normal integument. The reason for this is
+obvious, for in covering an heloma, for instance, a greater
+amount of pressure is brought to bear upon that excrescence,
+with the result that it is subjected to a greater amount
+of irritation and pressure than would be caused by the shoe
+itself.</p>
+
+<p><b>Thickness of the Shield.</b> Just as great harm is brought
+about by using a shield that is too thick or too thin as follows
+the absence of the protection which a shield provides.
+If it be too thick, the great amount of pressure put upon
+the surrounding area will depress those tissues to such an
+extent that severe congestion, with its accompanying pain
+and discomfort, is liable to ensue. In making a shield too
+thin, no protection is afforded to the area where it is desired
+and at the same time the toe is bundled up with a lot of
+<span class="pagenum" id="Page_101">[Pg 101]</span>padding and plaster which is entirely unnecessary, in that
+it does no good. The use of a shield should be avoided in all
+cases, when possible, but there are many situations in which
+a shield is indicated and which, when applied, proves highly
+effective. Shields naturally pack down more quickly when
+the weight of the whole body is constantly being applied,
+and so, naturally, the thicker varieties of shielding are used
+on the plantar surfaces. This applies to all shielding materials
+and in particular to felt.</p>
+
+<p><b>Skiving.</b> Skiving is a process by which the edges of a
+shield are thinned or bevelled to a “feather” edge. This
+is done for three principal reasons:</p>
+
+<p>(1) When a shield’s outer edges are skived to a
+“feather” edge, it no doubt adheres to the integument in
+a much more satisfactory and lasting manner than if those
+edges were allowed to retain a uniform thickness with the
+main body of the shield.</p>
+
+<p>(2) By thinning the shield down at the edges any danger
+of unneeded and detrimental pressure upon the underlying
+and surrounding areas is removed. The object is
+merely to protect a certain part, and, therefore, if a pad
+is used which is of sufficient thickness around the painful
+area to protect the diseased tissue, the aim is accomplished,
+and to have any considerable thickness to the shield, except
+as it is immediately adjacent to the area to be treated, is
+entirely unnecessary.</p>
+
+<p>(3) Skiving a shield at its outer extremities does away
+with, or at least minimizes, the danger of the shield being
+loosened or shifted, and consequently it will remain longer
+in place and with better results.</p>
+
+<p>The inner edges of the aperture made in the shield for
+the protection of the diseased part should also be skived.
+This is done with the idea of conforming the shield, as
+nearly as possible, to the shape of the indurated integument
+and does away with any irritation to the part which might
+be caused were these edges left perpendicular.</p>
+
+<figure class="figcenter illowe24" id="i_p102_fig01">
+  <img class="w100" src="images/i_p102_fig01.jpg" alt="">
+  <figcaption>
+    Fig. 1.
+
+    <p class="hang1">A. Oval; B. Half-moon or Crescent; C. Interdigital; D. Dorsal
+    (Intermediate Toes); E. Fifth Toe (Right and Left); F. Boot Shield;
+    G. Dorso-digital Half-moon (Built Up); H. Modified Half-moon I.
+    Medio-plantar Crescent (With Cut-out for 1st or 5th Joint)</p>
+  </figcaption>
+</figure>
+
+<p><b>Aperture.</b> For the purpose of protecting a diseased
+<span class="pagenum" id="Page_102">[Pg 102]</span>part from the pressure of footgear, an aperture or opening
+is made in the body of the shield. The size of this aperture
+is so fashioned as to be slightly larger than the part to be
+protected. Many mistakes are made in shielding, due to the
+aperture not being cut in the proper place, and care should
+be taken in this connection. This opening is not always
+made in the centre of the shield; in many instances it must
+be placed either to one or to the other side of the median
+line, running anterio-posteriorly, and in other cases it
+should be nearer the front rather than the back of the shield,
+and vice versa.</p>
+
+<p><span class="pagenum" id="Page_103">[Pg 103]</span></p>
+
+<p>For example: we are to shield an heloma on the fifth
+toe. Upon examination of the part we find that the growth
+occurs on the dorsal ridge of the digit and that while there
+is a considerable area of the normal integument on the
+toe’s outer lateral side, the space between the inner edge
+of the growth and the fourth toe is very narrow. The aperture
+must then be so made in the shield that a very narrow
+portion of the skin or fabric rests upon the strip of normal
+tissue toward the fourth toe and that the wider edge extends
+down the side of the fifth digit. Again: in some instances
+we find that the spot to be protected is much nearer
+the distal end of the toe and the nail than the proximal part.
+The opening should then be made much nearer the anterior
+part of the shield than the posterior, so that when
+applied, the anterior part of the shield will not cover the
+nail or overlap the distal end of the toe. Too much stress
+cannot be laid upon this particular feature of shield-making
+and their application, and the student and practitioner alike
+will do well to give these points great consideration.</p>
+
+<p><b>Method of Skiving.</b> The most generally used and in
+all probability the most efficient method of skiving a shield
+is as follows: the material used, after being cut to the shape
+and size desired, is placed with the left hand. The skiving
+knife is then taken firmly in the right hand and with an
+oblique stroke away from the operator, the edges of the
+shield are cut away and thinned to a “feather” edge. This
+is continued around the whole outer circumference of the
+shield until a uniform thickness is obtained. After this
+procedure, should the centre of the shield present any inequalities
+or uneven ridges, these are pared away in a like
+manner until the whole surface is uniformly smooth.</p>
+
+<p>One side of all pieces of buckskin will be found to be
+firmer and have a better body than the other. This is the
+surface to be allowed to remain intact, the bevelling being
+done on the reverse side. This insures a firm surface for
+the application of an adhesive substance.</p>
+
+<p><b>The Skiving Knife.</b> The knife which seems to be most
+<span class="pagenum" id="Page_104">[Pg 104]</span>practical for our purpose in this procedure should have a
+blade from three and one-half to five inches long, about
+three-quarters of an inch wide at its base and tapering
+gradually until, at the end, the width of the blade is about
+three-eighths of an inch. This insures a large cutting surface
+and the blade, being tapered instead of an even width
+from point to base, allows the operator to employ an oblique
+movement in skiving the shield.</p>
+
+<p>The handle of this instrument should be fairly large
+and round, so that it will admit of a firm hold. A so-called
+“Murphy knife” is found to be a very practical and inexpensive
+instrument for skiving.</p>
+
+
+<h3 id="APPLICATION_AND_STRAPPING_OF_SHIELDS">
+  APPLICATION AND STRAPPING OF SHIELDS
+</h3>
+
+<p>In applying a shield, care should always be taken that
+the aperture is of sufficient size to protect all of the affected
+area. If this is not done, great inconvenience and perhaps
+severe pain is caused to the patient, in that the shield rests
+upon tender tissue which should be protected. It is also
+good policy to allow for any shifting which may take place.
+As for example, in the instance of an heloma: the shield
+should be applied so as to leave some space between the
+anterior edge of the indurated integument and the anterior
+edge of the shield’s aperture. The foot in the process of
+walking (and particularly if the patient wears high-heeled
+shoes) is being constantly pushed towards the forward part
+of the shoe, and, therefore, a shield protecting an heloma on
+the dorsum of any of the toes will be pushed back rather
+than forward. By taking this into consideration the shield,
+if it does shift, will still have a sufficient amount of sound
+integument to rest upon before it pushes back on the growth
+itself.</p>
+
+<p><b>Adhesive Substances.</b> Adhesive substances for adhering
+the shield to the integument should have no irritating
+properties whatsoever. The late George Erff perfected a
+small, neat alcohol lamp with a “sauce pan” attachment in
+which these adhesive substances, usually sold in stick form,
+<span class="pagenum" id="Page_105">[Pg 105]</span>are easily and quickly melted to a fluid consistency when
+they may be easily applied to a shield by means of a fine
+camel’s hair brush. This enables the operator to spread the
+adhesive substance in a thin and even coat over the whole
+surface and is a much superior method to the older way of
+applying it directly from the heated stick.</p>
+
+<p><b>Strapping.</b> In adhesive plasters, by means of which
+shields may be securely held in place, we have a great assortment
+from which to choose. Plain rubber adhesive
+plasters are manufactured by many firms, as is the zinc
+oxide (medicated) adhesive plaster. Special plasters, medicated
+in various ways, are also on the market in abundance
+and no doubt find their use in special cases. It is found,
+however, that the zinc oxide plaster is perhaps the most
+practical in all instances, although by no means the cheapest.
+This plaster retains its adhesive properties much longer
+than the numerous other plasters which have been experimented
+with from time to time, and, being at the same time
+medicated with zinc oxide, an antiseptic, it makes a practical,
+cleanly and non-irritating adhesive plaster.</p>
+
+<p>There are several important points to take into consideration
+in applying adhesive plasters for fastening
+shields more firmly on the surfaces of the foot.</p>
+
+<p>(1) <b>No Strapping Should be Applied Too Tightly.</b> Too
+much cannot be said or written relative to allowance being
+made in strapping a shield for the natural movements of the
+foot. It must always be remembered, in the first place, that a
+patient’s foot, elevated on the support of the operating
+chair, is at rest. There is no weight upon it, and consequently
+the tissues of the foot are not expanded to their
+fullest extent. For this reason circular strapping placed
+around a toe to hold a shield in place may seem sufficiently
+loose to allow perfect comfort; but when the patient steps
+down and walks for a few minutes, this same toe is expanded
+to a considerable extent, with the consequence that the
+plaster either cuts into the tender integument between or
+under the digit, or if not that, at least causes a severe enough
+<span class="pagenum" id="Page_106">[Pg 106]</span>irritation to occasion great annoyance every time a step is
+taken. Therefore, one of the first important points to be
+taken into consideration in applying a shield is the tightness
+with which the adhesive strips may be drawn.</p>
+
+<p>This is equally important in applying shields to the
+plantar surfaces, because, here also, allowance must be
+made for a great amount of expansion. In applying shields
+to these surfaces the toes should be extended as far as possible
+(drawn back toward the dorsum of the foot), the strapping
+to be applied while the toes are held in this position.
+Were the adhesive strapping applied whilst the toes are
+in a flexed position, the integument on the plantar surfaces
+would be found in a series of folds or wrinkles. This integument
+is not always in that condition, however, and, consequently,
+when the patient allows the weight of his body
+to come upon the foot, in taking a step, and the toes are
+extended to their fullest, the tissues covering the plantar
+surfaces would be drawn and the strapping will pull on
+the skin, making the patient decidedly uncomfortable, or it
+will tear away altogether and so become useless.</p>
+
+<p>(2) <b>Allowance Made for a Swollen Toe.</b> In this connection
+particular attention must be paid to the strappings
+of a shield. In many cases of helomata, or more particularly
+in acute conditions of interphalangeal bursitis, the
+integument immediately adjacent to the induration is not
+alone inflamed, but the whole toe is ordinarily swollen. In
+cases of this nature it will be found advantageous not to
+carry the strappings completely around the digit, but rather
+to place them so that, while they will hold the shield in place,
+they do not cover or come in contact with more of the
+swollen areas than is absolutely necessary to secure adhesion.
+This applies, of course, more particularly to the dorsal
+and lateral surfaces of the four lesser digits. To accomplish
+this two strips of half-inch plaster, each about one
+inch in length, are placed parallel to each other, one over
+the anterior and one over the posterior end, and adhered
+to the integument on each side of the shield. In many instances
+<span class="pagenum" id="Page_107">[Pg 107]</span>it will be found advisable to do away with adhesive
+straps entirely and merely allow the shield to remain on
+for a day or two, when, the inflammation and swelling having
+subsided, a shield may be applied and strapped if
+necessary.</p>
+
+<p>(3) <b>Edges of the Shield to Be Covered as Much as Possible.</b>
+It should always be the endeavor of the operator to
+cover the anterior and posterior edges of the shield and as
+much of the lateral surfaces as is possible. This minimizes
+the danger of those edges being raised from the integument
+during the normal movements of the foot. With this
+in view, it is perhaps wise to use as wide plaster as possible
+on the plantar, and, in many instances, on the dorsal surfaces
+as well.</p>
+
+<p>There are five widths of plaster generally used in chiropody
+for the purpose of adhering shields. The narrow
+strip, manufactured by Johnson &amp; Johnson expressly for
+chiropodists, the one-half-inch strip, the one inch strip, the
+inch-and-a-half strip and the two-inch strip. The two-inch
+width is seldom used, and then never in connection with
+shielding, but rather for strapping weak ankles and arches.</p>
+
+<p>(4) <b>End of the Plaster to Be Rounded.</b> This is for the
+purpose of preventing the tendency of the plaster to loosen
+up at the ends. By doing away with as many “corners”
+as possible and instead making rounded ends, the plaster
+is found to adhere much more firmly and the tendency to
+curl is reduced to a minimum.</p>
+
+
+<h3 id="SPECIFIC_SHIELDING">
+  SPECIFIC SHIELDING
+</h3>
+
+<p><b>Great Toe.</b> The shields necessary in connection with
+affections of the hallux are four in number:</p>
+
+<p>1. Those used in connection with bunions or metatarsophalangeal
+joint affections.</p>
+
+<p>2. Those used in connection with corneous developments
+over the extensor tendon on the dorsum.</p>
+
+<p>3. Those used in connection with corneous developments
+along the inner border or on the plantar surface.</p>
+
+<p><span class="pagenum" id="Page_108">[Pg 108]</span></p>
+
+<p>4. Those used in connection with corneous developments
+on the adjacent sides of the great and second toes.</p>
+
+<p><i>Location 1.</i> Affections of the first metatarsophalangeal
+articulation or of the superadjacent tissues, usually
+require shields of considerable size, thickness and “body.”
+Buckskin or felt are the materials to be used in this situation,
+as they can be skived to considerable thinness at the
+edge where pressure is unnecessary and often detrimental.</p>
+
+<p>There are two forms of shields which may be used in
+this connection, viz.: the metatarsophalangeal oval or the
+metatarsophalangeal half-moon. In a majority of cases the
+half-moon shield is the most practical, but the full oval may
+be used at times with equal or even better results.</p>
+
+<p>The metatarsophalangeal oval (<a href="#i_p102_fig01">Fig. 1</a>-A), is an oval
+shield about three inches long and two inches wide, which
+is used principally where the pressure causing the painful
+affection comes from the under lateral side of the joint.
+The aperture is so placed that it is much nearer the edge of
+the shield which goes under the joint, for it must be remembered
+that this shield should not extend down and to the
+plantar surface of the foot, where it might cause an inequality
+and undue pressure. The greatest amount of protection
+should come from the position of the shield, and
+for this purpose that portion of the skin or fabric is left
+thick, so that its elevation will equal at least, if not exceed,
+that of the affected part.</p>
+
+<p>In strapping a shield in this location the half-inch, one inch,
+or inch-and-a-half strips may be used. The inch plaster
+is probably the most practical, as it is of sufficient
+width to bind down the anterior and posterior edges of the
+shield and still will not extend over on the affected part in
+the aperture. These strips should each be about four inches
+in length and should be so arranged as to cross each other
+on the dorsum, one binding down the other. Thus the anterior
+and posterior edges of the shield, as well as the lateral
+surface on the dorsum of the foot, are covered. Some practitioners
+even advocate the use of strips of sufficient length
+<span class="pagenum" id="Page_109">[Pg 109]</span>to “criss-cross” both on the dorsum and on the plantar surfaces.
+It will sometimes be found that the anterior strips
+of adhesive plaster will extend too far up on the dorsal
+surface of the great toe and thus may interfere with its
+proper movement. In these instances it is advisable to cut
+out a curved portion of the strip so as to allow normal extension
+of the toe, without irritation from the plaster. The
+same holds good if the plaster should for any reason extend
+over the affected part in the aperture. The plaster should
+be cut away with curved scissors so that it remains only
+on the body of the shield. The half-inch plaster is sometimes
+used in strapping the metatarsophalangeal oval shield
+and is most generally adhered in the form of a triangle, the
+strips to be of sufficient length to cover each other on the
+sound integument, and so applied as to bind down all edges
+of the shield. The inch-and-a-half plaster is generally used
+in this manner in cases where it is desirable to cover the
+affected part of the joint as well as the shield, making the
+whole dressing practically waterproof. Then two strips of
+the inch-and-a-half plaster are used; each strip is split on
+both ends and lapped over so that it may be drawn down
+tightly on all sides of the shield. Three strips of the inch
+width would answer the same purpose but would make a
+larger and more bulky dressing.</p>
+
+<p>The metatarsophalangeal half-moon (<a href="#i_p102_fig01">Fig. 1</a>-B) is used
+in all cases where the pressure or friction comes upon the
+dorsum or the dorso-lateral part of the affected joint. The
+reason for its use in these instances is obvious. If the
+pressure comes only upon one or both of these locations,
+there is surely no need of protecting the joint from plantar-lateral
+pressure, and the use of the full oval shield is contra-indicated
+in that its one lateral surface, resting on tissue
+upon which there is already much pressure, might become
+uncomfortable and detrimental to the general condition of
+the joint.</p>
+
+<p>The shield is adhered to the dorsal surface in such a
+manner that its two points are anterior and posterior to
+<span class="pagenum" id="Page_110">[Pg 110]</span>the affected part, with the broad lateral portion resting
+alongside on the dorsal surface. It will generally be found
+advisable and necessary to fashion the “anterior point”
+of the shield somewhat narrower and thinner than the posterior,
+as the former usually extends over upon the dorsum
+of the great toe and interferes with its movement if allowed
+to remain thick
+and bulky. In any event
+the greatest amount of
+protection is derived
+from the “posterior
+point” and the broad
+lateral surface of the
+shield, and this anterior
+point may be safely
+thinned or entirely eliminated
+(see <i>Modified
+Half-moon Shield</i>). In
+strapping the metatarsophalangeal
+“half-moon”
+shield, three
+strips of the inch width
+plaster, each four inches
+long, are adhered, one
+over the anterior tip of
+the crescent and extending
+well upon the dorsal
+and plantar surfaces,
+and the remaining two
+strips across the posterior
+part of the shield,
+overlapping each other
+and the two ends of the first applied strip (<a href="#i_p110_fig02">Fig. 2</a>).</p>
+
+<figure class="figcenter illowe15" id="i_p110_fig02">
+  <img class="w100" src="images/i_p110_fig02.jpg" alt="">
+  <figcaption>
+    Fig. 2.
+
+    STRAPPING FOR METATARSOPHALANGEAL
+    HALF-MOON SHIELD
+  </figcaption>
+</figure>
+
+<p><i>Location 2.</i> Shields are often required on the dorsum
+over the tendon of the extensor muscle for the protection
+of corneous formations or denuded spots due to rubbing of
+a new shoe on this prominence. Felt shields of considerable
+<span class="pagenum" id="Page_111">[Pg 111]</span>thickness are most generally used in these instances, as they
+are more pliable than those of buckskin and, in consequence,
+are not so harsh. They are usually cut in oval shape
+(though not so large as those described under <i>Location 1</i>),
+and are strapped in triangular arrangement with half-inch
+strips. In some instances, where pressure upon those portions
+of the tendon anterior and posterior to the affected
+area is undesirable, two straight pieces of felt of considerable
+thickness (so as to be of higher elevation than the
+prominence of the tendon) may be substituted with good
+results. They are placed on each side of the tendon and
+parallel with it. The strapping in this case consists of two
+half-inch strips placed across the felt shield at right angles
+to the long axis of the toe. A very practical protection of
+tender areas in this location is a half-moon shield whose
+opening is only of sufficient width to protect the affected
+spot. This shield is made from adhesive felt, and after it
+is fashioned and skived, a strip of the glazed adhesive,
+slightly wider than the tender prominence, is removed without
+disturbing the balance of the felt constituting the body
+of the shield. The shield is then applied and the adhesive
+substance thus comes only in contact with integument on
+each side of the tendon, allowing that cord to move at will
+without interference; at the same time ample protection is
+given the affected part.</p>
+
+<p>This shield is usually strapped by using two strips of
+one inch width plaster, each about three inches long. They
+are adhered, each overlapping the other, on the body of the
+shield, thus binding down its posterior and two lateral edges
+to the sound integument. Where a strapping of this nature
+would interfere with the normal movements of the tissues
+of the toes or of the great toe, one strip, three inches long
+and an inch-and-a-half wide, may be substituted and placed
+across the body of the shield (at right angles to the toes),
+thus binding down its posterior and a portion of its lateral
+edges.</p>
+
+<p><i>Location 3.</i> In cases of tyloma or heloma on the plantar
+<span class="pagenum" id="Page_112">[Pg 112]</span>or inner lateral border of the great toe, oval shields
+of buckskin are almost entirely used (same as <a href="#i_p102_fig01">Fig. 1</a>-B, only
+smaller, to accommodate the smaller surfaces). There are
+two impractical points to be considered and avoided in this
+connection: (<i>a</i>) on shielding a part on the inner border of
+the great toe, the shield should never be allowed to extend
+up on the dorsum of the toe and lap over or cover the
+lateral and posterior nail folds. The tissues about the nail
+are sensitive to a degree, and any untoward pressure will
+in most instances start new troubles in this region. The
+adhesive strappings will, of course, cover a greater portion
+of the nail; but as the plaster is unusually thin, a great
+amount of trouble from the strips is seldom experienced.
+(<i>b</i>) In shielding the plantar surface of the hallux, the pad
+should never be fashioned to such length as to interfere
+with the natural bending of the toe at the web. If this be
+allowed the patient will experience a feeling of “fullness”
+at that point which may seriously interfere with his natural
+gait and comfort, besides which, irritation may be caused
+in these parts.</p>
+
+<p>The strapping of shields applied to the plantar or to
+the inner border of the great toe is of necessity similar, as
+the pad is merely in a different position and the strips must
+practically cover the same territory. One-half-inch plaster
+answers most purposes and two strips are cut of sufficient
+length to encircle the toe and overlap each other on the
+side of the digit opposite the shield. Too many thicknesses
+of plaster between the toes should always be avoided, and
+to make this effective many practitioners prefer the narrow
+chiropodist strip, using one strip to encircle the toe
+twice, once on the posterior and once on the anterior edge
+of the shield. This is a matter of preference, but the
+writer favors the half-inch strip, as it has more adhesive
+surface and will consequently fasten the shield more firmly
+to the integument.</p>
+
+<p><i>Location 4.</i> Corneous excrescences, whether hard or
+soft, are not commonly found between the great and second
+<span class="pagenum" id="Page_113">[Pg 113]</span>toe but, when so located, a shield is generally needed as an
+aid to treatment. A shield for this condition may be of
+buckskin or chamois, if intended to last for any time, and
+should be strapped in place. Felt shields are often used,
+minus adhesive and strapping, where temporary protection
+is needed. Using a shield without adhesive in any interdigital
+disturbance enables the patient to remove it and
+set it back at will, in this way avoiding the hardening or
+shifting when the shield is allowed to remain in place during
+and after a bath.</p>
+
+<p>In fashioning any shield to be used in an interdigital
+location, the lower edge (that applied next to the web of
+the toe) should be cut on a slant (<a href="#i_p102_fig01">Fig. 1</a>-C), to conform with
+the angle of the toe web. This procedure not alone makes
+the wearing of the shield more comfortable, but also gives
+it a steady base to rest upon, whether adhesive be used or
+not. In shielding an heloma between the great and the second
+toes, and particularly if the heloma be of any size
+or on either toe, it will usually be found advantageous to
+adhere the shield to the great toe. The second toe is uncommonly
+long and slender, and in most instances presents a
+very small surface around the heloma, to which a shield may
+be made to adhere.</p>
+
+<p>The strapping of a shield in this location is similar to
+that applied on the opposite side (inner border) of the great
+toe; in most cases the half-inch plaster is employed and the
+ends are fashioned to overlap each other on the plantar or
+inner lateral surfaces of the digit.</p>
+
+<p><b>Intermediate Toes (2d, 3d, 4th): Dorsal Surfaces.</b> In
+shielding the dorsal surfaces of the intermediate digits, pads
+of buckskin, adhesive moleskin or chamois are exclusively
+used. On most feet the dorsal surfaces of these toes are
+quite narrow and care should be taken that the shield is not
+so wide as to interfere or rub against the toes adjoining or
+to lap around the toes on their interdigital surfaces. The
+shield should be wide in the centre (in which location the
+aperture is cut) and should taper slightly toward each end.
+<span class="pagenum" id="Page_114">[Pg 114]</span>“Tapering slightly” does not in any sense mean to a point,
+but merely sufficient to conform to the general shape of the
+toe. Proper skiving is essential to a well fitting shield in
+this location, as it must adhere firmly on all sides and must
+not act as an irritant to the underlying and surrounding
+areas nor to the adjacent toes. For a sample of this shield
+see <a href="#i_p102_fig01">Fig. 1</a>-D.</p>
+
+<p>In strapping a shield
+to the dorsal surfaces of
+the three intermediate
+toes, the narrow chiropodist
+strip is generally
+found to be the most
+practical and probably
+the most generally used.
+It is best made to adhere
+in the following manner:
+strip to be six inches in
+length; with one end of
+the strip start on the
+side of the toe carrying
+the plaster downward on
+a tangent to a point opposite
+the rear portion of
+the shield, then crossing
+this posterior part of the
+shield, so bringing it (the
+strip) completely around
+the toe to the place of
+beginning. Cover the beginning
+“end” with the
+strip and carry it over
+the anterior portion of the shield; complete the dressing
+by adhering the remaining end of the plaster to the side
+of the toe opposite the beginning. We thus have two strips
+of plaster over the anterior of the shield lying next to each
+other and making approximately a quarter-of-an-inch of
+<span class="pagenum" id="Page_115">[Pg 115]</span>adhesive surface and only one strip over the posterior
+portion. In this way the anterior portion, which is most
+liable to loosen up from the constant rubbing of the stocking
+and shoe in walking, is doubly bound to the toe (<a href="#i_p114_fig03">Fig. 3</a>).</p>
+
+<p>In many instances where a shield is to remain for a day
+or so only, glazed felt will admirably answer all purposes.
+It is cut similar in size
+and design to the buckskin
+or chamois shield,
+but is most generally
+applied without strapping.</p>
+
+<figure class="figcenter illowe15" id="i_p114_fig03">
+  <img class="w100" src="images/i_p114_fig03.jpg" alt="">
+  <figcaption>
+    Fig. 3.
+
+    SHIELD APPLIED TO DORSUM OF
+    FOURTH TOE
+  </figcaption>
+</figure>
+
+<p><b>The Dorso-Digital
+Oval Shield.</b> One more
+practical method of
+shielding an heloma on
+the dorsum of any of
+the intermediate toes
+may be described. In
+many instances, whether
+distinct hammer toe be
+present or not, the first
+interphalangeal articulation
+will be found decidedly
+prominent, and
+enlarged to such an extent
+as to make the application
+of an individual
+shield impractical.
+A large oval shield of
+buckskin or eighth-inch
+felt (<a href="#i_p115_fig04">Fig. 4</a>) should then
+be used. The aperture is fashioned to fit the part to be protected
+and the long axis of the shield is allowed to rest
+across and upon the adjacent toes. A shield of this nature
+is seldom if ever strapped, and is removable by the patient
+while at rest or during the bath, to be replaced when the shoe
+<span class="pagenum" id="Page_116">[Pg 116]</span>is worn. The writer has observed many cases where the
+proximal phalanges of the intermediate toes were in a state
+of constant extension due to the contraction of the extensor
+tendons, and leaving a decided hollow in the dorsum of the
+foot directly over their metatarsophalangeal joints. In a
+condition of this nature a thick shield of this pattern is particularly
+practical and may be used not alone to protect a
+tender part, but also to fill up this hollow and allow the
+shoe to fit more firmly.</p>
+
+<p>Where helomata are present on the dorsum of all of
+the phalangeal joints, this variety of shield is, of course,
+contra-indicated, as undue pressure would be brought to
+bear upon the already troublesome excrescences and a great
+amount of trouble would in this way be invited. In some
+instances a full oval shield is not used, but a dorso-digital
+half-moon, as shown in <a href="#i_p102_fig01">Fig. 1</a>-G, is substituted. No definite
+ruling can be made as to which form of shield should be
+used, as each case presents a different aspect and the mechanical
+work must be applied accordingly.</p>
+
+<figure class="figcenter illowe24" id="i_p115_fig04">
+  <img class="w100" src="images/i_p115_fig04.jpg" alt="">
+  <figcaption>
+    Fig. 4.
+
+    DORSO-DIGITAL OVAL SHIELD APPLIED
+    TO THIRD TOE
+  </figcaption>
+</figure>
+
+<p><b>End of the Intermediate Toes.</b> Shielding is often necessary
+on the ends of the toes, and in such instances the padding
+should, as a rule, be made very thin and the subsequent
+dressing not bulky. This is advisable for several reasons:
+first, helomata in this locality are usually under or immediately
+adjacent to the nails and too great an amount of
+pressure cannot be put upon these structures; second, that
+there is trouble on the end of the digit is proof positive of
+the shoe being too short and, therefore, if too thick a shield
+be used, the pressure on the surrounding tissues will be
+too great to be comfortable; third, helomata in these locations
+are seldom found to be elevated to any extent above
+the normal surface of the integument and when removed,
+the tissues are usually at their normal elevation, so that
+shields of material as heavy as those used in connection with
+helomata in other localities are unnecessary.</p>
+
+<p>A shield of thin buckskin, adhesive moleskin or chamois
+is best in these cases. It is applied, generally, so that the
+<span class="pagenum" id="Page_117">[Pg 117]</span>long axis is across the end of the toe and seldom so that
+the ends of the padding overlap the free edge of the nail
+or compress the plantar surface of the digit. Where the
+heloma to be protected is situated close to the nail, and it is
+advisable that the padding extend over that structure, by
+clipping the nail closely and filing it down and at the same
+time using an exceedingly thin shield, successful protection
+can be secured without unfavorable results. Such shortening
+of the nail is, however, not advisable in all cases. This
+article deals entirely with shielding, but attention must be
+here drawn to the fact that there are many instances of an
+heloma occurring on the end of one of the lesser toes, when a
+shield is contra-indicated. There are many cases where the
+toe nail, if allowed to grow long, will protect the tender part
+far more successfully than will a shield. Therefore, it is always
+well to consider if protection can be obtained from the
+nail itself before applying a shield in this location.</p>
+
+<p><b>Strappings.</b> The application of adhesive strips to a
+shield in this locality demands considerable ingenuity on
+the part of the operator, but there is no stereotyped method
+to be employed. One general method may, however, be
+explained: cut two pieces of chiropodist strip, each about
+two-and-one-half or three inches long. Apply the centre of
+one strip over one end of the shield, lateral to the aperture,
+and carry one end of the strip on a line running toward the
+proximal end of the toe and in a manner so as to cover as
+much of the edges of the shield on that side as possible.</p>
+
+<p>Overlap these plaster ends on the interdigital surface of
+the toe opposite to the place of beginning. Adhere the second
+in like manner to the other surface of the shield on the
+side of the aperture, and carry the plaster ends in such a
+way as to cause them to overlap each other on the interdigital
+surface of the toe opposite the place of beginning.
+In this way both lateral and nearly all of the plantar edges
+of the shield will be covered and bound down with adhesive
+plaster. It will be found generally that the edge of the
+shield coming under the free edge of the nail needs no reenforcement
+<span class="pagenum" id="Page_118">[Pg 118]</span>by adhesive strips, as the length of the nail
+will prevent any tendency to loosen up the plaster in that
+location. Cut a third strip about two inches long and with
+it circle the toe, binding down all four ends of the two
+strips already applied. Trim off the ends of the plaster,
+which extend from under this last applied strip, and the
+whole makes a neat
+practical shielding for
+trouble in this situation.
+(<a href="#i_p118_fig05">Fig. 5</a>).</p>
+
+<figure class="figcenter illowe24" id="i_p118_fig05">
+  <img class="w100" src="images/i_p118_fig05.jpg" alt="">
+  <figcaption>
+    Fig. 5.
+
+    SHOWING SHIELD APPLIED TO END
+    OF FOURTH TOE
+  </figcaption>
+</figure>
+
+<p>There are many ways
+in which a shield in
+this location may be
+strapped, but as always,
+and particularly
+in this instance, there
+are so many circumstances
+which go to
+alter the mode of strapping
+that it would be
+well-nigh impossible to
+explain them all or to
+outline a set method of
+procedure.</p>
+
+<p><b>Interdigital Surfaces.</b>
+Helomata, both hard
+and soft, often occur
+between the toes and,
+in these cases, to insure
+complete relief to the
+patient, a shield is
+usually an absolute
+necessity.</p>
+
+<p>Buckskin, sheepskin, adhesive moleskin, and chamois
+are the materials most generally used for interdigital shields
+although the thinner varieties of white felting, with or
+without adhesive, may be substituted in some instances.
+<span class="pagenum" id="Page_119">[Pg 119]</span>The shield should be fashioned of equal length to the surface
+of the toe, from the web to the distal end, and should
+be only wide enough to correspond to the thickness of the
+toe. If the shield be allowed to lap over on the dorsum of
+the toe or under on its plantar surface, new pressure is
+brought to bear on these parts, to the discomfort of the
+patient. It must always be remembered that the toes bend
+during the various movements in walking, and that if a
+shield be allowed to curl under the toe, the thickness of the
+material used will interfere, to a great extent, with the
+normal flexing and extending of the toe, even to such a
+degree in some instances as to cause lesions of more or
+less severe character on the skin.</p>
+
+<p>To allow any shield to cover or to press upon the tissues
+directly adjacent to the nail is always to the discomfort
+of those parts, and in this, as in all other instances, should
+be avoided.</p>
+
+<p>The bottom of the shield (<a href="#i_p102_fig01">Fig. 1</a>-C) should be cut on
+a tangent, so as to conform to the corresponding slant of the
+toe web. This insures not only the minimum danger of irritation
+on those tender parts, but also allows the shield a firm
+base upon which to rest, and prevents any possible tilting
+or shifting.</p>
+
+<p>Shields for application to the interdigital surfaces seldom
+need to be of great thickness, and the thinner the shield
+used the more flexible it is, and the less pressure is brought
+to bear on the outer surfaces of the toes. It must be remembered
+that everything placed between the toes, of necessity,
+spreads those members further apart, and naturally
+this causes a greater amount of pressure from the boot on
+the outer surfaces. Skiving is an essential requirement in
+interdigital shields, although in some instances where they
+are to be used between the great and second toes, this (skiving)
+may be omitted.</p>
+
+<p>Thin felt shields, minus adhesive, are often employed
+between the toes for transient protection, a fresh one being
+usually placed in position daily.</p>
+
+<p><span class="pagenum" id="Page_120">[Pg 120]</span></p>
+
+<p><b>Strapping.</b> The most practical method of strapping an
+interdigital shield is by means of the narrow chiropodist
+strip. The method used is similar in every particular
+to that employed in the use of the same width
+strip in applying a shield to the dorsum of the intermediate
+toes.</p>
+
+<p>Another less used method is as follows: take a six-inch
+chiropodist strip; at its centre adhere it to the upper
+end of the shield (that nearer the distal extremity of the
+toe), and carry both ends around the toe, crossing them on
+the side opposite to the starting point. Then bring the
+loose ends around the toe again to the side upon which the
+shield is adhered and overlap them over the bottom of the
+shield, allowing the ends to run for attachment on the
+sound integument.</p>
+
+<p><b>Fifth Toe: Dorsal Surface.</b> There are more corneous
+developments on this digit than on any of the others, and
+as this toe presents a free surface on its outer side, which
+is not the case with any of the other lesser digits, many
+varieties of shielding and of strapping are used.</p>
+
+<p>As with the dorsal surfaces of the intermediate toes,
+buckskin and adhesive moleskin are the most generally used
+shielding materials, and pads of the thinner varieties are in
+most cases sufficient for the needs. But, as this toe is
+probably the most abused of any and is often found distorted
+into positions of extreme flexion or extension and is
+sometimes lapped over the fourth toe, shields of a greater
+thickness, or “built up” pads, are very often indicated. The
+ordinary buckskin or adhesive moleskin shield is fashioned
+oval in shape, but the anterior end is cut either straight
+across or slanted toward the outer lateral edge, so that we
+have a shield, round at its posterior extremity and tapering
+toward the anterior end, having a straight edge (<a href="#i_p102_fig01">Fig. 1</a>-E).
+Shields for the fifth toe must be carefully skived, especially
+at the anterior end which goes toward the nail. The writer
+has often seen cases in which new helomata, sometimes as
+many as three or four, have developed on the dorsum of
+<span class="pagenum" id="Page_121">[Pg 121]</span>this toe anterior to the original callosity, exclusively caused
+by the habitual wearing of thick shields.</p>
+
+<p>The size of the shield depends wholly upon the size
+of the toe and the area to be protected, but the length of
+the shield should never be allowed to interfere with the
+bending of the toe at its metatarsophalangeal articulation.
+If this precaution is not observed, in walking the shield
+rubs against the dorsum of the foot and is not alone loosened
+at its posterior edge, but causes irritation to the skin
+in that region. As with those used on the dorsum of the
+intermediate toes, the aperture of a shield for the fifth toe
+should be cut of sufficient size to allow a space between its
+(the aperture) anterior edge, and that of the calloused area;
+this is to allow for backward shifting.</p>
+
+<p>Another form of shield used in cases where the small
+toe is flexed to a degree and an heloma has developed on
+its apex, is what may be called the fifth digital half-moon
+(<a href="#i_p102_fig01">Fig. 1</a>-B). It is usually necessary to build up a shield of
+this variety. By “built up” is meant that two thicknesses
+of material are used, one pasted upon the other, to give the
+shield greater thickness and stability. The upper thickness
+is formed so as to protect the rear and lateral sides of the
+corneous area, but not the front. The second, or under
+thickness, is fashioned round at its posterior edge and
+straight at its anterior surface. This, being placed under
+the upper layer, gives the shield sufficient thickness to be
+of equal height to the elevation of the heloma or even higher,
+thereby avoiding all undesirable pressure upon the painful
+area, and at the same time filling out whatever hollow there
+may be in the foot at this point.</p>
+
+<p><b>Strapping.</b> There are five general methods of strapping
+to adhere a shield to the dorsal surface of the fifth toe.
+Some conditions demand the use of one of these and none
+other, but in most instances any method may be used with
+good effect. These five methods are as follows:</p>
+
+<p><span class="pagenum" id="Page_122">[Pg 122]</span></p>
+
+<blockquote>
+<p>
+  1. Narrow chiropodist strip.<br>
+  2. Combination narrow and half-inch strip.<br>
+  3. Half-inch strip (using one strip).<br>
+  4. Half-inch strip (using two strips).<br>
+  5. Inch strip.
+</p>
+</blockquote>
+
+<p><b>Number 1.</b> In using the narrow chiropodist plaster,
+the strip is applied in a
+similar manner to that
+already described for
+toes, arranging the plaster
+so as to cover the
+anterior of the shield
+with two widths of the
+strip and the posterior
+surface with but one
+(<a href="#i_p122_fig06">Fig. 6</a>). As an alternative
+for this, the method
+described in the second
+instance in connection
+with interdigital shields
+may be utilized.</p>
+
+<div class="col2acontainer"><div class="col2"><figure class="figcenter illowe15" id="i_p122_fig06">
+  <img class="w100" src="images/i_p122_fig06.jpg" alt="">
+  <figcaption>
+    Fig. 6.
+
+    STRAPPING OF 5TH TOE SHIELD
+    WITH CHIROPODIST STRIP
+  </figcaption>
+</figure></div>
+
+<div class="col2"><figure class="figleft illowe15" id="i_p123_fig07">
+  <img class="w100" src="images/i_p123_fig07.jpg" alt="">
+  <figcaption>
+    Fig. 7.
+  </figcaption>
+</figure></div></div>
+
+<p class="clear"><b>Number 2.</b> The narrow
+strip and the half-inch
+combination consists of
+a narrow strip, about
+four inches in length,
+adhered to the inner surface
+of the toe and carried
+twice around the toe
+across the surface of the
+shield, anterior to the
+aperture. This, as will
+be seen, binds down the distal end of the shield. The half-inch
+strip, about three inches in length, is then cut as shown
+in <a href="#i_p123_fig07">Fig. 7</a>-B.</p>
+
+<p>Taking this strip in both hands, insert it between the
+toes in such a manner as to allow the narrow portion of the
+<span class="pagenum" id="Page_123">[Pg 123]</span>plaster to fit into the narrowest part of the toe web. Then
+carry the outer broad end of the strip around on the dorsum
+of the toe and adhere it across that part of the shield
+posterior to the aperture, taking care, however, that the
+adhesive plaster is half on the shield and half on the integument
+adjoining it. Adhere the remaining broad end of the
+plaster (that coming
+from between the toes)
+over the first applied
+posterior strips, taking
+the same care that shield
+and skin are both covered
+by the plaster (<a href="#i_p123_fig08">Fig. 8</a>).</p>
+
+<div class="clear col2acontainer"><div class="col2"><figure class="clear figcenter illowe15" id="i_p123_fig08">
+  <img class="w100" src="images/i_p123_fig08.jpg" alt="">
+  <figcaption>
+    Fig. 8.
+
+    SHOWING SHIELD STRAPPED WITH
+    NARROW AND HALF-INCH STRIP
+  </figcaption>
+</figure></div>
+
+<div class="col2"><figure class="figcenter illowe15" id="i_p124_fig08a">
+  <img class="w100" src="images/i_p124_fig08a.jpg" alt="">
+  <figcaption>
+    Fig. 8a.
+
+    SHOWING DRESSING COMPLETE
+    WITH COCOON OVER APERTURE
+  </figcaption>
+</figure></div></div>
+
+<p class="clear">This alternate style
+of strapping is particularly
+useful in cases
+where the narrow strips
+of method No. 1 are
+found to irritate the skin
+of the toe web, or if there
+be a corneous excrescence
+developed there
+which cannot be covered
+by the plaster; instead of
+using the half-inch strip,
+as just described, a half-inch
+or inch strip, about
+two inches in length, is
+cut and placed across the
+posterior of the shield and
+is adhered to the integument
+on the dorsum and
+plantar of the foot. Should
+any portion of this posterior
+<span class="pagenum" id="Page_124">[Pg 124]</span>strip lap over the aperture, it should, of course, be cut
+away.</p>
+
+<figure class="figcenter illowe15" id="i_p124_fig09">
+  <img class="w100" src="images/i_p124_fig09.jpg" alt="">
+  <figcaption>
+    Fig. 9.
+  </figcaption>
+</figure>
+
+<p><b>Number 3.</b> In this manner of strapping (using one
+one-half-inch strip) we have one of the most practical methods
+in vogue today. A strip about six inches in length is
+fashioned in the manner of <a href="#i_p124_fig09">Fig. 9</a>. The wide portion in the
+strip’s centre is then adhered
+to the anterior
+surface of the shield and
+the ends are carried
+around, one on each side
+of the toe, in such a manner
+as to allow the narrowest
+portions to criss-cross
+in the narrow part
+of the toe web on the
+plantar surface. The
+wide ends are then carried
+around the dorsum
+of the toe and are overlapped
+on the posterior
+portion of the shield.
+This method of applying
+the plaster supplies a
+greater amount of adhesive
+surface than by the
+use of the narrow strip
+and is just as practical,
+or more so, in many
+ways.</p>
+
+<p><b>Number 4.</b> In using
+two one-half-inch strips
+to adhere a shield to the dorsum of the fifth toe, the plaster
+is fashioned as shown in A and B (<a href="#i_p123_fig07">Fig. 7</a>). The strip
+marked “A” is cut
+about two inches in
+length and split on
+<span class="pagenum" id="Page_125">[Pg 125]</span>the square end. That marked “B” is about three or three
+and one-half inches in length. The strip “A” is laid over
+the anterior surface of the shield with the split end toward
+the inner side of the toe. The anterior one of the two split
+ends is then drawn tightly over the anterior edge of the
+shield and adhered to the inner surface of the toe; the remaining
+split end is adhered
+over the first and
+should also be drawn
+tightly, so that the anterior
+portion of the
+shield is closely bound to
+the dorsum of the toe.
+The rounded end of the
+plaster strip is then carried
+around the outer
+side of the toe in such a
+manner as to allow the
+narrow portion of the
+plaster to rest over the
+corresponding narrow
+part of the toe on its
+plantar surface. The
+wide extremity is
+brought around to the
+inner side of the toe and
+is placed over the split
+ends already adhered.
+This binds them securely
+to the interdigital surface
+of the toe. Any
+loose ends showing after
+the foregoing is completed
+should be
+clipped off. One
+wide end of the strip
+“B” is then adhered
+<span class="pagenum" id="Page_126">[Pg 126]</span>across the posterior surface of the shield and the plaster
+carried around the toe (the narrow portion of the plaster
+fitting in the narrow part of the toe web) and the remaining
+wide end is overlapped on the posterior portion
+of the shield, thus securing the other wide end already
+adhered to the shield.</p>
+
+<p>Another method,
+differing merely in the
+position of the last wide
+end of the strip “B,” is
+as follows: instead of adhering
+this end criss-cross
+over the posterior
+portion of the shield,
+bring it further toward
+the anterior of the toe
+and adhere it directly
+across and over the aperture,
+fastening the end
+upon the inner side of
+the toe. This makes a
+waterproof dressing with
+none of the shield showing
+when the dressing is
+complete; it is contra-indicated
+when a soft
+dressing is desired over
+the inflamed parts.</p>
+
+<figure class="figcenter illowe15" id="i_p125_fig10">
+  <img class="w100" src="images/i_p125_fig10.jpg" alt="">
+  <figcaption>
+    Fig. 10.
+  </figcaption>
+</figure>
+
+<p><b>Number 5.</b> The other
+method which may be used
+is to cut off about six inches of one inch plaster (although the
+length used depends upon the size of the toe), and fashion
+it as shown in <a href="#i_p125_fig10">Fig. 10</a>. The split ends are then adhered on
+the inner side of the toe, so that the wide portion next to
+them is drawn tightly over the anterior surface of the
+shield. The narrow portion is then carried around the
+outer side of the toe and is placed, as previously described,
+<span class="pagenum" id="Page_127">[Pg 127]</span>on the corresponding narrow surface of the toe web, and
+the remaining wide end is brought between the toes and
+over the posterior surface of the shield, entirely covering
+the pad and adhering it to the integument on the outer surface
+of the shield, over the metatarsophalangeal joint. This
+also makes a practically waterproof dressing (<a href="#i_p125_fig11">Fig. 11</a>).</p>
+
+<div class="col2acontainer"><div class="col2"><figure class="figcenter illowe15" id="i_p125_fig11">
+  <img class="w100" src="images/i_p125_fig11.jpg" alt="">
+  <figcaption>
+    Fig. 11.
+
+    SHOWING ANTERIOR PORTION OF
+    ADHESIVE STRIP APPLIED
+  </figcaption>
+</figure></div>
+
+<div class="col2"><figure class="figcenter illowe15" id="i_p126_fig11a">
+  <img class="w100" src="images/i_p126_fig11a.jpg" alt="">
+  <figcaption>
+    Fig. 11a.
+
+    SHOWING DRESSING COMPLETED
+  </figcaption>
+</figure></div></div>
+
+<p class="clear"><b>Fifth Digital, Built Up, Half-Moon Shield.</b> In strapping
+a “built up” half-moon shield in this connection there
+are one or two methods which will answer in all cases. The
+first method is the use of but one strip of plaster, either
+of one inch or of one-and-a-half inch width. This is placed
+transversely across the body of the shield so that no plaster
+extends over into the aperture, and it is adhered to the
+integument on the dorsal and plantar surfaces of the foot.
+As this shield is so much wider than the toe, it is not practical
+to encircle the toe with adhesive strips in fastening it.
+The other method at times employed, and the one that is
+advocated, in that it binds down the “points of the crescent,”
+situated laterally to the corn when the shield is in
+place, consists in the use of two strips of the one inch
+plaster. These are each cut about two inches in length,
+one being placed diagonally across the body of the shield
+in such a manner as to cover the outer lateral point of the
+shield, and the other in a like manner, so as to cover the
+inner lateral point of the shield and overlapping the first
+applied strip on the body of the shield. In many instances,
+however, this variety of shield is not strapped and is removed
+and reapplied by the wearer at will.</p>
+
+<p>It may sometimes be found advisable, when a small
+shield cannot be used and where the spot to be protected is
+nearer the distal part of the toe, and in consequence would
+not receive sufficient protection from a half-moon shield
+placed at its proximal end, to apply to the part a full oval
+shield, slightly modified as to its anterior edge. This shield
+is of the same shape as that shown in <a href="#i_p102_fig01">Fig. 1</a>-E, except that
+it is larger. It is made from the thicker grades of buckskin
+and is fashioned so as to rest on the fourth toe and over
+<span class="pagenum" id="Page_128">[Pg 128]</span>the fifth nail, and for this reason these two contact surfaces
+of the shield must be well skived. This shield is seldom
+strapped and then only at its posterior surface, and in
+like manner to the strappings described for the fifth digital
+half-moon. A large shield of this kind evens up the whole
+surface of that part of the foot and so equalizes the pressure
+that it is distributed generally.</p>
+
+<p><b>Lateral Surfaces.</b> Helomata on the outer lateral surface
+of the fifth toe are generally shielded in a manner similar
+to those occurring on the dorsum; the shield in the lateral
+location, however, should never be of great thickness. In
+most instances corneous developments of the small digit on
+these surfaces are situated adjacent to the nail and the
+shield, and to be comfortable, should not be allowed to overlap
+the nail structures. If, however, to obtain proper protection,
+overlapping must be allowed in order to cover these
+areas, the shield should be of paper thinness, especially at
+its anterior end.</p>
+
+<p>In this situation a shield is often used which gives protection
+from the anterior, posterior and outer lateral but
+not from the inner lateral surface, which would of necessity
+have to be adhered over the dorsum of the toe and the nail.</p>
+
+<p>This form of shield is practically of the same shape as
+the ordinary fifth toe protector but with the inner lateral
+surface next to the cut away aperture. It is particularly practical
+in cases where the spot to be protected is directly next
+to or in the corner of the nail. By a shield so fashioned,
+the protection of the part is derived from all but the nail.</p>
+
+<p><b>Strapping.</b> The narrow chiropodist strip affords the
+most practical method of strapping a shield in this location,
+and the method is similar to that employed on the dorsum
+of the fifth or intermediate toes.</p>
+
+<p>In strapping the last mentioned form of shield, the
+strips are applied in a similar manner. Care is taken to
+adhere the plaster over both points of the shield, anterior
+and posterior to the affected part.</p>
+
+<p><b>Interdigital Surfaces.</b> The shielding of helomata occurring
+<span class="pagenum" id="Page_129">[Pg 129]</span>on the inner surface of the fifth toe is similar in
+method to that employed in shielding like parts on the intermediate
+toes. This applies to the strapping as well.
+Thick shields are contra-indicated, as they force the fifth
+toe out against the shoe; if used on that part they will
+undoubtedly create trouble to the toe in question. Both
+hard and soft helomata often occur in this connection; they
+are located, not on the sides, but rather well down in the
+web of the toe. In such cases a specially fashioned shield is
+required which, from its shape, is known as a “boot shield”
+(<a href="#i_p102_fig01">Fig. 1</a>-F). This shield is of material such as is used in
+making the ordinary interdigital pad, being the thinner
+grades of adhesive moleskin, buckskin, or chamois. It is
+applied usually on the adjacent side of the fourth toe, the
+narrow portion uppermost and the wider part with its concave
+surface directly above the uppermost ridge of the
+corneous area. This not alone prevents lateral pressure, but,
+by means of the tongue-like shape at one side of its base, it
+also prevents pressure on the part from the plantar surface.</p>
+
+<p>It is often found that helomata, developing in the interdigital
+web of these toes, are caused by pressure on the
+part, due to the dropping of the fourth metatarsal bone.
+To bring the head of this bone up into position, and in that
+way relieve the pressure, it is often found necessary to apply
+a felt or buckskin shield on the plantar surface of the foot
+under this articulation. This may be done in addition to
+applying a shield between the toes or each may be used
+separately, as experience dictates. Alfred Ahrens, of New
+York, one of the teaching staff of The First Institute of
+Podiatry, has devised a shield, known by its shape as the
+“duck shield,” which is so fashioned as to present a shielding
+surface between the fourth and fifth toes, as well as an
+expanded end which extends down upon the plantar surface
+and throws the head of the fourth metatarsal up into
+normal position.</p>
+
+<p><b>Strapping.</b> The narrow strip is the most practical
+means of strapping a “boot shield” to the fourth toe. Two
+<span class="pagenum" id="Page_130">[Pg 130]</span>turns of the plaster are carried around the digit, the first
+covering the shield about at its centre and the second crossing
+near its uppermost end. One half-inch strip may also
+be used, its two ends crossing each other on the side of the
+fourth toe, opposite the shield; or in some instances, if
+the shape of the toe permits, the ends may be adhered to
+the dorsal and plantar surfaces of the foot.</p>
+
+<p><b>Metatarsophalangeal Articulation.</b> In protecting a
+part in this location three styles of shield may be employed:</p>
+
+<blockquote>
+<p>
+  1. Oval.<br>
+  2. Half-moon.<br>
+  3. Modified half-moon.
+</p>
+</blockquote>
+
+<p><b>Number 1.</b> The thicker grades of buckskin or felt are
+generally used for this protection, as the part, if affected,
+is usually considerably elevated above the surrounding integument.
+As in connection with the first metatarsophalangeal
+articulation, the oval shield is so fashioned that
+the principal protection will be derived from the upper
+lateral and posterior surfaces. The anterior and under
+lateral surfaces are made correspondingly thin and narrow,
+so that no undesirable pressure is brought to bear on the
+integument beneath these surfaces. In this instance, two
+reasons may be given for such a course: first, all unnecessary
+pressure is naturally contra-indicated; second, the protection
+from these sides is, in nearly every instance, useless
+and unproductive of results. Usually, if the point to be
+protected be near the band of the fifth toe, the shield must
+be scalloped so as to allow for the backward movement of
+this digit when in an extended position. Great care must
+be taken in applying all shields to allow for the natural
+movements of the parts in walking. In this position, more
+particularly, a cumbersome, ill-fashioned shield may become
+a source of irritation during the movements of the foot in
+exercise. Ninety per cent. of shield troubles are due to their
+being improperly fitted or to their imperfect fashioning.</p>
+
+<p>If a shield used in protecting the fifth metatarsophalangeal
+<span class="pagenum" id="Page_131">[Pg 131]</span>articulation is not scalloped, as previously mentioned,
+to allow for the backward movement of the proximal phalanges
+of this digit, irritation is not only bound to occur, but
+the movement of the toe will loosen up the anterior rim of
+the shield (despite strapping), and consequently shifting of
+the shield is sure to occur.</p>
+
+<p>In strapping an oval shield to this part, two strips about
+four or five inches long are cut from the one inch width
+plaster. They are adhered so as to cover the anterior and
+posterior portions of the shield and the upper loose ends,
+made to overlap on the dorsum of the foot, are carried
+firmly over the side to the plantar surface, overlapping also
+on the sole of the foot.</p>
+
+<p>From experience, the writer much prefers the substitution
+of the so-called half-moon, or the modified half-moon
+shields (<a href="#i_p102_fig01">Fig. 1</a>-H) in place of the oval just described.</p>
+
+<p><b>Number 2.</b> The metatarsophalangeal half-moon shield
+supplies all the necessary protection from its upper lateral
+and posterior surfaces without extending down around and
+under the plantar surface of the joint. It must always be
+remembered that the insole of the shoe joins its shank at
+this point and, in many instances, particularly if the shoe
+has been worn to any extent, the insole is inclined to curl
+up and to thicken, and in nearly every case where the shield
+is allowed to run over the edge of the foot, undue pressure,
+with its train of bad effects, is made on the parts.</p>
+
+<p>The half-moon shield is placed on the dorsum of the
+foot, the “points of the crescent” extending anteriorly and
+posteriorly to the part to be protected. The anterior is
+made narrower and thinner than the posterior point for,
+as is the case with the oval shield, the greatest amount of
+protection must come from the wide lateral surface (the
+main body of the shield) and from that portion lying posterior
+to the protected part.</p>
+
+<p>As is the case in any shield, the anterior part of the
+crescent or half-moon variety must be placed far enough
+forward so that if it does shift, there will still be sufficient
+<span class="pagenum" id="Page_132">[Pg 132]</span>normal integument for it to rest upon before it comes in
+direct contact with the anterior edge of the calloused area.
+However, care must also be taken and allowance made so
+that backward movement of the fifth toe does not tend to
+loosen up this anterior edge.</p>
+
+<p>In strapping the half-moon shield, two strips, four
+inches long and one inch wide, are used in like manner as
+that described in the strapping of the oval shield. In some
+instances the anterior point of the crescent is found to be
+narrow enough so that a strip of the half-inch plaster, cut
+the same length, may be substituted with equally good results.
+The inch width, or in some cases the inch-and-a-half
+width, is used across the posterior portion of the shield.</p>
+
+<p><b>Number 3.</b> The modified metatarsophalangeal half-moon
+shield is practically the regular half-moon minus its
+anterior point. Many practitioners have suggested a shield
+of this nature for protection of the first and fifth metatarsophalangeal
+joints for the reason that the anterior point is of
+little or of no use and may become a decidedly detrimental
+feature should the shield shift in any way. Its application
+and strapping is similar in every particular to that of the
+half-moon. The writer, however, has often used two strips
+of one inch width plaster, each about three inches long, and
+has adhered them in criss-cross fashion over the posterior
+of the shield so as to cover the entire posterior portion and
+some part of the lateral edge, and has also found this method
+entirely satisfactory.</p>
+
+<p><b>Plantar Surfaces.</b> The plantar surfaces of the foot, being
+subject to continued pressure and at times to considerable
+friction, are prone to develop many calloused and corneous
+areas. In many of these cases shielding is absolutely
+imperative to successful treatment.</p>
+
+<p>It must always be remembered that these excrescences
+are, in a measure at least, a protection to the underlying
+parts, and their removal often makes the patient conscious
+of their loss. Ofttimes the tissues so exposed become congested
+and decidedly tender. This, of course, is to be considered
+<span class="pagenum" id="Page_133">[Pg 133]</span>at all times, but particularly so on the plantar surfaces
+of the foot. Another point which must be taken into
+consideration in this connection is that the normal tissue
+padding (fat and muscles) of some people’s feet is very
+thin; in consequence, the heads of the metatarsal bones are
+unprotected. In most cases of this kind shields must be
+applied to take the place of nature in order to insure any
+degree of comfort to the patient.</p>
+
+<p>Shields to be placed on the plantar surfaces, and particularly
+those to be applied to the metatarsophalangeal regions
+on the “ball” of the foot, must of necessity be of decidedly
+heavier quality and contain more “body” than
+those applied to the dorsal or lateral regions. The reason
+is that the constant weight of the body quickly flattens the
+shields out to such an extent as to render them useless as
+far as protection is concerned.</p>
+
+<p>The full oval shield (<a href="#i_p102_fig01">Fig. 1</a>-A) is the agent best calculated
+to protect sensitive areas on the plantar surfaces, and
+it can be safely said that it may be and is used in almost
+every case of this kind. Naturally the most general locality
+for the formation of helomata is under the metatarsophalangeal
+articulations. These areas, particularly in persons
+whose feet are thin and lack the proper natural padding, become
+the seats of severe callosities and helomata. The shield
+to be used should always be of sufficient size to allow surface
+enough so that the patient will rest upon the shield rather
+than on the integument; but they should never be allowed to
+extend up under the toes or be placed in any way so as to
+irritate the tender tissues surrounding the diseased area. For
+this reason many practitioners have advocated the use of the
+medio-plantar crescent shield (<a href="#i_p102_fig01">Fig. 1</a>-I), so placed that the
+greater body of the shield is posterior to the heloma and the
+“points of the crescent” extend forward laterally to the
+heloma and point toward the toes. This variety of shielding
+is particularly efficient when the part to be protected is
+located rather anterior to the metatarsophalangeal articulations,
+as is often found in cases of blisters and verrucæ.
+<span class="pagenum" id="Page_134">[Pg 134]</span>However, in most instances where the trouble is situated
+directly over these joints, an oval shield may be used with
+perfect impunity and good results will usually follow.</p>
+
+<p>The long axis of the oval shield is placed, as a rule, crosswise
+on the foot, as the greater amount of protection is derived
+from the surfaces immediately adjoining the affected
+area, laterally rather than anteriorly and posteriorly. In
+cases of excessively arched feet (not necessarily <i>pes cavus</i>)
+and when the integument is quite thin, a great deal of protection
+may be afforded by “building up” the shield on
+its surfaces, which are to be posterior to the areas to be
+protected. This fills up, to some extent, the hollow caused
+by the high longitudinal arch and gives the patient a larger
+surface upon which to stand or walk. This same theory of
+shielding may be successfully applied in cases where the
+calloused area covers the whole “ball” of the foot, making
+it impractical to shield any one spot without jeopardizing
+the comfort of the rest of the integument by placing a
+shield over it. A large piece of felt may then be applied directly
+posterior to the callosity, the felt to be of sufficient
+thickness to allow the patient to rest upon the shield rather
+than upon the painful calloused area.</p>
+
+<p><b>Strapping.</b> In strapping the plantar oval shield, the
+one inch width plaster is most generally used. Three strips
+are cut, one about two inches and the remaining ones approximately
+three or four inches in length. The short strip
+is then placed over the anterior edge of the shield and is
+adhered to the integument, adjacent laterally to the shield.
+One of the longer strips, placed diagonally over the shield’s
+lateral edge, starting from and covering the plaster strip
+already adhered transversely across the anterior end and
+running backwards and covering the whole lateral surface
+of the shield, is adhered to the integument immediately posterior.
+The remaining long plaster strip is then placed in
+like manner over the other lateral surface of the shield and
+is adhered so as to cover the posterior end of the first placed
+lateral strip. This lapping of the plaster ends lends reenforcement
+<span class="pagenum" id="Page_135">[Pg 135]</span>to the strapping and undoubtedly minimizes the
+danger of the plaster loosening and at the same time all the
+edges of the shield are bound down to the integument
+(<a href="#i_p135_fig12">Fig. 12</a>).</p>
+
+<figure class="figcenter illowe24" id="i_p135_fig12">
+  <img class="w100" src="images/i_p135_fig12.jpg" alt="">
+  <figcaption>
+    Fig. 12.
+
+    SHOWING COMPLETE STRAPPING
+    FOR MEDIO-PLANTAR OVAL
+    SHIELD
+  </figcaption>
+</figure>
+
+<p>It should be remembered that when applying adhesive
+strips in the strapping of a plantar shield, the toes should
+always be drawn backward
+towards the dorsum
+of the foot to their
+fullest extent, the
+straps to be applied
+whilst the toes are held
+in this position. This is
+to allow for the extension
+of the toes in the
+last position of walking
+and prevents the plaster
+from pulling on the
+sound integument.</p>
+
+<p>In several instances
+it has been advocated
+that but two one inch
+width strips be used on
+a shield of this nature,
+and the same method
+may well be applied to
+the strapping of the
+medio-plantar crescent
+shield previously described.
+These strips
+are cut of equal length,
+each about four-and-a-half
+or five inches.
+About one inch from one end, each strip is narrowed
+from the sides so as to allow the admission of the
+plaster between the toes. This one end is then adhered to
+the integument on the dorsum of the foot, the narrow portion
+<span class="pagenum" id="Page_136">[Pg 136]</span>being carried between the third and fourth or the
+fourth and fifth toes (as the size of the shield may indicate)
+and the remaining portion of plaster is adhered diagonally
+across the outer lateral surface of the shield. The other
+strip, adhered in like manner on the dorsal surface, is carried
+between the toes (usually the great and second) over
+the inner lateral surface of the shield, lapping over the end
+of the first strip applied. This method of strapping covers,
+to a considerable extent, the anterior portion of the shield
+and does away with the transverse strip which in many
+cases becomes an irritating agent to the tender integument
+under the toes.</p>
+
+<p>The argument against this method of strapping may be
+the danger of irritation between the toes. From the experience
+had in using this method, the writer has had no bad
+results, and if the strips are properly adhered, the normal
+movements of the foot being taken into consideration and
+the plaster lying between the toes cut sufficiently narrow,
+no bad results can take place and there is no doubt of the
+greater efficiency and lasting power of the strapping.</p>
+
+<p><b>The Lateral Plantar Half-moon.</b> When the area to be
+protected is situated on the extreme lateral edges of the
+plantar surface, as often found in these locations, and the
+callosity extends to or sometimes over the lateral border of
+the foot, the full oval shield is contra-indicated. In its place
+the lateral plantar half-moon is substituted with better
+results in all cases.</p>
+
+<p>This variety is identical with the dorsal half-moon
+shield and is applied so that the main body of the shield lies
+laterally on the plantar surface, while the “points” are
+allowed to extend somewhat over the lateral border of the
+foot so that some protection is afforded from this source.
+The major protection, however, is, of course, obtained from
+the main body of the shield on the plantar surface.</p>
+
+<p>The anterior “point of the crescent” is generally fashioned
+so as to be narrower and thinner than the posterior,
+for in nearly every instance this must extend near the under
+<span class="pagenum" id="Page_137">[Pg 137]</span>surface of the great toe and of the small digit, and must in
+no way be allowed to interfere with their movements. Two
+strips of one inch width plaster are generally used in
+strapping the lateral plantar half-moon, although in some
+instances it will be found necessary (due to the close proximity
+of the digital webs) to substitute a strip one-half inch
+in width for the anterior strapping.</p>
+
+<p>The straps are so placed as to overlap both on the
+dorsal and plantar surfaces and to bind down the anterior
+and posterior edges of the pad. In all strapping the result
+to be obtained is the binding down of the edges of the shield
+rather than merely binding down the main body.</p>
+
+<p><b>Lateral Borders.</b> Practically the only spot on the lateral
+borders of the foot where callous formations may be
+met is over the expanded base of the fifth metatarsal bone,
+although blister formations or other tender areas may
+develop anywhere along the edges.</p>
+
+<p>The full oval shield is almost entirely used in connection
+with protection in these locations and is usually
+strapped with three strips of the inch width plaster or, if
+the shield be small, three strips of one-half inch width
+plaster will answer.</p>
+
+<p>These are placed as follows: one strip slightly shorter
+than the other two is adhered transversely across one end of
+the shield and the other two are applied diagonally from the
+ends of the first, so as to completely cover the lateral edges
+of the shield and overlap each other on the sound integument
+beyond its end.</p>
+
+<p><b>Os Calcis Region.</b> Many cases coming to the notice of
+the podiatrist require the application of a shield in the
+region of the os calcis, either on the plantar, lateral and
+posterior surfaces of the heel itself, or further upward on
+the prominence of the tendo Achillis. The oval shield is
+most generally used in these instances, and felt will usually
+be found to be the most practical shielding material. Felt,
+in particular, is advocated because it is softer and more
+yielding than most other materials, and in shielding a tender
+<span class="pagenum" id="Page_138">[Pg 138]</span>area on the tendo Achillis, nothing harsh can be used
+without danger of causing irritation to the surrounding and
+underlying soft parts.</p>
+
+<p>Strapping is similar to that used in adhering the oval
+shield to the lateral border, but naturally the operator must
+exercise his own ingenuity in the method of strapping to
+meet the conditions present.</p>
+
+<p>The art of applying a shield is not one to which any set
+rules can be applied. Each case is individual and the operator
+who goes about this branch of his work in a stereotyped
+manner will find his efforts devoid of results.</p>
+
+<p>Often a half-moon shield is used where the part to be
+protected is so located that a full oval shield may not be
+applied. Sometimes the “points” are applied upward and
+sometimes the main body of the shield lies above the protected
+area and the “points” are downward. The strapping
+is similar to a strapping for any such shield and the strips
+are applied in such a way as not to interfere with normal
+movements of the heel or of the tendon.</p>
+
+<p>There are many instances in which incipient bursal inflammations
+are developed adjacent to the tendo Achillis, due
+to the wearing of a new or stiff pump or boot. Many cases
+of this nature were found among the militiamen preparing to
+go to the “border” last Spring. The constant marching in
+new and stiff shoes, which was part of their training, caused
+a great amount of trouble just above and at the insertion of
+this tendon. In these cases two pieces of felt, shaped to the
+tendon and thick enough to fill up the hollows at its sides,
+were applied and then strapped securely in place by strips of
+adhesive plaster, one inch in width, which covered felt,
+tendon and all. This strapping served not alone to secure
+the felt shielding in place, but also to immobilize the part so
+that these deeper inflammations had a chance to subside.</p>
+
+<p><b>Dorsal Surfaces.</b> On the dorsal surfaces of the foot,
+over the articulations of the metatarsal bone with the internal
+cuneiform and the cuneiform with the navicular, small
+and seemingly insignificant, helomata miliare (seed corns)
+<span class="pagenum" id="Page_139">[Pg 139]</span>are found to develop. In many instances the removal
+of these growths will not bring relief unless a shield is applied
+with the final dressing. This is due to the lack of
+muscular padding over these bones and the skin becomes
+irritated by tight lacing of the shoes.</p>
+
+<p>A small oval shield, not too thick and usually of thin
+buckskin, kid or adhesive moleskin, is usually applied, although
+the thinner varieties of felt may be used with good
+results. The shield is generally strapped in a manner similar
+to those applied to the lateral borders or to the os calcis
+region, that is, with three strips of one-half inch width plaster
+applied to cover all edges of the shield in triangular
+form.</p>
+
+
+<h3 id="MORTONS_TOE_AND_METATARSALGIA">
+  MORTON’S TOE AND METATARSALGIA
+</h3>
+
+<p>The treatment of anterior arch trouble is usually and
+wisely recommended to the orthopedic specialist, but there
+are numerous incipient and advanced cases for which the
+podiatrist must necessarily give at least temporary relief.
+Shields, as well as strapping, play an important part in the
+rectification of these annoying conditions, and under this
+heading the shielding in particular will be discussed.</p>
+
+<p>The heads of the metatarsal bones forming the anterior
+metatarsal arch, having dropped from their normal positions,
+cause pressure upon the digital nerves and bring on
+the varieties of pain which are found in these conditions. It
+seems a logical theory that in order to alleviate these painful
+manifestations, support so designed as to return these bones
+to their normal position and hold them there would constitute
+a practical and efficient treatment.</p>
+
+<p>From the podiatrist’s standpoint, this may be accomplished
+by means of shields of felt or buckskin, adhered to
+the plantar surface of the foot in this region or by placing
+such supports in the shoe. These methods may at least
+afford temporary relief and in some instances, if their use
+be persisted in, permanent cures have been effected. The
+cure, however, is usually attempted by means of metal appliances
+<span class="pagenum" id="Page_140">[Pg 140]</span>which are worn in the shoe and which have a raised
+portion or “button” just posterior to the metatarsal heads.</p>
+
+<p>There are several forms of shields (or rather in this
+instance pads or supports) which are in general use for the
+correction of anterior arch trouble. These vary in size,
+shape, and thickness according to the number of bones involved
+in the displacement. Varying success is met with in
+the use of these supports and each individual case is usually
+found to demand changes or modifications in the support, so
+that the following description should be taken for the general
+points alone:</p>
+
+<p><b>Morton’s Toe.</b> This affection, being limited to a displacement
+of the head of the fourth metatarsal bone with the
+lateral pressure from it upon the digital nerve, naturally
+does not need so large a shield as would be demanded were
+the bones of the whole anterior arch out of alignment.</p>
+
+<p>A pad of felt, about two-and-one-half inches long, an
+inch-and-a-half wide at the anterior point, made to taper
+slightly towards the posterior end, and three-eighths-of-an-inch
+thick, will be found to give relief in most cases. The
+felt is skived at the posterior end so that its thickness lessens
+gradually as it extends posteriorly along the metatarsal
+bone. The pad is applied directly to the rear of the head of
+the fourth metatarsal bone, and the thickness of the pad
+serves to force the depressed bone upwards and thus into
+proper alignment. It may be found necessary at times to use
+even thicker material in the manufacture of the pad or to
+place a small piece of felt upon its upper surface, so that as
+it is adhered to the part, this elevated area will come directly
+posterior to the depressed metatarsal head and thus elevate
+it.</p>
+
+<p>In strapping the piece of felt, two or three strips of one
+inch plaster are used. These are long enough to cover the
+width of the plantar surface and to extend upon the dorsal
+surface on each side. One end of the plaster is firmly
+adhered to the dorsum of the foot, the plaster being carried
+around under the foot over the pad, to be then adhered to the
+<span class="pagenum" id="Page_141">[Pg 141]</span>inner dorsum of the foot. Sufficient tension should be put
+on the adhesive strips to pull both borders of the foot down,
+thus aiding the pad in pushing the heads of the affected
+metatarsal bones up in place. In fact, in some cases a strapping
+of this nature with adhesive plaster will serve to give
+at least temporary relief to the patient without the use of a
+pad. Some practitioners advocate a pad of sufficient length
+to cover a greater portion of the metatarsal bone.</p>
+
+<p>If the pad is entirely covered by the three lengths of
+adhesive plaster, it will not alone last longer but the danger
+of its slipping out of place is minimized.</p>
+
+<p><b>Metatarsalgia.</b> When the whole anterior arch is involved
+in a displacement, a pad of sufficient size and thickness
+to support the heads of all the metatarsals is necessary.
+There are two principal forms of support in general use. A
+strip of buckskin or felt of sufficient length (which will, of
+course, vary in different feet) to cover the four lesser metatarsal
+heads and about one-and-one-half to two inches in
+width, is adhered to the foot just posterior to the depressed
+parts. This is covered with adhesive plaster and serves as
+a support to the whole anterior arch region.</p>
+
+<p>In the writer’s experience, however, the fifth metatarsal
+bone is rarely involved in this general depression, and this
+seems natural when it is considered that the first and the
+fifth metatarsal bones act as pillars for this arch in the
+normal foot.</p>
+
+<p>Should complaint be made of a pain coming from the
+anterior arch trouble and occurring between the fourth and
+fifth toes, it usually will be found to emanate from the depression
+of the fourth metatarsal head. Keeping this in
+mind, a pad or support, which has found great favor, is
+fashioned from thick felt or buckskin (one-quarter to three-eighths)
+in such a way as to allow its anterior edge to come
+just behind the metatarsal heads. This pad should be about
+four or five inches long and the portion that extends back
+under the longitudinal arch should be skived so that it easily
+conforms to the contours of the foot in that region. In order
+<span class="pagenum" id="Page_142">[Pg 142]</span>to obtain support to the three middle metatarsal heads, the
+corners of this pad, which would extend over those of the
+first and fifth, are to be cut away; otherwise the pad would
+cause undue pressure upon parts requiring no support and
+thus prove detrimental.</p>
+
+<p>The pad is held in place with adhesive strips extending
+from the outer to the inner dorsum, applied in the same
+manner as described for the Morton’s toe pad.</p>
+
+<p>This pad practically gives the patient a new sole to walk
+on, and at the same time holds the depressed bones up in
+place. It will often be found advantageous to apply a pad
+of this kind, about one-eighth or one-quarter of an inch
+thick, in conditions where the patient complains of a burning
+sensation in the soles of the feet, even though there be no
+apparent lesion or displacement of the metatarsal bones.</p>
+
+<p>A number of devices are on the market for the relief of
+all forms of affections common to the arches of the foot.
+The relative merits of such contrivances will be fully discussed
+in the forthcoming volume on Podiatry Orthopedics
+(Schuster and Stafford), to be published under the auspices
+of The First Institute of Podiatry.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_143">[Pg 143]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_IX">
+    <span class="chap">CHAPTER IX</span>
+    <br>
+    LOCAL ANESTHESIA
+  </h2>
+</div>
+
+
+<p>Local anesthesia is a condition of insensibility brought
+about in a part of the body by the use of agents called local
+anesthetics. The person in whom the local anesthesia is
+produced does not lose consciousness as in general anesthesia,
+the part alone being made insensible.</p>
+
+<p>There are many agents which, when applied to a part,
+by one means or another, cause that part to become insensible
+to pain, but for the podiatrist the following agents are
+best calculated to serve his purposes: cocaine, novocaine,
+alypin and urea hydrochloride, ethyl chloride, ethyl bromide,
+carbon dioxide snow, apothesine and ice. (See footnote
+page 148.)</p>
+
+<p><i>Cocaine</i> is an alkaloid extracted from coca leaves. These
+latter are not to be confused with cocoa, the seed of the
+chocolate tree. When cocaine is treated with hydrochloric
+acid, hydrochloride of cocaine is produced which occurs in
+a white crystalline powder, soluble in water and alcohol.
+When injected into the skin, or applied to an open wound,
+it acts as a paralyzant to the vasodilators and as a stimulant
+to the vasoconstrictors. When applying this drug, a
+tourniquet should be used wherever possible, so as to prevent
+absorption. This precaution is essential, as cocaine&#x2060;<a id="FNanchor_2_2" href="#Footnote_2_2" class="fnanchor">[2]</a>
+is very toxic, and even small quantities may produce bad
+effects in some persons. There are cases on record in which
+¹⁄₁₀₀ of a grain of this drug has produced all the symptoms
+of toxemia, whereas there are persons who can stand doses
+up to one grain. It is therefore essential to use judgment
+and care in administering a drug which on account of the
+idiosyncrasies of some people, is likely, even in minute doses,
+to produce serious, if not fatal symptoms.</p>
+
+<p><span class="pagenum" id="Page_144">[Pg 144]</span></p>
+
+<p>In podiatry, a ¹⁄₂% solution is strong enough for general
+use, provided that time enough is allowed for the drug to be
+diffused. For an ordinary ingrown toe nail, two cubic centimeters
+of the above solution is usually sufficient to produce
+anesthesia of the part.</p>
+
+<p><i>Novocaine</i> is a synthetic preparation and occurs in
+colorless needles. It can be heated to 120 degrees Centigrade,
+without undergoing decomposition, which is not the
+case with cocaine hydrochloride. Although not quite as
+efficient as an anesthetic, novocaine is only ¹⁄₇ as toxic as
+cocaine and therefore can be used with greater safety and
+podiatrists generally have abandoned cocaine for novocaine.
+It has a slightly irritating action while being injected, but
+on the whole it is preferable to cocaine for podiatry practice.
+Physiologically, it has the same action as cocaine, and
+is indicated wherever the latter drug is used. It is usually
+injected in one per cent. solutions.</p>
+
+<p><i>Alypin</i> occurs as a crystalline powder. It is a most
+efficient anesthetic and because of its non-toxic action, it is
+to be preferred in cases in which there is a fear of toxemia.
+Maximilian Stern, M.D., Professor of Surgery at the First
+Institute of Podiatry, has used this drug extensively for
+producing local anesthesia, and his results have been very
+satisfactory. For use in podiatry, a ¹⁄₄ to ¹⁄₈ per cent.
+solution is often sufficient. It may be used freely in ¹⁄₄ per
+cent. strength without danger of toxemia. When injected,
+it produces no anemia, and consequently there is no danger
+of subsequent hemorrhage, such as might accompany the
+use of either cocaine or novocaine.</p>
+
+<p><i>Quinine and urea hydrochloride</i> is one of the quinine
+salts, consisting of one molecule of quinine hydrochloride
+and one molecule of urea. It has no toxic action when
+injected into the tissues, but it retards healing, and scar
+tissue forms over operated areas where it has been used.
+Many operators prefer this drug on account of its non-toxic
+action when used in large quantities, despite the likelihood
+of a scar and slow union. In parts of the body where contraction
+<span class="pagenum" id="Page_145">[Pg 145]</span>of the tissues is a desirable after-effect (such as
+would be the case in hemorrhoids), quinine and urea hydrochloride
+is to be preferred over other local anesthetics.
+David H. Levy, M.D., a well known surgeon of New York
+City, prefers it to all other local anesthetics.</p>
+
+<p><i>Ethyl chloride</i> and <i>ethyl bromide</i> are clear volatile
+liquids, and upon their rapid evaporation depend their anesthetic
+qualities. When a substance evaporates rapidly, it
+extracts the heat from surrounding bodies in doing so, and,
+consequently, when such a substance is applied to the skin, it
+soon extracts the heat from the part and with the local
+anemia thus produced, sensation is lost. Ethyl chloride and
+ethyl bromide are manufactured in tubes so arranged as to
+eject a fine stream of the liquid. When this stream comes
+in contact with the skin, evaporation is rapid and gradually
+the part becomes numb; continued, it becomes frozen. This
+method is not as efficient as the hypodermic injection
+because the anesthesia is not so lasting, moreover, the reaction
+is severe and painful. Otto Sjogren and Fred Schmitt,
+practitioners of known repute, have entirely discarded both
+of these drugs from their list of local anesthetics, for
+reasons above mentioned.</p>
+
+<p><i>Carbon dioxide snow</i> is prepared by allowing liquified
+carbon dioxide gas to slowly escape from its container
+into a glove finger, where it solidifies into a mass, assuming
+the shape and form of the receptacle; it is called the <i>carbon
+dioxide pencil</i>. When this mass or pencil is applied to a
+part, it extracts the heat and anesthetizes by freezing. The
+dangers attending the use of the carbon dioxide pencil are
+the same as with ethyl chloride or ethyl bromide and, due
+to its extremely low temperature, there is danger of causing
+death of the tissues and of producing conditions giving rise
+to subsequent ulcerations that are slow to heal. As an anesthetic,
+it is not advised for podiatry.</p>
+
+<p><b>Technic of Producing Local Anesthesia.</b> There are
+three methods of producing local anesthesia: (1) the hypodermatic
+method: (2) the pressure method: (3) freezing.</p>
+
+<p><span class="pagenum" id="Page_146">[Pg 146]</span></p>
+
+<p>The freezing method is of no great value to the podiatrist,
+and having been already briefly described, further
+comment is deemed unnecessary.</p>
+
+<p>The pressure method of producing local anesthesia is
+new, and although extensively employed in the practice of
+dentistry, podiatry offers but little opportunity for its free
+use. It is necessary to have an exposed nerve, such as is
+found in the cavities of painful teeth, or an open wound
+into which the drug can be absorbed, before this method can
+be used. In cases of ingrown toe nail, in which the groove
+is lacerated, either by the patient or by the nail itself, pressure
+anesthesia is often efficacious. Small pellets containing
+cocaine or novocaine, with adrenalin, are put on the market
+for this purpose. One of these pellets is placed in the
+nail groove, and a drop of alcohol is made to fall on it. The
+contents of the pellet are promptly dissolved by the alcohol,
+whereupon the operator places his thumb over the nail
+groove between the nail and the nail flap and exerts downward
+pressure. This forces the dissolved fluid into the tissues,
+where it acts the same as if it were injected. This procedure
+is painful for just a moment while the pressure is
+being applied, but the pain soon ceases and nerve sensibility
+is lost.</p>
+
+<p>The most generally used method of applying local anesthetics
+is by means of the hypodermic syringe and is called
+the <a id="FNanchor_3_3" href="#Footnote_3_3" class="fnanchor">[3]</a>&#x2060;hypodermatic method. This is preferable to all other
+forms of inducing local insensibility, and if the technic is
+mastered, operations will be painless with the exception of
+the initial prick of the needle.</p>
+
+<p><b>The Hypodermic Syringe</b> should be so constructed that
+it may be sterilized by boiling. There are many types of
+such instruments sold, and in making a selection, only those
+which will permit such boiling should be considered. The
+all-glass syringe or the glass and metal syringe with the
+metal piston are best, because the fluid contained therein is
+<span class="pagenum" id="Page_147">[Pg 147]</span>visible, thus preventing the injection of air. Needles should
+be of the rust-proof variety and for use in podiatry, they
+should be one-half or one inch long and have a twenty or
+twenty-two gauge lumen.</p>
+
+<p>After the syringe has been sterilized, it should be
+adjusted and the fluid drawn into it after the needle is
+attached to the barrel. The entire instrument is then
+turned, needle up, and the air that may be in the barrel is
+expelled by pressure on the piston. When this is done, the
+syringe is ready for use.</p>
+
+<p>If the needle is sterile, the only preparation necessary
+for the skin is to paint it with tincture of iodine, and then
+the injection of the anesthetic may be commenced. The area
+to be anesthetized is determined, and then at the most proximal
+portion, the skin is grasped between the thumb and
+forefinger of the left hand. The syringe should be held in
+the right hand with the barrel between the first and middle
+fingers, and the thumb on the piston. When the skin has
+been blanched by the pressure of the fingers of the left hand,
+the point of the needle, lumen downward, is thrust into the
+skin with a quick movement and immediately after, pressure
+is brought to bear upon the piston. As the fluid enters the
+tissues, it produces a blanched area which is called a wheal.
+As the wheal is formed, the needle is gradually moved forward
+in the derma until it is inserted as far as the base.
+It is then withdrawn, and a second injection is commenced,
+a little back of the distal end of the wheal. This second
+injection, being started in a part already anesthetized, will
+cause no pain. So the needle is gradually moved forward
+in the derma until the desired area has been covered.</p>
+
+<p>When the deeper tissues are to be anesthetized, the
+needle may be directed at an angle to the surface, pressure
+being borne on the piston of the syringe as the needle gradually
+moves deeper into the flesh. It must be remembered that
+if the needle is re-inserted into an area that is already
+deadened, there will be no pain. The fluid should be ejected
+from the syringe slowly, which insures an even distribution
+<span class="pagenum" id="Page_148">[Pg 148]</span>of the drug, as well as comfort to the patient, while the anesthetic
+is being administered. Most drugs cause a burning
+sensation if injected too rapidly.</p>
+
+<p>The most common lesion for which local anesthetics are
+used in podiatry is the ingrown toe nail, and to get good
+results in these cases, the technic must be followed in detail.
+After the derma has been anesthetized over the region of
+the nail root and groove, one deep injection should be made
+at the root, and vertically to the skin. This will insure loss
+of sensation when the root is cut and when the matrix at
+this point is curetted.</p>
+
+<p>To prevent the absorption of toxic drugs into the system,
+some means should be devised to cut off the circulation
+during the operation. This is accomplished by the tourniquet,
+which is usually made of flexible, solid rubber, about
+one-sixteenth or one-eighth inch in diameter and about a
+foot long. When this band is tied around the base of the
+toe, and pulled tight, it cuts off the circulation. Tourniquets
+cannot be used when operating upon the foot proper, and in
+these cases it is necessary to be guarded in the use of toxic
+drugs.</p>
+
+<p>After the use of cocaine&#x2060;<a id="FNanchor_4_4" href="#Footnote_4_4" class="fnanchor">[4]</a> or novocaine there is a reaction,
+and occasionally the pains produced by this reaction are
+severe. These pains may be alleviated to some extent by
+the use of wet dressings, but they last only for a short time
+so that it is often unnecessary to treat them. The patient
+should be warned of the reaction. The local anemia produced
+by the injection of these drugs is subsequently followed
+by hyperemia, and it is therefore necessary to guard
+against hemorrhage in cases in which free incisions have
+been made. Wounds should be packed, and proper bandages
+should be applied to prevent any such possibilities.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_149">[Pg 149]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_X">
+    <span class="chap">CHAPTER X</span>
+    <br>
+    HELOMA
+  </h2>
+</div>
+
+
+<p><b>Derivation.</b> The word has its origin in the Greek
+“<i>helos</i>,” meaning corn; (plural: <i>helomata</i>).</p>
+
+<figure class="figcenter illowe15" id="i_p149">
+  <img class="w100" src="images/i_p149.jpg" alt="">
+  <figcaption>
+    BUILDING NAILS (HELOS) USED IN PRE-HISTORIC TIMES
+  </figcaption>
+</figure>
+
+<p>In the accompanying cut will be found a photograph of
+two building nails bearing the name and time of the reign
+of King Gudea in Ur, Chaldea, about 2500 B.C. Plaster casts
+of the above were presented to The First Institute of
+Podiatry by Fridtjov Anderson, Colonel in the Norwegian
+Artillery. These nails were called helos and because of
+<span class="pagenum" id="Page_150">[Pg 150]</span>their semblance to the foot excrescences, commonly called
+corns, the latter were therefore named helomata.</p>
+
+<p><b>Synonyms.</b> Corn, clavus, horn.</p>
+
+<p><b>Definition.</b> An heloma is a circumscribed, conical, deep-seated
+overgrowth of the epidermis, the apex of which
+presses down upon the derma. Corns usually occur about
+the toes, but may appear upon any part of the body subject
+to friction or pressure. They range in size from a
+pinhead to a ten cent piece.</p>
+
+<p>According to their appearance, texture or composition,
+helomata are classified as follows:</p>
+
+<blockquote>
+<p>
+  Heloma durum, or hard corn.<br>
+  Heloma molle, or soft corn.<br>
+  Heloma vasculare, or vascular corn.<br>
+  Heloma miliare, or seed corn.
+</p>
+</blockquote>
+
+
+<h3 id="HELOMA_DURUM">
+  HELOMA DURUM
+</h3>
+
+<p><b>Heloma durum</b> is a hard circumscribed overgrowth of
+the epidermis and may occur as above stated, but is usually
+found on the outer side of the fifth toe, the dorsum of the
+second, third and fourth toes, and on the plantar surface
+of the interphalangeal joint of the great toe.</p>
+
+<p><b>Symptoms.</b> The symptoms of an heloma durum may
+be classified as subjective and objective. The chief subjective
+symptom is pain in varying degrees. The formation
+of the growth produces a pressure upon the nerves
+which, in turn, gives rise to pain varying from a dull and
+mild sensation to a sharp and intense excitation. These
+pains are increased when the part affected is further irritated
+by ill-fitting shoes, by friction or by other pressure.</p>
+
+<p>It is a well known fact that the pain in a corn is increased
+when the weather is about to change. Helomata,
+which at other times cause no inconvenience, will prove a
+source of annoyance at this time. This is due to certain
+physiologic changes that take place in the body as follows:
+the atmosphere preceding a storm becomes more and more
+charged with moisture. As this increases, the function of
+<span class="pagenum" id="Page_151">[Pg 151]</span>the skin, namely the elimination of liquid waste, is gradually
+diminished. This function is taken up and performed
+by the kidneys, and as the air becomes fully charged with
+moisture, the entire work of elimination is carried on by
+these latter organs. This physiologic change requires a readjustment
+of the blood supply and the nerves which control
+it, so as to bring about a proper equilibrium. In this latter
+procedure the little nerve fibres are unfavorably influenced,
+and pain results. The gradually increased uncomfortableness
+that is experienced is due to gradual increase in the
+humidity and when precipitation takes place and the air
+is freed from this atmospheric pressure, relief is afforded.</p>
+
+<p>The patient will complain of pain while shoes and
+stockings are worn, but will feel relieved when they are
+removed, except in cases where inflammatory processes have
+commenced. The pains at these times are of the throbbing,
+pulsating variety, such as accompany all inflammations.</p>
+
+<p>A clinical examination of an heloma durum shows a
+horny mass of epidermic cells crowded together with no
+regular formation within the growth. There is a sharp line
+of demarcation between it and the surrounding tissues
+and it is also distinguished by its darker, yellowish color
+in contradistinction to the healthy pink of the normal skin.
+Within the growth, and usually at its centre, may be seen
+a darker, more compact mass, which penetrates deeper into
+the tissues. This is the radix or nucleus, incorrectly termed
+the root, or the eye, of the corn. The skin immediately
+surrounding the heloma usually presents a red line, due
+to the somewhat lessened irritation that originally produced
+the corn. The color is due to congestion in the derma.</p>
+
+<p><b>Etiology.</b> Helomata dura are commonly caused by
+direct intermittent friction or pressure of ill-fitting shoes.
+The shoes may be too tight, thereby causing pressure, or
+they may be too loose, thereby causing friction. Helomata
+that appear on the plantar surface of the foot may be
+caused either by some roughness in the finish of the shoe
+or by soles which are too thin, or by downward displacement
+<span class="pagenum" id="Page_152">[Pg 152]</span>of the heads of the metatarsal bones beneath, caused
+by wearing shoes that are not anatomically correct.</p>
+
+<p>Imperfections in the stockings, such as knots in the
+worsted or poor workmanship in darning, are also factors
+in producing helomata. Any concentrated or undue local
+pressure is capable of causing this overgrowth, provided,
+however, that the pressure is not primarily of sufficient intensity
+to set up such an amount of congestion and consequent
+inflammation as to lead at once to an ulceration of
+the part.</p>
+
+<p>The same principle of intermittent friction and pressure,
+with counter-pressure, as a cause for helomata holds
+good on any part of the body surface.</p>
+
+<p><b>Pathology.</b> The pathologic changes accompanying the
+development of an heloma are mostly morphologic. The
+intermittent friction and pressure produce first an irritation
+or excitation of the cutaneous nerves; this causes an increased
+blood supply to the part and congestion takes place
+in the derma immediately beneath.</p>
+
+<p>Were this pressure or friction to cease at this time,
+nature would restore the tissues to their normal condition
+in a very short time; but, as this pressure or friction is
+continued from day to day, the habitual congestion produces
+a chronic enlargement or hypertrophy of the papillæ
+of the derma.</p>
+
+<p>The epidermic cells originate from the material supplied
+by the blood plasma, which is conveyed through the
+walls of the capillaries to the surface of the basement membrane
+by endosomis, where it forms into granules which
+contain nuclei of unusual size. These granules, the first
+organic shape of the future cells, gradually develop into
+nucleated cells.</p>
+
+<p>Bearing in mind the development of the cells in the
+normal skin, with an increased blood supply, there will
+naturally be a more rapid proliferation or development of
+cells taking place over the enlarged papillæ than over the
+surrounding normal ones. This excessive development of
+<span class="pagenum" id="Page_153">[Pg 153]</span>cells causes an abnormal upward crowding of the preceding
+cells, with the result that the horny layer gradually becomes
+thickened. With this thickened layer acting as a
+counter-pressure from above, cornification of the tender cells
+takes place more rapidly with each succeeding new layer
+that is added to the under portion of that already formed.
+The growth at this time takes place at the interior and
+lateral portions of the heloma, principally the former.</p>
+
+<p>This process in due time causes the epidermis to become
+transformed into a dense homogeneous mass of cells
+which is called a <i>callosity</i>. The size of the callosity is determined
+by the area of the papillæ affected.</p>
+
+<p>The etiologic factors which cause the enlargement of
+the papillæ and the overgrowth of the epidermic cells continue,
+and that part of the growth which was first formed
+and is most usually central, becomes more dense than the
+surrounding callosity. This is due to the greater irritation
+to which it is subjected, and eventually this extends downward
+and penetrates the derma. The pressure of this new
+development, known as a “radix,” against the papillæ,
+causes these organisms to undergo progressive atrophy with
+the result that they are at times completely absorbed.
+Thus, we have the common heloma durum. The heloma now
+receives its nourishment from the lateral portions, which
+still continue to maintain their increased vascularity.</p>
+
+<p>It often happens that an heloma is subjected to unusual
+pressure during its formation, which causes serous effusion
+or even subcutaneous hemorrhage in minute quantities.
+This effusion is absorbed by the soft cells which are in
+the process of transition into horny tissue. These cells take
+on a laminated appearance which present different tints,
+from a light yellow to a dark red.</p>
+
+<p>The nerve filaments of the skin are also affected during
+the development of an heloma, and when this process is
+marked, the condition known as neuro-fibrous heloma is the
+result. These little neuromata very often become quite enlarged.
+The favorite location for this condition is the inner
+<span class="pagenum" id="Page_154">[Pg 154]</span>plantar edge of the great toe, and sometimes the outer
+plantar edge of the metatarsophalangeal joint of the fifth
+toe.</p>
+
+<p>These helomata consist of two or three little irregularly
+shaped structures extending downward into the derma
+and in juxtaposition to each other, the septum dividing these
+structures being made up of one or more rows of enlarged
+papillæ which have become highly vitalized through the
+enlargement of the nerve fibres contained in them. The
+condition is very painful and great care must be exercised
+when operating upon them. The most logical reason for
+their appearance upon the plantar edges seems to be the
+fact that the long papillæ of the plantar surface leave off
+abruptly and are joined by the shorter ones of the dorsum.
+The line of junction is undoubtedly subjected to a greater
+degree of irritation than where the size of the papillæ is
+uniform.</p>
+
+<p><b>Diagnosis.</b> A typical heloma durum is a mass of epidermic
+cells, round in shape and varying in size. The color
+is usually yellow, but in cases where serous or bloody infiltration
+has taken place, the color may increase to red or
+even to dark purple.</p>
+
+<p>Heloma durum may be mistaken for heloma vasculare
+or verruca, on account of the dark blood stains which are
+often in evidence, but when the top layers of the heloma are
+removed, the dark spots which were mistaken for blood
+vessels are not found in the growth proper, but are deep
+in the structure resting against the derma. When these
+spots, which are clots, are cut with the knife, no bleeding
+occurs; whereas, if the condition were one of heloma vasculare
+or verruca, hemorrhage would be produced.</p>
+
+<p>Lesions of several skin diseases, such as eczema and
+psoriasis, very often produce scales or crusts on the feet
+which might be mistaken for helomata, for when the fingers
+are passed over them they feel as if they were an overgrowth
+of the skin. These scales or crusts, however, are
+usually loosened at the edges and the color is quite different,
+<span class="pagenum" id="Page_155">[Pg 155]</span>being red or white. Other indications of the presence
+of a skin affection will usually be found on other parts of
+the foot.</p>
+
+<p>The radix, or nucleus, of the heloma is a characteristic
+which differentiates it from the ordinary callosity. The
+radix is a dark solid mass of epidermic cells which has an
+almost transparent appearance.
+When cutting
+an heloma, the
+radix may be felt by the
+tension produced as the
+knife passes through it.</p>
+
+<p>Helomata dura
+found on the plantar
+surface of the foot over
+the heads of the metatarsal
+bones are not
+readily distinguished,
+due to the fact that they
+are covered by a layer
+of callous, which, when
+removed, exposes the
+nuclei to view.</p>
+
+<figure class="figcenter illowe24" id="i_p155">
+  <img class="w100" src="images/i_p155.jpg" alt="">
+  <figcaption>
+    HELOMA DURUM ON PLANTAR
+    SURFACE
+  </figcaption>
+</figure>
+
+<p><b>Prognosis.</b> The
+prognosis of heloma
+durum is uncertain.
+There are many cases
+on record which have
+disappeared after the
+first treatment and, on
+the other hand, some
+cases regularly recur notwithstanding many years of regular
+attention. This is due to two conditions: first, the cause
+of the heloma, namely, the continued wearing of the shoe,
+and, second, the papillæ beneath the growth remain enlarged
+and continue their function of excessive cell proliferation.
+The latter reason is more important than the first, for, even
+<span class="pagenum" id="Page_156">[Pg 156]</span>in cases where proper footgear is provided and no friction
+or pressure is permitted, the heloma may continue to grow.
+The only way to account for the total disappearance of some
+helomata, after treatment, is, that when the growth is removed,
+the size of the papillæ diminishes and normal function
+is restored. The situation of heloma durum is very
+important in considering the ultimate cure of the growth.
+Those on the outer aspect of the little toe rarely get well, due
+to the prominent position of that digit, while those on the
+plantar surface over the heads of the metatarsals are often
+completely cured after the proper treatment has been applied.
+When the heads of the metatarsal bones have been
+properly adjusted, the helomata produced by their downward
+displacement gradually disappear.</p>
+
+<p><b>Treatment.</b> The treatment of heloma durum is divided
+into three classes, viz.: preventive, palliative and operative.</p>
+
+<p><b>Preventive treatment</b> consists in securing freedom
+from friction of or pressure on the parts affected. Footgear
+of proper size and shape is essential. The shoes
+should be neither too tight nor too loose; they should
+fit snugly in the heel, and the toe box and front of the
+shoe should be broad enough to allow of freedom for the
+toes. The quality and kind of leather used for the shoe
+should also be considered. This should be soft and well
+seasoned, vici kid and calf skin being preferred. Patent
+leather and colt skin are undesirable, in that they are hard
+and almost air tight. Shoes made to measure on a last
+constructed from a plaster of Paris cast of the foot, are the
+best. In making a shoe, consideration should be given to
+other deformities, such as flat foot, metatarsalgia, etc., and
+means for correcting these ailments should be taken.</p>
+
+<p>The stocking should be large enough to prevent pressure
+on either lateral side of the foot. There are stockings
+on the market which are cut for each foot and are known
+as right and left stockings. These are very desirable, as
+they prevent distortion of the toes, which is often produced
+<span class="pagenum" id="Page_157">[Pg 157]</span>by the regular stocking cut to a point at the third toe. The
+material is of little consequence, except that wool or cotton
+absorbs moisture excreted by the glands better than silk.</p>
+
+<p><b>Palliative treatment</b> includes the application of palliative
+agents, among which silver nitrate and salicylic acid
+are most serviceable. These remedies cause desiccation and
+shrinkage of the horny growth, which is thus made to shell
+out from the bed in which it lies. This method of treating
+an heloma durum is long and tedious, as many applications
+of the drugs are required to obtain a result. Great care
+must be exercised to prevent the applications from touching
+the surrounding normal skin. The virtue of so-called
+corn cures, which are very plentiful and are given artistic
+names, all depend upon some drug or chemical, chief among
+which is salicylic acid. The danger to the layman is readily
+seen, for when these agents are applied carelessly or in
+large quantities, the action is too severe, and ulceration and
+infection is the result.</p>
+
+<p>When the practitioner finds it necessary to resort to
+palliative measures in the treatment of an heloma durum
+the following procedure is advised: the tissues surrounding
+the horny growth are protected by painting with several
+layers of collodion or glycerine jelly (Unna). A piece of
+salicylic acid plaster is cut to the size of the heloma and
+placed over it and a proper protection applied. Or, a shield
+can be fitted around the part and in the aperture is placed
+a 25% salicylic ointment, and the entire dressing is covered
+with adhesive plaster. This dressing is allowed to remain
+in contact with the part for two or three days, when the
+dressing is removed and the white, macerated tissues are
+scraped or cut away. The treatment is again applied and
+repeated as often as necessary. (See chapter, <i>Shields and
+Shielding</i>.)</p>
+
+<p><b>Operative treatment</b> may be divided into two classes,
+the radical and the non-radical. The <i>radical</i> method is painful,
+but with the use of local anesthetics, good results are
+obtained without discomfort to the patient. Alypin, 1 : 2%,
+<span class="pagenum" id="Page_158">[Pg 158]</span>quinine and urea hydrochloride, 2%, or novocaine, 1% (the
+latter being preferred by the writer) may be used to produce
+local anesthesia&#x2060;<a id="FNanchor_5_5" href="#Footnote_5_5" class="fnanchor">[5]</a>&#x2060;. The parts are thoroughly cleansed
+and made aseptic by washing with the tincture of green
+soap, followed by alcohol, 60%, and finally painting the
+entire surface, including the surrounding parts with tincture
+of iodine. The hypodermic needle and syringe and all the
+instruments to be used in the operation are boiled in water
+for at least ten minutes. A spot is selected for the injection
+of the anesthetic, and ethyl chloride is sprayed on it,
+to make the primary injection of the needle painless. The
+needle is forced into the derma and pressure brought to bear
+on the piston of the syringe, as it moves forward into the
+tissues. By following the wheal thus produced, the entire
+area surrounding the heloma can be anesthetized.</p>
+
+<p>When the anesthesia is complete, two semi-elliptic incisions,
+meeting at their extremities, are made through the
+skin, care being taken that they penetrate the subcutaneous
+tissue. These incisions should completely envelop the
+growth. The tissues between the incisions are seized with
+an artery forceps, and the entire wedge, including the derma
+and subcutaneous tissue, is dissected out. This produces
+free oozing, and it may be necessary to twist a small vessel.
+Hemorrhage is never severe. The edges of the wound are
+brought together (apposition should be perfect) by one or
+two fine sutures and primary union takes place in a few
+days, or, if the wound is not large, the part may be dressed
+and allowed to heal by granulation. Subsequent dressings
+should include shields for the prevention of friction or
+pressure.</p>
+
+<p>Dr. Robert T. Morris, of New York City, recommends
+skin grafting with this operation, in order to prevent the
+formation of scar tissue, a very desirable consideration.
+After the tissue has been dissected out, some skin is taken
+from the fleshy part of the leg and is attached over the
+wound. This eliminates drawing the edges of the wound together,
+which procedure often causes harmful after-effects.</p>
+
+<p><span class="pagenum" id="Page_159">[Pg 159]</span></p>
+
+<p>The <i>non-radical operative</i> treatment of heloma durum
+is the most popular and practical method employed by
+chiropodists today. The growth is removed down to the
+true skin, care being taken that this layer is not punctured
+and bleeding thus produced.</p>
+
+<p>There are two general methods of procedure for the
+surgical treatment of callositas and helomata in vogue today.
+These are known as the paring or shaving method
+and the dissection or excision method. This nomenclature
+is derived from the operations themselves.</p>
+
+<p>As the term implies, the paring method consists of removing
+the callouses with the chisel, knife or scalpel by
+shaving away the growth with a series of knife strokes or
+cuts, and the subsequent removal of the cone body or radix
+with the point of the same or a similar instrument.</p>
+
+<p><b>Technic of the Shaving Method.</b> The part is thoroughly
+cleansed with a standard antiseptic, such as phenol, 5%,
+lysol, 1%, or cresol, 1%, and this is followed by alcohol,
+60%, which is allowed to remain in contact with the heloma
+for a few minutes. The instrument employed should be
+sterilized by boiling in water for at least fifteen minutes or
+by placing it in phenol, 95%, until the liquid clings to the
+blade, followed by alcohol, 95%.</p>
+
+<p>After thorough asepsis has been obtained, the tissues
+adjoining the area to be removed are held firmly between
+the thumb and index finger of the left hand and the knife
+is grasped firmly with the fingers of the right hand.</p>
+
+<p>By holding the tissues of the part firmly so that they
+may not move, the pain to the patient and the danger of
+invading the vascular tissues is minimized. A knife, no
+matter how sharp, is bound to pull the tissues overlying a
+tender and inflamed part unless these tissues are in some
+way prevented from moving.</p>
+
+<p>After the overlying callouses have been thoroughly
+pared away, and the part is found to be soft and flexible,
+the nuclei are removed. In removing these hard bodies the
+operator who shaves or pares, practically becomes a dissector.
+<span class="pagenum" id="Page_160">[Pg 160]</span>With a sharp pointed knife the heloma is loosened
+from the surrounding soft parts until entirely freed, when
+it is lifted out. Should there be two or more helomata under
+one callous, the same procedure is adopted for each individual
+growth until all are removed and the whole area is
+found flexible.</p>
+
+<p>The stroke of the knife in the shaving method is usually
+toward the operator, his fingers and thumbs being so
+arranged as to limit the distance which the blade may travel
+and so prevent cutting the patient or himself.</p>
+
+<p>In shaving an heloma on the dorsum of the intermediate
+toes, the index finger of the left hand is placed anterior
+to the hardened area and the thumb, posterior. The knife
+is then held as a penholder and the strokes are made toward
+the operator, the toe being moved or rotated to bring all
+the surfaces of the growth under the blade of the knife.</p>
+
+<p>On the plantar surface the operator, at times, is forced
+to work away from himself, but in most cases the blade is
+directed toward himself.</p>
+
+<p>For operating on helomata between the toes, the knife
+is held as a penholder and the blade is directed toward the
+toe or web. Many of the practitioners who “shave” use
+a distinct dissection method for the removal of helomata
+in this location. They employ what is known as a “spoon”—a
+shallow flattened curette—and starting from the outer
+edge of the calloused area, work under the hardened layers
+until the entire growth is loosened, whereupon it is deftly
+removed.</p>
+
+<p>The stroke of the chisel in the shaving method is usually
+away from the operator. This is in contradistinction
+to the stroke of the knife or scalpel. When operating on the
+dorsum of the toes, however, most operators using the chisel
+direct the blade toward themselves, unless, as is common,
+the operator moves around in front of the patient, when
+the cutting is done away from the operator.</p>
+
+<p><b>Technic of the Dissection Method.</b> One of the oldest,
+yet one of the most popular methods of operation is that
+<span class="pagenum" id="Page_161">[Pg 161]</span>known as dissection. As will be understood by the term,
+this method is a procedure whereby the growth is excised
+by the helotomon, as a whole, from the underlying tissues.
+This is in contradistinction to the paring or shaving
+method.</p>
+
+<p>Two of the best known practitioners who use this
+method of procedure are E. C. Rice, M.D., of Washington,
+D. C., and Charles F. Stevens, of Elmira, N. Y. Dr. E. C.
+Rice has this to say on the subject:</p>
+
+<p>“The limited knowledge of the chiropodists of earlier
+years did not apply to their handling of instruments, which
+was professionally scientific to the highest degree. The dissecting
+method was the method of operating in the early
+days.</p>
+
+<p>“In the late fifties a practitioner by the name of Josiah
+Briggs taught many young men, among them Elliott W.
+Johnson, and the writer’s father, W. E. Rice. A Scotchman
+also instructed Nehemiah Kenison. They in turn
+taught others the dissection method. There will always be
+two professional methods of operating on helomata, the
+shaving (exfoliating) and the dissecting (excision) methods,
+and practitioners should understand both.</p>
+
+<p>“Those who have a light touch, if determined to learn,
+can become skillful in the art of dissecting, and, when acquired,
+their life’s work will become a daily fascination.
+The procedure calls for skill that compares with that employed
+by the eye, nose and throat specialists and is appreciated
+by the most eminent surgeons.</p>
+
+<p>“The word ‘dissect’ implies a separation, and this
+method permits the operator to separate the heloma from
+the normal tissue in one piece so that classification is made
+simple. In removing the growth in its entirety, it is possible
+to observe the various forms the nuclei take, and
+the classification the writer would make is as follows:
+granular, grain-like in appearance, sometimes called ‘surface
+corn’; crescent, forming a semi-circle about the joint;
+wedge, having a wedge-shaped nucleus, commonly found on
+<span class="pagenum" id="Page_162">[Pg 162]</span>the plantar surface; cone, from its shape; thumb tack, also
+named from its shape; multiple nuclei, resembling any of
+the above named and having numerous central points; soft,
+the gristly tissue between the toes; elevated, protruding,
+horn shaped; circular, because of the form of the nucleus.</p>
+
+<p>“The instruments used in this method of operating are
+the chisel (helotomon—Dr. F. Oefele, editor,) and the iris
+mouse-toothed forceps.</p>
+
+<p>“The original chiropodist’s instrument in this country
+was a cross between the surgeon’s scalpel and a chisel. The
+blade was shaped much like the human foot and was on a
+handle such as is used on the standard razor. From this
+first instrument of chiropody was evolved the only distinctive
+instrument of our profession, the chisel, which has been
+successfully used for more than half a century.</p>
+
+<p>“It is distinctly a chiropodist’s instrument, as much
+as the plane is the tool of the carpenter. With this chisel
+the dissecting method is made possible, for its cutting edge,
+as its name suggests, is on the end of the instrument, and
+permits of the most delicate work. The chisel should be five
+and one-half inches long and should have a rough hexagon
+handle. The round or oval handles do not permit perfect
+finger control. The blade or cutting edge may be oblique,
+straight or oval, as the operator desires.</p>
+
+<p>“The technic of the dissecting method of operating is
+as follows:</p>
+
+<p>“The chisel is held in the right hand and the forceps
+in the left. Hold each as you would a correctly held penholder;
+to support and to steady the hands, let them rest
+gently on the fourth and fifth fingers; when operating between
+the toes, the supporting fingers rest upon and press
+aside the toes so as to give plenty of room for operating.</p>
+
+<p>“The tissues at the periphery of the heloma are separated;
+with the forceps grasp the free edge and raise sufficiently
+to see the line of demarcation and use enough traction
+on the forceps to overcome the pressure of the chisel,
+not enough, however, to produce the sensation of pulling.</p>
+
+<p><span class="pagenum" id="Page_163">[Pg 163]</span></p>
+
+<p>“When properly performed, the gentle lifting of the
+tissue prevents the nerve being pressed upon or pinched between
+the blade of the instrument and the underlying bone.
+The line of demarcation is made by the union of the light
+and dark shades of tissue, the normal being the light and
+the darker shade belonging to the heloma.</p>
+
+<figure class="figcenter illowe18" id="i_p163">
+  <img class="w100" src="images/i_p163.jpg" alt="">
+  <figcaption>
+    ILLUSTRATING METHOD OF SPREADING
+    TOES APART BY USING FOURTH
+    FINGER OF EACH HAND, MAKING
+    OPERATION EASY
+  </figcaption>
+</figure>
+
+<p>“Those who use the
+oval chisel find they can
+do more work and have
+fewer hemorrhages,
+and only occasionally
+do they find it necessary
+to use the nucleus
+dissector, which is required
+to remove an
+heloma of the thumb
+tack variety, as its
+shaft may extend to a
+depth of a fourth or a
+third of an inch. In dissecting
+this type of
+heloma, when the head
+of the same has been
+separated back to its
+shaft, the traction on
+the forceps is increased, the tissue being gently lifted and
+turned back. This tends to present the shaft toward the
+blade, and as cutting proceeds the shaft seems to be lifted
+up and out of the soft tissue into which it is embedded.</p>
+
+<p>“To beginners, the writer would suggest the oval-shaped
+chisel and would advise practising first on the plantar
+surface.”</p>
+
+<p>C. F. Stevens contributes the following:</p>
+
+<p>“Speaking generally and taking the average heloma as
+an example, my method of procedure would be somewhat as
+follows:</p>
+
+<p>“These growths are hardly ever deep, and are removed
+<span class="pagenum" id="Page_164">[Pg 164]</span>by the following process more easily than to chisel or pare.
+After the usual antiseptic precautions as to the operator’s
+hands, instruments and the patient’s foot have been taken,
+the operator grasps a sharp, pointed, slim instrument.</p>
+
+<p>“Holding this knife with the right hand and with a
+small forceps in the left, he grasps the free part of the
+growth with the forceps,
+carefully raising
+this part to determine
+if possible how much is
+free and how much is
+attached to the deeper
+tissues.</p>
+
+<figure class="figcenter illowe18" id="i_p164">
+  <img class="w100" src="images/i_p164.jpg" alt="">
+  <figcaption>
+    PROPER USE OF FINGERS ELIMINATES
+    NECESSITY OF TOE SPREADERS
+  </figcaption>
+</figure>
+
+<p>“With a sharp blade
+he makes a series of
+slight strokes, cutting
+but little at a time, on
+a line between the
+growth and the skin
+(the growth being darker
+than the skin), thus
+separating the excess
+deposit of horny cuticle
+from the skin, following every curve, deep part or point,
+until all is separated in the one mass. In this manner he
+is enabled to remove all in one piece. Dressings vary,
+according to the prominence of the part and the shoe worn.</p>
+
+<p>“Since the writer was taught this method of procedure
+he has found it to be much easier to separate such a horny
+growth from its bed, than to try to pare it off in bits or
+shave it as the patient himself tries to do. Helomata being
+hard, very naturally resist the cutting of a knife, and the
+blade, therefore, when trying to pierce the hard mass, pulls
+on the sensitive tissues beneath, thus causing pain. Following
+the line between the normal and the abnormal tissues
+in operating, much softer integument is encountered;
+therefore, the cutting is easier and can be done with practically
+no pain.</p>
+
+<p><span class="pagenum" id="Page_165">[Pg 165]</span></p>
+
+<p>“The cautious, careful operator will seldom invade the
+healthy tissues beneath sufficiently to cause capillary hemorrhage.
+A paring or shaving process could, of course, first
+be employed to remove the indurated callous, then proceed
+to carefully separate the deep parts as described in the
+case of heloma. Simply raising gently with the thumb forceps
+and cutting a very little at each stroke with a sharp
+pointed blade, following each wave or indentation indicated,
+as the work progresses, until each piece or mass is
+separated and removed, will be found a preferable procedure.
+However, we have found it as simple and easy to
+dissect the mass as a whole as to operate by paring and
+then removing the deeper parts.</p>
+
+<p>“In case of a deep-seated hard corn where the toe is
+red, inflamed and very sensitive, the first described method
+(as in heloma) is usually best. Often upon reaching the
+lowermost layers, one finds a quantity of pus. When this
+escapes, as it does, the pressure on the inflamed tissues is
+lessened, and the patient will allow the operator to proceed
+faster.</p>
+
+<p>“With a deep-seated heloma on the sole of the foot,
+the same method is followed, no matter how deep or serrated.
+The operator (after one or two small cuts) gently
+raises the edge with the forceps, while with the same style
+of blade he cuts down and around the growth, until the
+whole piece with its radix is lifted out.</p>
+
+<p>“In connection with this the writer hears some one say,
+‘even though you do remove the growth scientifically and
+without pain, severe pain will follow in an attempt to walk.’</p>
+
+<p>“Of course, comfort depends in many instances on the
+dressing. The writer is not a great believer in heavy shielding
+and the method of dressing he employs is as follows:
+take a pledget of cotton which, when rolled, is about as large
+as the heloma just removed; place thereon a small amount
+of sedative in ointment form; place this in the cavity left
+by the removal of the growth, then cover all with a goodly
+sized piece of adhesive plaster. Instruct the patient to
+<span class="pagenum" id="Page_166">[Pg 166]</span>wear this for twenty-four hours, when he may remove the
+plaster. By this dressing the tissues that had been held up
+by the large heloma, are still held up by the rolled pledget of
+cotton, at the same time the cotton gradually flattens down
+with the patient’s weight. Thus the tissues are allowed to
+resume their normal position slowly and easily.</p>
+
+<p>“When the adhesive plaster is removed, the cotton
+dressing comes with it. The tissues adjust themselves in
+from twelve to twenty hours and thus an equilibrium is painlessly
+established.</p>
+
+<p>“Several years ago the writer chanced on to this
+method of dressing and since then he has used it and found
+it to be very efficacious in a large majority of cases; he
+has termed it the ‘filling dressing.’</p>
+
+<p>“In operations on heloma molle the same surgical procedure
+is employed. It matters not whether the growth be
+on the side of the toe, or deep down between the toes on the
+web. The sharp, fine-pointed, narrow blade enables one to
+operate in a closely contracted space, and when used with
+short little cuts the blade reaches down, around and under
+the growth, thus loosening it completely and leaving its
+usually deep seat, clear and free from any parts which
+might remain, if chiseling or gouging were employed.”</p>
+
+<p>(The authors of this work all operate with the knife
+or scalpel and have found that form of instrument very satisfactory.
+The beginner is advised to study and learn both
+methods so that he may be able to use both at any time. The
+fact that there are two methods does not mean that one is
+better than the other. There are many successful practitioners
+of both classes.)</p>
+
+<p>Some persons have a great amount of dorsi-flexion of
+the toes, due to hammer toe or hallux flexus, and they usually
+develop an heloma on the distal end of the toe, under
+the nail. This is treated by cutting away the nail over the
+growth, and when the heloma is exposed to view it is treated
+in the same way as other helomata dura.</p>
+
+<p>The subsequent dressings for helomata depend upon
+<span class="pagenum" id="Page_167">[Pg 167]</span>the state of the tissues beneath. Care should be exercised
+in operating so as not to cut too close to the normal skin,
+otherwise the parts become extremely sensitive.</p>
+
+<p>The epidermis is a storehouse for bacteria, and when
+an heloma is removed, there is always a possibility that
+some of these bacteria may enter the body through some
+slight and invisible abrasion which does not necessarily
+bleed. It is, therefore, necessary to take precautions against
+this danger, and this is best done by painting all surfaces
+operated upon with a 4% solution of tincture of iodine (this
+may be made by diluting the official tincture with an equal
+amount of grain alcohol). This should be followed by
+painting these same surfaces with icthyolated collodion or
+nafalan collodion.</p>
+
+<p>If the toe is inflamed it is treated with an agent that
+has the power to reduce inflammation. In severe inflammations,
+a wet dressing of Burow’s solution may be used
+to good advantage. The principal ingredient of this solution
+is aluminum acetate, which is astringent in its action,
+and a wet dressing applied for twenty-four hours will usually
+reduce the condition. In milder cases of inflammation,
+ointments of ichthyol, 10 or 15%, may be applied. This
+means of medication is very desirable whenever the application
+of a shield is indicated, because the aperture of the
+shield is a suitable place for ointment dressings.</p>
+
+<p>When an heloma is found to be infected, the growth
+should be removed and the pus present evacuated. This
+should be followed by the application of hydrogen peroxide
+and the parts should then be irrigated with bichloride of
+mercury solution (¹⁄₄₀₀₀). The wound may now be treated
+with a wet dressing of Burow’s solution or, in severe cases
+in which there is an indication of the presence of cellulitis,
+bichloride of mercury solution (¹⁄₅₀₀₀) for twenty-four to
+forty-eight hours, should be similarly applied.</p>
+
+<p>Subsequent dressings to stimulate granulation and promote
+healing may be applied, balsam of Peru or silver nitrate
+ointment or colloidal iodine being very efficacious.</p>
+
+<p><span class="pagenum" id="Page_168">[Pg 168]</span></p>
+
+<p>The latest medication for infected areas, either great or
+small, and one of the many discoveries in surgical treatment
+since the beginning of the present war, is the Dakin
+solution. The worth of the application of this solution is
+based upon the helpful influence of free chlorine in small
+quantities, to tissues that have been mutilated either by
+injury or infection.
+Chlorazene tablets,
+purchasable in all
+drug stores, contain
+the elements desired
+for this treatment.
+Liquid chlorine ampules
+(J &amp; J) also
+make an accurate Dakin
+solution.</p>
+
+<figure class="figcenter illowe24" id="i_p168">
+  <img class="w100" src="images/i_p168.jpg" alt="">
+  <figcaption>
+    INFECTED HELOMA
+  </figcaption>
+</figure>
+
+<p>If, upon examination,
+an infection
+shows that the deeper
+tissues, such as the
+periosteum or the
+bone, are involved,
+the patient should be
+sent to the surgeon,
+whose function it is
+to treat such cases,
+who will make incisions
+into the soft
+tissues so as to establish
+free drainage.
+The wound thus produced is packed with sterile gauze, and
+often with the aid of wet dressings, and nothing more, the
+wound is allowed to drain and heal.</p>
+
+<p>The protection of the parts after an heloma has been
+removed, so as to insure comfort to the patient, is an all important
+part of the treatment of this ailment and a special
+chapter has been devoted to this feature of chiropody practice.
+<span class="pagenum" id="Page_169">[Pg 169]</span>(See Chapter <i>Shields and Shielding</i>.) There are certain
+types of helomata dura that are never relieved of pain,
+even after operation, unless a well-fitted shield has been
+applied.</p>
+
+
+<h3 id="HELOMA_MOLLE">
+  HELOMA MOLLE
+</h3>
+
+<p><b>Definition.</b> Heloma molle is a soft, white, macerated
+growth found between the toes, principally in the web of
+the fourth interosseous space and on the lateral sides of the
+interphalangeal joints of the toes.</p>
+
+<p><b>Symptoms.</b> The pain accompanying heloma molle
+varies with the degree of pressure brought to bear upon
+the toes. Where the heloma is situated in the web of the
+fourth and fifth toes, there is a sensation as if there were
+some foreign body, such as a pebble, between the toes, and
+as the growth develops the pain becomes gradually worse.
+The pain of an heloma molle, in other parts, is similar to
+the pain of heloma durum, and usually ceases when the foot
+is not encased in a shoe.</p>
+
+<p>Upon examination, an heloma molle presents a white
+soft mass, having the consistency of rubber. There is no
+sharp line of demarcation between the lesion and the healthy
+skin. This is due to the blanching of all the tissues that
+come in contact with the excretions. In some instances there
+is a yellow ridge surrounding the neoplasm. The growth
+is superficial, due to its anatomic position. There is very
+little soft tissue between the epidermis and the lateral sides
+of the extremities of the phalanges, and therefore there is
+no possibility of the growth becoming deep-seated, as in
+heloma durum. The radix, or nucleus, when present, is of
+a dirty white color.</p>
+
+<p>Helomata mollia found in the web of the fourth and
+fifth toes, have well defined nuclei which penetrate into
+the interosseous space between the metatarsal bones.
+These are easily distinguished since, as the surrounding
+callous is removed, they appear as a dirty white spot in an
+area of healthy pink skin.</p>
+
+<p><span class="pagenum" id="Page_170">[Pg 170]</span></p>
+
+<p><b>Etiology.</b> Helomata mollia are caused by shoes, the
+same as other types of helomata, but in this case the footgear
+acts as a secondary cause. Normally the phalanges
+are placed so that the base of one bone is opposite the head
+of another. When lateral pressure is brought to bear upon
+the toes, these bones press upon each other and thus produce
+an overgrowth of skin cells.</p>
+
+<p>The sweat glands continue to functionate, but the parts
+being pressed together, do not allow the perspiration to
+evaporate; hence, there is an accumulation of moisture
+which acts upon the skin, producing a soft, white, macerated
+mass, with a rubber-like texture.</p>
+
+<p>In the case of helomata mollia found in the web of the
+fourth and fifth toes, there is an outward rotation of the
+head of the fourth metatarsal bone, due to the lateral pressure
+on this region, causing the bone to drop and rotate
+outward; this in turn presses upon the base of the fifth
+proximal phalanx.</p>
+
+<p><b>Pathology.</b> The pathology of heloma molle is identical
+with that of heloma durum, except that the nucleus is rarely
+deep-seated. The epidermis composing heloma molle has no
+distinct cell formation, because of the macerated condition
+of the mass, but occasionally the nucleus of such a lesion,
+found in the web of the fourth and fifth toes, shows some
+of the original cell formation. Inflammation, terminating
+in suppuration, is very often encountered in this condition.
+Because of uncleanliness of the parts, bacteria thrive in this
+locality and the acidity of the moisture very often produces
+a fissure or abrasion in the tissues which may lead to infection
+and subsequent suppuration.</p>
+
+<p><b>Diagnosis.</b> The typical heloma molle is a mass of epidermic
+cells rarely larger than half the size of a dime.
+The color is white, with a dark grey centre, denoting the
+radix.</p>
+
+<p>Very often an ordinary exfoliation of the epidermis
+between the toes may take on the appearance of an heloma
+molle, but careful examination will show that there is no
+<span class="pagenum" id="Page_171">[Pg 171]</span>overgrowth of epidermis. This exfoliation is easily loosened
+with a pair of forceps.</p>
+
+<p>Fissured toe webs, accompanied by exudation and exfoliation
+of skin, may be mistaken for heloma molle, and
+treatment inaugurated for the latter condition will produce
+bad results, particularly if chemicals are used.</p>
+
+<p>There need be no
+doubt about making a
+positive diagnosis if
+the color and texture of
+the growth be borne in
+mind. The finger passed
+over the affected surface
+will give the sensation
+of increased tissue.</p>
+
+<figure class="figcenter illowe18" id="i_p171">
+  <img class="w100" src="images/i_p171.jpg" alt="">
+  <figcaption>
+    HELOMA MOLLE
+  </figcaption>
+</figure>
+
+<p><b>Prognosis.</b> The possibilities
+of the ultimate
+disappearance of helomata
+mollia is good. If
+the proper shoes are
+worn and the proper
+treatment be installed,
+the growths will gradually
+become smaller and
+will finally disappear.</p>
+
+<p>The helomata that appear
+between the toes
+on the interphalangeal
+joints are most easily
+cured, by simply keeping
+the adjacent sides of the toes separated. Those that
+appear on the outer lateral side of the great toe do not
+respond to treatment as readily as the other types, for
+there is more soft tissue over this joint and usually the great
+toe is in a fixed position and does not easily straighten.</p>
+
+<p>Helomata mollia that appear in the web of the fourth
+and fifth toes can also be permanently cured, but it is necessary
+<span class="pagenum" id="Page_172">[Pg 172]</span>to raise the head of the offending metatarsal bone, as
+well as to separate the toes.</p>
+
+<p>Bearing in mind the etiology of heloma molle, and installing
+treatment which will correct or remove these
+causes, time and conscientious treatment will ordinarily insure
+a favorable outcome.</p>
+
+<p><b>Treatment.</b> Treatment of helomata mollia is divided
+into two classes: the non-radical surgical and the therapeutic.
+The latter method is the most popular, as it is very often
+impossible to use the knife. The texture of the skin, and the
+anatomic position of the growth often make it impossible
+to use an instrument with a cutting edge with a view to obtaining
+good results.</p>
+
+<p>The <i>non-radical surgical</i> method consists of removing
+the corn in much the same way that an heloma durum is
+removed. The long cutting edges of knives and chisels are
+not well adapted for work between the toes, and for this
+purpose the “golf stick” and the “soft corn spoon” have
+been devised and are used extensively. The “golf stick”
+is an instrument which, as its name indicates, resembles the
+stick used by the golfer. Its cutting edge is almost at right
+angles to the handle and is about three-eighths of an inch
+long. This makes a very desirable instrument for removing
+helomata mollia on the lateral sides of the interphalangeal
+joints. The end of the instrument is rounded so as
+to allow for the removal of nuclei, if present. The cutting
+edge of the “soft corn spoon” extends almost around the
+entire instrument, and admits of a circular movement such
+as is employed in dissecting helomata dura. This instrument
+is used for removing soft corns that appear in the
+web of the toes, and is very efficient, inasmuch as by its use
+the operator is enabled to remove the growth without cutting
+into the tissues, as is often done with a knife or a chisel
+having a long straight edge.</p>
+
+<p>The <i>therapeutic</i> method of treating heloma molle depends
+upon the caustic action of several drugs, among which
+may be mentioned salicylic acid, trichloracetic acid and
+<span class="pagenum" id="Page_173">[Pg 173]</span>silver nitrate. The two latter are used only occasionally, as
+they are powerful caustics, and unless applied with great
+caution they may produce harmful results.</p>
+
+<p>Salicylic acid finds great favor among practitioners of
+podiatry, and the usual technic is as follows: after asepsis
+has been practised and the growth cannot be removed by
+the use of the knife, an ointment of salicylic acid, 15%, is
+applied over the growth, care being taken that the medication
+does not come in contact with the surrounding normal
+tissues. This is covered with a protective cocoon dressing,
+or the ointment may be applied into the aperture of the
+shield, if one is used. The dressing is allowed to remain in
+contact with the part for from four to seven days, depending
+upon the thickness of the skin. When the dressing is
+removed, the entire mass will be found, as a rule, to be
+loosened from the tissues beneath. If all of the growth is
+not thus loosed, the treatment is repeated and the patient is
+instructed to return in the prescribed length of time.</p>
+
+<p>Shielding plays an important part in the treatment of
+heloma molle. For the type that forms on the lateral sides
+of the interphalangeal joints, a shield of the oval type with
+the aperture over the affected part, is most efficient, while
+for those that appear in the web of the toes, an oval shield
+with a semi-circular opening on the proximal end, which sets
+between the toes and protects the growth, is most desirable.
+In connection with a shield to protect the growth and separate
+the toes, it is necessary to raise the head of the affected
+metatarsal bone, which is the cause of this type of heloma
+molle. For this purpose, Alfred Ahrens, of New York City,
+has devised a dressing which he terms the “duck shield,”
+because of its resemblance to that animal. This shield
+has a dual function. It separates the toes and then passes
+down to the plantar surface of the foot over the metatarsal
+bone, and acts as a pad to raise the bone. The continuous
+application of this device to helomata mollia of this variety
+will produce good results.</p>
+
+<p><span class="pagenum" id="Page_174">[Pg 174]</span></p>
+
+
+<h3 id="HELOMA_VASCULARE">
+  HELOMA VASCULARE
+</h3>
+
+<p><b>Definition.</b> Heloma vasculare, or vascular corn, is an
+overgrowth of the epidermis in which enlarged and elongated
+blood vessels are found.</p>
+
+<p><b>Symptoms.</b> The growths usually appear on the plantar
+surface of the foot, but occasionally they may develop in
+old callouses and helomata situated on the dorsal surface
+of the fifth toe. Pain is more severe than in other forms of
+helomata, the patient complaining of a burning sensation
+when not in a standing position. This form of growth is
+similar in appearance to heloma durum, having in addition
+small dark red spots scattered throughout it, which
+bleed upon being cut. These spots are not blood clots, such
+as are found in helomata dura as the result of injury, but
+are distinct blood vessels. The composition of the tissues
+is very dense, particularly when the growth is situated over
+the head of a bone, as is ordinarily the case when it appears
+on the plantar surface. The color of the entire mass
+is somewhat darker than in heloma durum, being grayish,
+or sometimes brownish, in appearance.</p>
+
+<p><b>Etiology.</b> As previously stated, helomata of all types
+are due to intermittent friction and pressure. The blood
+vessels that are found in this particular form are forced
+into the epidermis owing to lateral pressure of the shoes,
+or to the pinching of tight stockings. Why the blood vessels
+should be forced up into the epidermis is most peculiar, but
+helomata vasculare appear where the normal papillæ are
+longest, and this increased length of the vessels tends to
+force them up into the dead skin. Athletes, particularly
+runners and jumpers, are most commonly afflicted.</p>
+
+<p><b>Pathology.</b> Heloma vasculare consists of an overgrowth
+of epidermic cells in which are found the elongated
+vessels. There is an increase in epithelial tissue, but there
+is no increase in the quantity of the connective tissue and
+blood vessels, as in verruca. The blood vessels leave the
+papillary layer of the derma and enter directly into the
+epidermis, without any elevation of the surrounding connective
+<span class="pagenum" id="Page_175">[Pg 175]</span>tissue. On some occasions a nerve ending is found
+embedded in the callous mass. This adds considerably to
+the pain, but is not the true neuro-fibrous corn described
+under heloma durum, which has no accompanying blood
+vessels. The area surrounding an heloma vasculare is usually
+inflamed, but the inflammation rarely terminates in suppuration.</p>
+
+<p><b>Diagnosis.</b> The true heloma vasculare may be easily
+distinguished from verruca when the two conditions appear
+on the dorsal surface or any surface not subjected to extreme
+pressure, in that the latter is an overgrowth of all
+the layers of the skin, including the derma, and has a characteristic
+cauliflower appearance. However, when verrucæ
+appear on the plantar surface, they lose their cauliflower
+appearance and become flattened; they then resemble heloma
+vasculare, except that they are somewhat darker.</p>
+
+<p>The blood vessels in heloma vasculare are not so numerous
+as in verruca, but this diagnostic point may not
+always manifest itself to the naked eye. A differential diagnosis
+between these two conditions is of no great importance,
+as the treatment is practically identical.</p>
+
+<p>Heloma vasculare may be readily distinguished from
+heloma durum by the small red spots found therein which
+bleed when cut. Very often an heloma durum has a dark
+red spot at the base of the mass, due to the rupture of a
+small vessel and consequent clotting of the blood. This
+dark red spot does not bleed when the knife is passed
+through it, denoting the absence of blood vessels.</p>
+
+<p><b>Prognosis.</b> Heloma vasculare will always respond
+when the treatment is thorough. There may be a recurrence
+of heloma durum over the spot where the original growth
+was located, but the vascular condition, when once eradicated,
+should not return.</p>
+
+<p><b>Treatment.</b> The treatment of heloma vasculare may be
+divided into three classes, viz.: surgical, medicinal and mechanical.</p>
+
+<p>The technic of the <i>surgical</i> method is as follows: the
+<span class="pagenum" id="Page_176">[Pg 176]</span>part is cleansed with tincture of green soap, followed by
+the application of tincture of iodine, 4%. The instruments
+having been sterilized, the part is anesthetized by the hypodermic
+method and a semi-elliptic incision is made a little
+to the outside of one-half the growth. The flap thus produced
+is seized with an artery forceps. The forceps are
+then raised and the rest of the growth is dissected out with
+a sharp knife or with a heavy pointed scissors. When the
+entire growth has thus been eradicated, a few layers of
+gauze should be placed over the part to produce pressure.
+A bandage should be applied over all to hold the dressing in
+place. This may be removed in three or four days, provided
+no inflammation is present, and the subsequent dressing
+should contain balsam of Peru or some other stimulant.</p>
+
+<p>The <i>medicinal</i> or <i>chemical</i> treatment of heloma vasculare
+consists of the gradual destruction of the growth by
+means of chemicals, chief among which are nitric acid, potassium
+hydroxide and salicylic acid. If nitric acid is employed,
+the callous is removed so as to produce a slight
+oozing of blood, and a drop of the acid is allowed to fall
+in the centre of the mass. This is allowed to remain in
+contact with the part for two days, when the eschar produced
+is removed, and the acid is again applied. This
+treatment is continued as long as necessary to completely
+destroy the growth; when a slight exudation of pus is
+noticed, the application of the acid should cease. The subsequent
+ulcer thus produced is treated in the same manner
+as any other ulcer (see chapter <i>Ulcers</i>).</p>
+
+<p>The salicylic acid method of treating heloma vasculare
+varies greatly depending upon the strength of
+the acid employed. If a weaker percentage is used,
+the treatment is practically the same as that with
+nitric acid. Several applications are necessary to
+completely remove the entire excrescence. The weaker
+solutions of this drug are the 10 to 15% ointments.
+The stronger ointments contain from 50 to 60% of the acid.
+The treatment with the 60% salicylic acid is preceded by
+<span class="pagenum" id="Page_177">[Pg 177]</span>cleansing the parts and removing the superfluous callous.
+The acid is then applied and the part protected. The dressing
+is allowed to remain in contact with the part for from
+ten days to two weeks, and when removed, the entire mass
+may be easily scooped out. When the stronger acid is used,
+it is often necessary to warn the patient that if there should
+be any throbbing pain experienced, he must return for
+treatment at once. This pain is due to the rapid action of
+the drug, and to a mechanical inflammation which ensues.
+Examination will usually reveal a newly formed ulcer,
+which must be cleansed and treated in the usual manner.
+The salicylic ointment method is finding great favor, particularly
+on account of the few treatments necessary. Those
+inclined to nervousness and imaginary fears, regarding
+chiropodical or any other operations, are also usually highly
+pleased with this non-surgical method of treatment because
+the use of the knife is avoided and cure is not long delayed.</p>
+
+<p>In treating these cases medically, it is well to remember
+that the chemicals employed have a destructive action on
+the healthy tissue beneath the heloma as well as upon the
+heloma itself, and caution should be exercised in applying
+them. The case should be carefully watched and at no
+time should the operator allow the patient to remain away
+from the office for a greater length of time than above specified.
+It is also well to remember to warn the patient of
+the dull throbbing so characteristic of inflammation,
+which gradually increases as the pains become worse. These
+pains are due to a chemic inflammation produced by the
+action of the drug upon the normal tissue beneath the
+growth, and are always an indication to discontinue treatment,
+remove what is left of the destroyed tissue, and direct
+treatment to the healing of the parts.</p>
+
+<p>The <i>mechanical</i> treatment of heloma vasculare consists
+of the removal of the growth by means of electricity. The
+fulguration spark and electrolysis are the two methods
+employed.</p>
+
+<p>The fulguration spark is a concentrated violet ray, or
+<span class="pagenum" id="Page_178">[Pg 178]</span>high frequency current. The current is concentrated by
+passing it from the coil through a narrow glass electrode, at
+the far end of which is inserted a small piece of platinum
+or copper wire. As the current passes through the tube and
+the charged wire is brought in apposition to the excrescence,
+instead of the usual blue spark that is produced by the high
+frequency current in an ordinary vacuum electrode, there
+is a yellow spark produced which is quite painful to the
+body tissues. This spark has a caustic action, and after
+penetrating the superficial layers it enters into the deeper
+structures and there causes a destruction of the tissues.</p>
+
+<p>Two, or at the most three, applications of this current,
+each of thirty seconds duration, will suffice for helomata
+vasculare which are situated on the dorsum of the foot. On
+the plantar surface, however, the tissues are more dense
+and many more treatments are required. It is on account
+of this density of the tissues that fulguration or any other
+form of electricity for the treatment of plantar growths is
+inadvisable.</p>
+
+<p>Electrolysis consists of inserting a needle or other
+sharply pointed instrument to which the negative
+pole of a galvanic cell has been attached, beneath and
+around the growth. The positive pole is attached to
+a spot near where the condition is found, usually the
+calf of the leg. As the current is passing through the
+foot, the water in the tissues undergoes electrolysis, and
+after a time, as the hydrogen goes to the negative pole,
+bubbles of this gas are noticed around the free surface of
+the needles. This is an evidence that the decomposition has
+gone on sufficiently and the needle may be withdrawn. If
+the growth is a large one, the needle should be re-inserted
+at right angles to the original insertion, and the process repeated.
+If this is done properly, after two or three days,
+the entire mass will separate from the surrounding tissues.
+The greatest care must be observed in practising asepsis,
+as the electrolysis method is not an antiseptic one. The
+needle must be thoroughly boiled, and the part cleansed in
+<span class="pagenum" id="Page_179">[Pg 179]</span>the same manner as if a surgical operation were to be performed.
+This method, as well as the previous one, is not
+practical for helomata vasculare that appear on the plantar
+surface of the foot.</p>
+
+<p>The carbon dioxide pencil may also be used in the
+treatment of this condition. This method, however, is not
+advised, as the parts become frozen from the contact and
+the pain of reaction is severe.</p>
+
+<p>As previously stated, the treatment of heloma vasculare
+is almost identical with that of verruca and the reader
+is advised to consult the chapter on verruca for further
+knowledge along this line of treatment.</p>
+
+
+<h3 id="HELOMA_MILIARE">
+  HELOMA MILIARE
+</h3>
+
+<p><b>Definition.</b> Heloma miliare, or heloma disseminatum,
+or seed corn, is a small excrescence usually found in large
+numbers on the plantar surface of the foot, around the heel,
+or over the dorsal and inner lateral surface of the great toe
+joint. The growth is about the size of a millet seed.</p>
+
+<p><b>Symptoms.</b> This form of heloma does not produce the
+extreme pains caused by the other types of this growth, and
+only when they develop in great numbers do they become
+annoying. The patient then complains of an uncomfortable
+feeling, as if there were a foreign body in the shoe or
+stocking. Upon examination, several small helomata are
+seen, which appear to be all nuclei.</p>
+
+<p><b>Etiology.</b> Wrinkles produced by wearing loose stockings
+are a factor in producing helomata miliare; nails
+which protrude from the plantar surface of the shoe are
+also a fruitful cause of this condition. The wrinkling of the
+stockings produces an uneven surface over the length of
+the wrinkle and the weave of the material, usually wool,
+causes these helomata to develop. The nails found in shoes
+are usually caused by imperfect repairing. They do not
+extend out more than just the smallest fraction; in fact they
+protrude just enough to allow the patient to go along for
+<span class="pagenum" id="Page_180">[Pg 180]</span>several days or weeks without noticing that something is
+wrong.</p>
+
+<p><b>Pathology.</b> Hypertrophy of the epidermis takes place
+at the nucleus only, but the area immediately surrounding
+the heloma miliare feels hard and congested to the touch.
+Hypertrophy of the papillæ occurs, but only a small number
+are involved. There is no disturbance in the skin between
+the individual growths, each of the neoplasms having a distinct
+etiologic factor in its production.</p>
+
+<p><b>Diagnosis.</b> The heloma miliare is characteristic and
+cannot be mistaken for any other condition. As stated, the
+growth is rarely larger than a millet seed and appears to
+be all nucleus. There is an area of normal skin between
+these helomata, when they occur in numbers.</p>
+
+<p><b>Prognosis.</b> Careful operating and intelligent after-care
+will produce a cure in from four to five treatments. There
+are cases on record that have entirely disappeared after
+one treatment, but these are rare. The footgear, both shoes
+and stockings, should be examined and if found faulty
+should be corrected. This aids in a rapid cure and will, as
+well, prove a preventive.</p>
+
+<p><b>Treatment.</b> The removal of these helomata may be
+accomplished with the knife, but the ordinary scalpel is useless.
+It is necessary to have a very finely pointed small
+knife, and the procedure is the same as that followed in the
+treatment of the nucleus of heloma durum, except that more
+care must be practised, because of the smallness of the
+growth. The helomata miliare occur in groups containing
+as many as twenty or even thirty distinct minute growths,
+and it is necessary to take as much care with each one of
+them as with the first one removed. This is trying both to
+the patient and to the operator, but as it is essential to the
+successful cure to have the growths removed individually
+and carefully, patience is necessary. The after dressings
+may consist of ichthyol ointment, 15%, applied on a piece of
+lint, or balsam of Peru painted on after the helomata have
+been removed, and covered by a lint or cocoon dressing.
+<span class="pagenum" id="Page_181">[Pg 181]</span>Some practitioners apply tincture of iodine to the part
+without further dressing.</p>
+
+<p>The therapeutic method of treatment consists of applying
+salicylic acid plaster, cut so as to fit over the affected
+area, and allowing this to remain in contact with the part
+for several days. This softens the tissues, so that the small
+growths may be easily removed, but care must be taken, as
+the acid will destroy the healthy tissue between the helomata
+unless each growth is isolated in treatment. The disintegrating
+process must not be allowed to continue to the extent
+that it does in the treatment of heloma molle or in the
+other conditions in which salicylic acid is employed. It is
+then often necessary to use the knife to remove the remaining
+tissue.</p>
+
+<p>Recurrence is the rule in helomata miliare, but after
+persistent treatment the condition usually disappears. It
+must be borne in mind, however, that the footgear of the
+patient must be carefully examined and necessary corrections
+made. This, in itself, without the thorough treatment
+prescribed above, will often result in a cure of the most
+annoying cases of heloma miliare.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_182">[Pg 182]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_XI">
+    <span class="chap">CHAPTER XI</span>
+    <br>
+    CALLOSITAS
+  </h2>
+</div>
+
+
+<p><b>Derivation.</b> The word callositas is derived from the
+Latin “callus,” meaning horn.</p>
+
+<p><b>Synonyms.</b> Callus, callosity, callous, tyloma, tylosis.</p>
+
+<p><b>Definition.</b> Callositas, or callouses, are a thickening of
+the epidermis, usually found on the plantar surface of the
+foot. They also occur on the dorsum of the toes, and are
+found on the hands of mechanics who continuously use hand
+tools involving pressure on the parts. Coachmen develop
+callouses between their fingers on account of the manner in
+which they hold the reins while driving. In rare instances,
+women have been known to have callouses on their hips, due
+to the pressure of the steel in their corsets, and cavalry men
+who sit in the saddle for long periods develop callous on the
+parts exposed to irritation.</p>
+
+<p><b>Symptoms.</b> Callosities are composed of variously sized
+areas of yellowish or grayish, horny excrescences of epidermic
+cells. They are hard, dry and horn-like, thicker in
+the centre of the growth and gradually becoming thinner at
+the periphery. There is no sharp line of demarcation between
+a callous and the surrounding skin, such as is found
+in helomata, but the thickened cuticle gradually blends with
+the surrounding skin.</p>
+
+<p><b>Etiology.</b> A callosity is the result of an irritation of
+some form and is nature’s way of protecting the delicate
+structures beneath the skin from the direct pressure or friction
+to the parts. The outer layers of the skin become thickened
+and act as a buffer, which absorbs shock and prevents
+inflammation and tissue destruction. When found on the
+soles of the feet, callouses are due to standing or walking
+<span class="pagenum" id="Page_183">[Pg 183]</span>in improper footgear. The ball of the great toe is a very
+common site for callosities; also the region over the heads
+of the metatarsal bones, due to high heels which force one
+to walk directly on these parts without equal weight distribution,
+is subject to them.</p>
+
+<p>Callosities may occur as the result of chronic skin lesions
+such as eczema, psoriasis, lichen planus and ichthyosis
+and after the prolonged use of arsenic.</p>
+
+<p>Callosities occurring on the dorsum of the toes are
+caused by the pressure of the skin against the top of the
+shoe. The parts beneath the callous at this point usually
+show the presence of bursitis, which causes a swelling and
+subsequent pressure on the skin.</p>
+
+<p><b>Pathology.</b> The changes that take place in the formation
+of callosities are the same as those which arise in
+heloma, except that the deeper layers of the epidermis and
+the true skin are not affected unless accidentally infected
+or injured.</p>
+
+<p>There is no inflammation present except in cases of
+infection or injury. The upper layers of the epidermis are
+the only ones involved, and the condition is really a physiologic
+rather than a pathologic one. It is more of a protection
+than a true hypertrophy. The overgrowth may continue
+to a greater extent, and then even helomata may develop.</p>
+
+<p><b>Diagnosis.</b> The callosity is yellow to grey in color and
+is composed of a horn-like mass of epidermic cells. It is
+easily distinguished from an heloma in that there is no
+nucleus present, and the part is not severely painful on
+pressure. It may be mistaken for some of the chronic skin
+lesions, previously mentioned, but the skin eruption presents
+a scale or crust which readily peels off, en masse,
+leaving the bare rete Malpighii exposed. The callosity
+comes off in layers and, as the deeper structures are reached,
+a healthy pink color is noticed.</p>
+
+<p><b>Prognosis.</b> A change in occupation or a change of
+footgear often results in the disappearance of this condition.
+<span class="pagenum" id="Page_184">[Pg 184]</span>Unless the direct cause is removed there will be a recurrence,
+which is an indication that the part again needs protection
+and care. Persons who have been accustomed to standing
+or walking for protracted periods of time, such as policemen,
+floor walkers, etc., soon lose the callouses they
+developed, after they change their occupation.</p>
+
+<p><b>Treatment.</b> If the growth becomes thick enough to
+cause discomfort, it may be easily removed, by softening it
+and then scraping or paring it. The foot may be soaked in
+an alkaline foot bath composed of one-half ounce of
+sodium bicarbonate to two quarts of hot water, or painting
+the part with a dilute solution of potassium hydroxide
+(caustic potash), 5%, several applications every few minutes,
+the softened area being scraped away after each application.
+Salicylic acid plaster, 25%, placed over the affected
+area and allowed to remain in contact for forty-eight hours,
+will usually loosen the redundant mass. If the callosity
+appears over the head of the first or fourth metatarsal bone,
+mechanical adjustment should be made, whereby the pressure
+in walking is thrown upon the entire surface of the
+anterior part of the foot. Pads of felt or buckskin, properly
+skived and fitted, will accomplish this result.</p>
+
+<p>Care must be taken that too much of the induration is
+not removed when treating this condition. As previously
+stated, the calloused mass acts as a protective for the parts
+beneath and is nature’s way of preventing serious trouble,
+and if too much is removed, pain will be experienced when
+the foot is used in walking. If this should occur, the part
+should be painted with tincture of iodine, 4%, and covered
+with moleskin or adhesive plaster. If an abrasion has been
+made, it is important to dress the part with an antiseptic,
+followed by a stimulating agent, all of this to be covered
+with a cocoon dressing or a lint shield.</p>
+
+<p>Where callosities are caused by a displacement of the
+anterior metatarsal arch, or by any of its bony constituents,
+the bony lesion must be corrected before the callosities
+will respond to treatment.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_185">[Pg 185]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_XII">
+    <span class="chap">CHAPTER XII</span>
+    <br>
+    VERRUCA
+  </h2>
+</div>
+
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><b>Synonyms.</b> Papilloma, Wart. Fr. verrue.</p>
+
+<p><b>Derivation.</b> Verruca is derived from the Latin, meaning
+wart.</p>
+
+<p><b>Etiology.</b> 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
+<span class="pagenum" id="Page_186">[Pg 186]</span>the patients who have been questioned thoroughly, all seem
+to give a history of trauma or of some chronic irritation.</p>
+
+<p>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.</p>
+
+<figure class="figcenter illowe18" id="i_p186">
+  <img class="w100" src="images/i_p186.jpg" alt="">
+  <figcaption>
+    VERRUCA HUMIDA OR CALCIS
+  </figcaption>
+</figure>
+
+<p>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,
+<span class="pagenum" id="Page_187">[Pg 187]</span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><b>Pathology.</b> 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.</p>
+
+<p>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_188">[Pg 188]</span>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.</p>
+
+
+<h3 id="VARIETIES_OF_VERRUCA">
+  VARIETIES OF VERRUCA
+</h3>
+
+<p>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.</p>
+
+<p><b>The Verruca Vulgaris</b>, 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.</p>
+
+<p><b>The Verruca Arida</b>, or dry wart of the foot, usually
+<span class="pagenum" id="Page_189">[Pg 189]</span>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.</p>
+
+<p><b>The Verruca Humida</b>, 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.</p>
+
+<p><b>Diagnosis.</b> 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.</p>
+
+<p>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.</p>
+
+<p>Some lesions of syphilis taking on a papillary character,
+may be mistaken for verruca, but other indications of a
+<span class="pagenum" id="Page_190">[Pg 190]</span>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—<i>Syphilis</i>)
+will
+make it possible for the
+practitioner to eliminate
+syphilis as a
+factor.</p>
+
+<p>Venereal warts occur
+on the genitals only
+and need not be considered
+in this chapter.</p>
+
+<p>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.</p>
+
+<figure class="figcenter illowe24" id="i_p190">
+  <img class="w100" src="images/i_p190.jpg" alt="">
+  <figcaption>
+    EPITHELIOMA
+  </figcaption>
+</figure>
+
+<p><b>Prognosis.</b> 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
+<span class="pagenum" id="Page_191">[Pg 191]</span>changes its nature and becomes malignant, is the prognosis
+unfavorable.</p>
+
+<p><b>Treatment.</b> 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.</p>
+
+<p>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.</p>
+
+<p>The various
+treatments are as follows:</p>
+
+<figure class="figcenter illowe24" id="i_p191">
+  <img class="w100" src="images/i_p191.jpg" alt="">
+  <figcaption>
+    MULTIPLE VERRUCA
+  </figcaption>
+</figure>
+
+<p>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.</p>
+
+<blockquote>
+<p>
+  Excision.<br>
+  Fulguration.<br>
+  Electrolysis.<br>
+  Direct Cautery.<br>
+  Carbon Dioxide Pencil.
+</p>
+</blockquote>
+
+<p><span class="pagenum" id="Page_192">[Pg 192]</span></p>
+
+<p><b>Potential Cautery.</b> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>The method of procedure for the treatment of verruca
+by the use of acid caustics generally is as follows:</p>
+
+<p>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
+<span class="pagenum" id="Page_193">[Pg 193]</span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>The treatment of verruca by means of the alkali
+caustics is much the same as with the acid caustics, except
+<span class="pagenum" id="Page_194">[Pg 194]</span>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.</p>
+
+<p><i>Nitric acid</i> is extensively used in this condition in the
+pure state. The treatment of the eschar produced varies.</p>
+
+<p>S. Rutherford Levy, of San Francisco, California,
+uses the nitric acid pure, and reports very favorable results.
+He removes the eschar after each treatment.</p>
+
+<p>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.</p>
+
+<p>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:</p>
+
+<p>“<i>Trichloracetic acid</i> 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
+<span class="pagenum" id="Page_195">[Pg 195]</span>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.</p>
+
+<p>“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.”</p>
+
+<p>F. S. Sargent, of Providence, R. I., prefers <i>silver
+nitrate</i> 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.</p>
+
+<p>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:</p>
+
+<p>“Place a small wad of cotton soaked with a 5% solution
+of <i>potassium hydroxide</i> 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
+<span class="pagenum" id="Page_196">[Pg 196]</span>in a period of three weeks, electrolysis is resorted to.”</p>
+
+<p>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:</p>
+
+<p>“Take a small piece of caustic potash (<i>potassium
+hydroxide</i>) 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.”</p>
+
+<p>Oscar Klotzbach, of Cleveland, Ohio, is using
+<i>methylene blue</i> for the treatment of verruca, applying the
+drug (once a week), and protecting the part with sterile
+dressings. This is a painless method.</p>
+
+<p>Bertha DeWolfe, of Denver, Colo., is using <i>ethylate
+of soda</i> 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.</p>
+
+<p>Anna Moyde Savage, of Syracuse, N. Y., who has
+had experience with many treatments for verruca, has been
+using and recommends <i>pyrogallol</i> for this lesion. Her statement
+follows:</p>
+
+<p>“Pyrogallol is a white, lustrous, bitter crystalline substance
+<span class="pagenum" id="Page_197">[Pg 197]</span>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.</p>
+
+<p>“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.”</p>
+
+<p><i>Salicylic Acid</i> 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
+<span class="pagenum" id="Page_198">[Pg 198]</span>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.</p>
+
+<p><b>Excision.</b> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>To afford relief from the reaction of the anesthetic,
+<span class="pagenum" id="Page_199">[Pg 199]</span>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.</p>
+
+<p><b>Fulguration.</b> 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.</p>
+
+<p>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.</p>
+
+<p>For the destruction of verruca the part is cleansed with
+alcohol, and the electrode is placed directly over and in close
+<span class="pagenum" id="Page_200">[Pg 200]</span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><b>Electrolysis.</b> 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.</p>
+
+<p>James R. Bennie, of Philadelphia, Pa., who uses
+<span class="pagenum" id="Page_201">[Pg 201]</span>this method of treating verruca exclusively, has developed
+a technic that is fully described in the following:</p>
+
+<p>“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.</p>
+
+<p>“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.</p>
+
+<p>“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.</p>
+
+<p>“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
+<span class="pagenum" id="Page_202">[Pg 202]</span>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.</p>
+
+<p>“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.</p>
+
+<p>“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.</p>
+
+<p>“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.”</p>
+
+<p><b>Direct Cautery.</b> 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
+<span class="pagenum" id="Page_203">[Pg 203]</span>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><b>Carbon Dioxide Pencil.</b> 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.</p>
+
+<p>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,
+<span class="pagenum" id="Page_204">[Pg 204]</span>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.</p>
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_205">[Pg 205]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_XIII">
+    <span class="chap">CHAPTER XIII</span>
+    <br>
+    CALLOUSED NAIL GROOVE
+  </h2>
+</div>
+
+
+<p>The formation of hardened, or calloused skin in the
+nail groove is, unhappily, a very common occurrence. In
+our present day of high-heeled and pointed shoes the nail
+grooves of all the nails, but particularly those of the great
+toe, are subject to a great amount of pressure and friction.
+This irritation develops conditions in these structures, ranging
+from a transient inflammation to the formation of
+distinct helomata, or the general callousing of the whole
+surface of the groove, both under and beside the nail.</p>
+
+<p>In many cases where an heloma has developed in the
+inner lateral nail groove of the great toe, the condition is
+judged and treated as an ingrown nail.</p>
+
+<p>Why this error in diagnosis should occur is hard to
+reason out, for, while the subjective symptoms of the two
+conditions may be and usually are similar, the objective
+symptoms are so entirely different that the only accountable
+reason for a mistaken diagnosis is carelessness or
+ignorance on the part of the practitioner. The true ingrown
+nail is not a particularly common occurrence and, as has
+been previously explained, a nail to be classified as ingrowing,
+must present an edge that has invaded and is imbedded
+in the softer tissues of the adjacent nail fold. In calloused
+nail groove, nothing of this nature has occurred and it is
+the maltreatment of cases of this kind that usually leads
+to true cases of ingrown nail.</p>
+
+<p><b>Definition.</b> A calloused nail groove is a condition in
+which a localized heloma (sometimes several disseminated
+helomata), or a general calloused condition has developed
+in a lateral nail groove.</p>
+
+<p><span class="pagenum" id="Page_206">[Pg 206]</span></p>
+
+<p><b>Symptoms.</b> <i>Subjective symptoms</i>: excruciating pain
+on the slightest pressure, heat, and throbbing in severe and
+neglected cases.</p>
+
+<p><i>Objective symptoms</i>: swelling, usually localized in the
+nail fold involved; redness and general inflammatory condition;
+upon close examination the heloma or the callous is
+easily demonstrated in the fold by reason of its unyielding
+qualities.</p>
+
+<p><b>Etiology.</b> This condition may be caused by irritation
+of the tender tissues of the nail fold brought on by persons
+who persist and delight in “digging” about the edges of
+the nail with some instrument. In most instances, however,
+a short or narrow shoe or stocking will cause sufficient pressure
+of the edge of the nail upon the tissues of the groove
+to cause nature to provide a protection which tends to prevent
+the nail from piercing these softer tissues; the protection
+appears in the form of callous. This callous will
+appear as a hard development throughout the whole nail
+groove, and we find those tissues to be unyielding and to
+have lost nearly if not all of the pinkish tint which the
+great amount of vascularity underneath normally gives to
+the tissues about the nail. The color is yellowish or sometimes
+greyish white. Where a distinct heloma is present,
+it may be found covered by a thin sheet of callous which
+covers some part of the groove, or it may be distinctly independent
+and isolated from any such development. When
+this latter condition is met, the heloma will usually be found
+to be circumscribed, its edges regular and its shape circular.
+These latter instances are not so common as the general
+callousing of the entire groove. Where the helomata are
+found disseminated, they will usually occur on the inside of
+the flap next the nail, although in some cases they will be
+found under the edge of the nail itself. In these first mentioned
+instances the pain will be greatest upon lateral pressure
+and in the latter upon dorsal or plantar pressure.</p>
+
+<p><b>Treatment.</b> Various methods of treatment are employed
+for the alleviation or cure of this painful ailment.
+<span class="pagenum" id="Page_207">[Pg 207]</span>They may be divided, for discussion, into two general
+classes: surgical and medical.</p>
+
+<p><b>Surgical Treatment.</b> This method consists in removing
+the callous or the heloma by means of a fine-pointed scalpel
+or a small curette. The nail groove is first well softened by
+the application of small pledgets of cotton saturated with
+warm water, or by the use of some epidermic solvent such
+as liquor potassae, after which the parts are dried and the
+operation is begun. With a sterile nail chisel sufficient of
+the edge of the nail is cut away so that the heloma or the
+callous is exposed. This not only gives the patient instant
+relief but also allows room for the operation and the subsequent
+dressing.</p>
+
+<p>With a pointed scalpel or bistoury, the growths are
+removed, much in the same manner as helomata in any
+location might be treated. If the calloused condition be
+general throughout the groove, a small curette is used and
+the callous is loosened from the anterior end of the fold and
+stripped backward toward the root of the nail.</p>
+
+<p>The subsequent treatment consists in applying an ointment,
+such as ammoniated mercury (5%), and packing the
+nail groove with sterile gauze. Should the operator prefer
+a liquid, the gauze packing may be saturated with bichloride
+of mercury, ¹⁄₅₀₀₀, or boric acid, saturated solution; but it
+will be generally found that the ointment is more effective
+in reducing the inflammatory symptoms present and also
+any irritation which may have been caused during the operation.</p>
+
+<p>Whilst this operation is being constantly performed
+and seems to be generally in vogue, much more satisfactory
+results are obtainable from local medical applications.</p>
+
+<p>In the first place, in using a scalpel or curette in the
+nail fold, the operator must be very skillful in order not
+to cause a hemorrhage and subsequently a tender digit. In
+many instances, no matter how skillful the operator, or how
+much care be exercised in the operation, it will be found a
+practical impossibility to strip the callous from a nail groove
+<span class="pagenum" id="Page_208">[Pg 208]</span>without capillary rupture. This latter, of course, is undesirable
+and usually, no matter how the lesion is dressed, the
+groove remains tender for days.</p>
+
+<p>In some cases the small helomata found in the nail fold
+should at once be at least partly removed, to give the patient
+relief. This may be done with a fine-pointed scalpel and
+local treatment may then be applied.</p>
+
+<p><b>Medical Treatment.</b> There are two methods of medical
+treatment employed. One finds its efficacy in the use of
+salicylic acid as an epidermic disintegrant, and the other in
+the application of liquor potassae (potass. hydrox. 5%) as a
+cuticle solvent.</p>
+
+<p><i>Salicylic Acid.</i> After a sufficient portion of the nail has
+been removed to give relief to the patient, the nail fold is
+thoroughly cleansed and dried and the following ointment
+applied in the groove:</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl">
+Acidi salicylici
+</td>
+<td class="tdl">
+</td>
+<td class="tdr">
+8.00
+</td>
+</tr>
+<tr>
+<td colspan="3">
+Camphorae
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Chloral
+</td>
+<td class="tdl">
+aa
+</td>
+<td class="tdr">
+0.30
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Ceratum
+</td>
+<td class="tdl">
+</td>
+<td class="tdr">
+30.00
+</td>
+</tr>
+<tr>
+<td class="tdl">
+M. ft. unguentum
+</td>
+<td class="tdl">
+</td>
+<td class="tdr">
+</td>
+</tr>
+</table>
+
+
+<p>After a week or ten days has elapsed, the whole calloused
+area will be found to be entirely disintegrated and
+may be easily removed with a fine-pointed excavator. The
+groove is then packed with either gauze or cotton, and an
+appropriate ointment or solution is applied to alleviate the
+inflammatory condition.</p>
+
+<p>The treatment with salicylic acid is easily combined
+with the surgical treatment, if it be found necessary to remove
+a portion of the corneous formation in order to afford
+relief to the patient.</p>
+
+<p>In some cases it will be found efficacious, after the callous
+has been removed by means of the salicylic ointment,
+to apply silver nitrate (50%) to the groove. This will
+reduce the inflammatory conditions and at the same time
+act as an astringent to the underlying capillaries and as a
+<span class="pagenum" id="Page_209">[Pg 209]</span>sedative to the inflamed tissues. The alternate weekly use
+of the ointment and the silver salt is advocated, and gratifying
+results are usually obtained from this treatment in
+cases where it can be used.</p>
+
+<p><i>Liquor Potassae.</i> Potassium hydroxide solution is most
+generally used in cases where the callous is general in the
+nail fold rather than where there is simply a localized
+heloma.</p>
+
+<p>An applicator is saturated in the solution and rubbed
+over the calloused area until the mass is softened, when it
+may be easily removed. While this mode of treatment is
+a popular one it has been the experience of many practitioners
+that the liquor potassae merely softens the calloused
+condition, failing to disintegrate it entirely, and allows the
+parts to harden, directly the application is discontinued.
+Joseph Renk, a well known New York practitioner, reports
+the best of results from this treatment, when carefully used.</p>
+
+<p>No doubt there are good features in both treatments
+and a wise practitioner, utilizing both, will adopt that from
+which he obtains the best results.</p>
+
+<p>In no instance should the nail fold be packed tightly in
+these cases. The operator should remember that if he removes
+a sliver of nail one-sixteenth of an inch in width and
+then packs the resultant space with a pledget of cotton, gauze
+or lamb’s wool one-eighth of an inch in thickness, he will
+cause more pressure to be brought to bear on the parts
+than there was originally present; this is, of course, to be
+avoided under all circumstances.</p>
+
+<p>On the other hand it must be remembered that sufficient
+packing should be used to retain the normal line of the nail
+fold and to keep these softer tissues in the proper place.
+Under no circumstances should they be allowed to crowd
+up and over the nail, for if this does take place we are merely
+setting the stage for a possible ingrown nail. Jack Grossman,
+M.Cp., makes this a strong point in his talks to the
+students of The First Institute of Podiatry.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_210">[Pg 210]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_XIV">
+    <span class="chap">CHAPTER XIV</span>
+    <br>
+    ONYCHOCRYPTOSIS OR INGROWN
+    TOE NAIL
+  </h2>
+</div>
+
+
+<p><b>Definition.</b> Onychocryptosis, or ingrowing or ingrown
+toe nail, is a condition in which the lateral edge of a nail
+has penetrated through the epidermic layers and has become
+imbedded in the adjacent or subjacent soft parts of
+the lateral nail groove. This abnormal condition gives rise
+to a number of complications, viz: simple inflammation, ulceration,
+circumscribed or diffused cellulitis and the formation
+of proud flesh. These may occur singly or as is commonly
+found, the last three in unison. The unclean condition
+of people’s footgear, the general unsanitary conditions
+of the foot, or maltreatment of ingrown nail in its incipiency,
+often give rise to the still graver septic complications
+which ultimate in a general septicemia.</p>
+
+<p>A nail then to be classed as an ingrowing nail must be
+specifically ingrowing. Mention is made of this fact, which
+many in their wisdom may deem superfluous, because so
+many conditions of callous or helomata in the nail groove
+are mistaken for ingrowing nail and their treatment as
+such is not only useless, so far as a cure is concerned, but is
+decidedly detrimental to the comfort of the patient and to
+the future general condition of the nail involved.</p>
+
+<p><b>Etiology.</b> A large percentage, perhaps larger than
+most people imagine, of ingrown nails arise from the injudicious
+cutting of the part by an inexperienced person.
+Directly after an amateur operation upon a painful nail,
+acute symptoms of ingrowing nail do not necessarily develop—although
+it does happen in many cases; but the
+<span class="pagenum" id="Page_211">[Pg 211]</span>etiology of a great number of acute and well defined cases of
+ingrown nail, as stated, can be traced primarily to self-inflicted
+nail injury at some previous time.</p>
+
+<p>The changes taking place in the nail and in the tissues
+of the nail groove after the removal of the lateral border of
+the nail, are pronounced. Take, for example, the great toe
+nail, as this is the most easily studied on account of its size
+and at the same time is the most general seat of troubles
+of this nature.</p>
+
+<p>The nails are placed on the dorsal surfaces of the toes
+as a means of protection to the expanded extremities of
+the distal phalanges. Perhaps the Divine Providence in
+moulding his masterpiece, man, foresaw the advent of modern
+footgear and realizing its baneful effect upon the human
+extremity, developed upon the great toe a heavy nail
+from which a great deal of protection for the more tender
+tissues beneath might be obtained. At any rate, the great
+toe nail today bears the brunt of the pressure from our
+leather footgear and for that reason is probably the seat of
+so many painful afflictions.</p>
+
+<p>The free edge of the normal great toe nail is found to
+be more flattened and expanded than the posterior portions
+of the nail nearer its root. This flattened expansion holds
+the softer tissues of the end of the toe and of the lateral
+border of the nail groove in place under the nail and also
+prevents them, if allowed to remain untouched, from crowding
+up or around the nail at any quarter. But allow the
+free edge and the lateral border of the nail to be removed,
+and particularly by inexperienced hands—and observe what
+takes place. These softer tissues which were normally held
+in place by the free borders of the nail, fill up the spaces
+left by the removal of the nail borders. Even this condition,
+were the nail to remain stationary and cease to grow,
+would not be conducive to great pain or inconvenience. But
+the nail is being continually pushed forward by the formation
+of new cells at its posterior extremity. This is embedded
+in the posterior nail fold, and when the newly
+<span class="pagenum" id="Page_212">[Pg 212]</span>formed portion of the same width as originally found arrives
+at the point where the softer tissues are crowded up
+and into the space left by the removal of the borders of the
+nail, instead of growing over them and forcing them back
+into their normal position, it finds this impossible, and
+grows into them.</p>
+
+<p>From the foregoing we are not to take it for granted
+that all cases occur from injudicious cutting of the nail’s
+lateral borders. Short and tight shoes and hose are in
+some cases the exciting causes of ingrowing nails and, from
+observation, we are led to believe that while the actual ingrowing
+nail is not hereditary, nevertheless the predisposition
+toward nail inversion is manifest through an entire
+family or even through a generation.</p>
+
+<p>In the case of tight footgear or hosiery, the cause is the
+crowding of the great toe against its neighbor, forcing
+the softer tissues of the nail groove and flap to be crowded
+against the lateral edge of the nail. In these cases the
+principal site of occurrence will naturally be the outer sides
+of the great toe; in fact, in most cases, this groove will be
+found to be the most general site of occurrence. The soft
+tissues of the nail flap being crowded over and around the
+nail’s lateral edge, there naturally follows an irritation in
+the groove, caused by the nail rubbing upon these tissues
+which, in time no doubt leads to ulceration of the parts with
+the accompanying inflammatory symptoms.</p>
+
+<p>Uric acid diathesis may in one sense be said to be the
+cause of some cases of ingrown nail in that when patients
+so suffer, the nails are prone to chip off at the edges leaving
+the latter ragged and so allowing a chance for irritation
+from the saw-like projections, ultimating in an ulcerated
+condition of the wounded parts.</p>
+
+<p><b>Complications.</b> Other than the general inflammatory
+conditions brought about in connection with the ulceration
+caused by the edge of the nail penetrating the softer tissues,
+proud flesh is probably the complication most generally met
+with in these cases.</p>
+
+<p><span class="pagenum" id="Page_213">[Pg 213]</span></p>
+
+<p>Proud flesh, thus produced, is due undoubtedly to the
+constant irritation of the nail upon the exposed surfaces of
+ulcerated area. It forms in many shapes and the mass developed
+depends largely upon the length of time the condition
+is allowed to progress without proper treatment. The
+excess growth is usually found covering the whole exposed
+area, or only forming in a teat-like prominence with a small
+circumscribed base and expanded extremity. The pain to
+the patient is undoubtedly augmented by the presence of
+proud flesh and the discharge from the ulcerated areas is
+thereby increased. Hemorrhage from the movement of the
+toe in walking is prone to occur and the general unwholesomeness
+of the part is thus exaggerated.</p>
+
+<p>In some cases the production of these exuberant
+granulations takes place under the body of the nail as well
+as in the groove or on the flap and they are not clearly discernible
+until the imbedded portion of the nail is removed,
+when they will be seen to crowd upward into view.</p>
+
+<p>Any open wound upon the surfaces of the foot is very
+liable to septic infection. Regardless of the cleanly care
+one may give his feet and regardless of the washing of
+hose, infection will still take place, and only naturally so.
+The feet are coming constantly in contact with septic surfaces
+and the inside of a shoe presents large areas for the
+resting place of countless microorganisms in that it combines
+the three elements which are best suited for the growth
+of bacteria, viz: heat, moisture and darkness.</p>
+
+<p>Ingrown nails are even more prone to infection than
+is a lesion in connection with an heloma or a fissured toe
+web, and in many instances where cases have been allowed
+to run for some time before the surgeon or podiatrist is
+called into consultation, infection has already occurred.</p>
+
+<p>In connection with septic cases, abscess cavities are
+often found immediately in the nail groove, under the body
+of the nail itself or with a suppurative sinus burrowing
+backward under the posterior nail fold and involving the
+whole of the matrix in an acute suppurative process. In
+<span class="pagenum" id="Page_214">[Pg 214]</span>exaggerated cases, the cellulitis may be diffused throughout
+the whole digital region. However, these cases are rare,
+as walking has become well-nigh impossible long before
+this takes place and the patient will have been under scientific
+treatment before the case has reached such proportions.</p>
+
+<p><b>Treatment.</b> From the standpoint of the podiatrist,
+there are two distinct methods of operative technic in ingrown
+nail cases, the radical and the palliative. They differ
+as to the exact technic of the removal of the ingrown portion,
+but agree on practically all other points.</p>
+
+<p>In that but for the first part of the operation these two
+methods are similar, they will be discussed separately as
+to that alone, and the post-operative procedures and dressing
+of both will be combined into one general discussion.
+Under each heading the treatment of the surrounding tissues
+is mentioned, but the reader is referred to the heading
+“Prophylaxis” for a thorough and comprehensive discussion
+of the various procedures necessary to their proper
+care.</p>
+
+<p><b>Asepsis.</b> Proper aseptic precautions must be observed
+in all lesions and particularly so with ingrown nail cases.
+As has already been stated, conditions of this nature are
+prone to infection because the surfaces and recesses or the
+nail groove present excellent lodgment for bacteria, and
+this point should always be borne in mind.</p>
+
+<p>The parts should first be thoroughly cleansed with
+ether. This removes all greasy or oily matter from the
+field of operation and allows the antiseptic solutions subsequently
+used to come in direct contact with the affected
+surfaces.</p>
+
+<p>Some effective antiseptic should then be used as a spray
+to prevent the washing in of bacteria from the surrounding
+parts. There are a number of solutions which are useful for
+this purpose; liq. zinci et alumini compositus, N.F., and
+liq. zinci et ferri compositus, N.F., are both highly recommended.
+Liq. cresolis compositus may also be used with
+excellent results, although it carries the somewhat disagreeable
+<span class="pagenum" id="Page_215">[Pg 215]</span>odor of the cresols. These solutions are all active in
+strengths ranging from two to five per cent.</p>
+
+<p>Iodine is unquestionably the best antiseptic that can be
+applied to the field of operation, but as its discoloration of
+the tissues prevents the operator from visually observing
+geographic points he may need for further diagnosis, and
+as this drug also acts as a corrosive to metal instruments,
+it is found advisable in many instances to refrain from its
+use.</p>
+
+<p>As a substitute for iodine, alcohol is the next most efficient
+germicide. Sixty per cent. strength is recommended,
+as in that proportion it has greater penetrative and antiseptic
+value than the stronger solutions.</p>
+
+<p>The alcohol, applied by means of a cotton wound applicator,
+is rubbed into the parts, or a pledget of sterile cotton
+or gauze, saturated in the solution, may be applied over the
+field and allowed to remain for two or three minutes prior
+to operation.</p>
+
+<p>When the operator has followed the foregoing, or a
+similar line of procedure, the removal of the ingrown portion
+of nail may be begun. For simplicity’s sake, the methods
+of treatment will be discussed, beginning with the uncomplicated
+case, and the various complications will be considered
+under separate headings.</p>
+
+
+<h3 id="UNCOMPLICATED_CASES">
+  UNCOMPLICATED CASES
+</h3>
+
+<p><b>Removal of the Ingrown Portion.</b> Having obtained
+thorough asepsis of the affected and surrounding areas, the
+operator by means of a small, blunt sterile probe, should endeavor
+to locate the exact position and size of the ingrown
+portion of nail, which should then be removed by means of
+a sterile nail chisel.</p>
+
+<p><b>The Nail Chisel.</b> This instrument is a narrow steel
+blade set in a long or short handle, as the operator desires,
+the operating end of which is slightly oblique so that, upon
+direct pressure, the blade cuts in a diagonal manner. This
+is for the purpose of minimizing the danger of penetration
+<span class="pagenum" id="Page_216">[Pg 216]</span>into the nail bed. In the radical operation a broader and
+heavier chisel is sometimes used so that the softer tissues
+may be included in the incision.</p>
+
+<p><b>The Radical Method.</b> Proper antiseptic precautions
+having been taken, the circulation is cut off at the base of the
+toe by the application of a tourniquet. Under local anesthesia,
+induced preferably by the hypodermatic injection of
+novocaine, 1%, the nail is split longitudinally to the root
+with an ingrown nail chisel, care being taken not to split the
+nail at or near its centre—a procedure practised by some
+surgeons. When the nail has been cut through the root, the
+free portion is grasped with an artery forceps and is lifted
+out of the nail groove. It is often necessary to dissect the
+nail from adhesions which have formed.</p>
+
+<p>The proud flesh, should any be present, is now snipped
+off with a pair of curved scissors and if necessary a portion
+of the enlarged nail flap is also included in the cut. The
+soft tissues should be cut so that the structure remaining
+appears normal in size.</p>
+
+<p>The nail matrix is thoroughly curetted over its entire
+exposed area, as is the nail bed along its whole surface to
+the distal end. This procedure must be thorough to insure
+against recurrence. Bleeding is of a capillary type and is
+easily controlled by digital pressure.</p>
+
+<p><b>The Palliative Method.</b> With a sterile nail clipper, a
+small cut is made on the affected side in the free edge of
+the nail. The chisel is then placed in this notch and gentle
+yet firm pressure is exerted so that the instrument cuts
+through and splits the nail.</p>
+
+<p>The cut made is in the shape of an arc, following as
+nearly as possible the normal line of the lateral edge of the
+nail. The broadest part of the arc is at the anterior or free
+edge of the nail, gradually reducing the width of the piece to
+be removed until the lateral edge is reached. In this way a
+clean sweeping cut is made which does not invade and consequently
+does not irritate the tissues about the nail root.</p>
+
+<p>The palliative method of operative technic in ingrown
+<span class="pagenum" id="Page_217">[Pg 217]</span>nail cases is based on the theory that the condition is not
+one of a misdirected growth of the nail, but rather a case
+of the soft tissues adjacent to the nail crowding up, around
+and over the nail proper; and that the nail body as it
+pushes continually forward, cannot force this mass back
+into its normal position and, of necessity, must grow into it.</p>
+
+<p>There is no lateral
+hypertrophy of the nail
+nor does it present any
+misdirected growth.</p>
+
+<figure class="figcenter illowe24" id="i_p217">
+  <img class="w100" src="images/i_p217.jpg" alt="">
+  <figcaption>
+    ONYCHOCRYPTOSIS (SUPPURATING)
+  </figcaption>
+</figure>
+
+<p>Keeping this theory
+in mind, it would
+seem unnecessary and
+poor surgery to remove
+the portions of the
+matrix of the nail from
+which the affected side
+develops when in reality
+it is not the nail
+that is at fault but
+rather the soft tissues
+adjacent to it; and the
+ingrowing of the nail
+body is purely secondary
+to the displacement
+of these soft tissues.
+As ever in surgery,
+however, it remains
+a matter of judgment
+as to which operation
+should be done so
+as to obtain the best results. When the palliative methods
+fail to be effective, the radical operation is permissible—never
+the reverse.</p>
+
+<p>The palliative method has for its object the removal
+of the portion of nail whose irritant free border is embedded
+in the tissues and, this accomplished, to treat these softer
+<span class="pagenum" id="Page_218">[Pg 218]</span>tissues in such a manner that they will become normal as
+to position and all else. By such a manner and method of
+treatment, sufficient space is obtained at its lateral edge for
+the nail to grow to its full width and in time to become perfectly
+normal as to appearance, function and feeling.</p>
+
+<p>The straight nail chisel, in most instances, can be used,
+but where the ingrown portion of nail is deeply embedded,
+a right or left curved chisel can be substituted with greater
+success. The curve in this variety of chisel aids the operator
+in lifting the nail out of its bed, while at the same time
+the cutting process is not hindered.</p>
+
+<p><b>Dressing.</b> Following the removal of the offending portion
+of nail, the operator should make sure that no nail
+slivers, previously existing or of his own making, remain
+in the nail fold. Assured of this, the parts should then be
+thoroughly irrigated either with alcohol, 60%, or mercuric
+chloride, ¹⁄₄₀₀₀. Hydrogen peroxide may be used as an
+irrigant where pus is present, but it should not be depended
+upon as a germicide as its action is very transient and superficial.
+A final dressing is then put in place.</p>
+
+<p>There seems to be a wide diversity of opinion as to what
+constitutes a proper dressing after the nail has been removed.
+Whatever else individual experience may show to
+be useful, the dressing should be one embodying antiseptic,
+astringent and healing properties. The antiseptic, surely
+regardless of what other action is to be desired; the astringent,
+so that inflammatory symptoms may be speedily combated
+and the ulcerated areas contracted; and the healing
+so that granulation may be the more speedily promoted.</p>
+
+<p>Three forms of dressings may be classified: the wet;
+the dry; the ointment.</p>
+
+<p><b>The Wet Dressing.</b> The nail groove is packed with a
+small piece of sterile gauze. Care should be exercised that a
+thin fold of the gauze be placed under the edge of the nail
+between it and the tissues into which the ingrown portion
+of nail was embedded. A piece of sterile gauze, of about
+three or four thicknesses and about two inches square, is
+<span class="pagenum" id="Page_219">[Pg 219]</span>then placed over the affected fold of the nail, covering the
+inflamed area and extending over the nail itself. This
+pledget is then saturated with a solution of the operator’s
+choosing to meet the needs of the case under treatment.
+Two solutions seem to be favored above all others in this
+connection: mercuric chloride, ¹⁄₅₀₀₀, or weaker, and liq.
+aluminum acetate. The latter solution is at most times
+preferable, as it possesses antiseptic qualities (nearly, if
+not equal to corrosive sublimate without exhibiting the
+toxic properties of the latter) and produces an astringent
+and antiphlogistic action on the tissues. Strong germicidal
+solutions such as the mercuric chloride are at times found
+to be decidedly detrimental, in that they not alone cause
+maceration and desquamation of the skin, but in some
+instances, if too strong, they destroy the newly formed connective
+tissue granules.</p>
+
+<p>The gauze square which covers the whole end of the toe,
+and which is saturated with either solution just described, is
+held in place by a roller bandage or by adhesive strips.</p>
+
+<p>The usual method of applying these strips is to place one
+on each side of the gauze square, adhering them over the
+end of the toe and to and on the skin, and one over the
+centre of the dressing, carrying it over the end and down
+to and on the plantar surface of the toe. A circular strip
+is then carried around the toe, over the posterior end of the
+dressing, thus binding down the ends of the three strips
+previously applied.</p>
+
+<p>No impervious covering such as gutta percha, oiled silk,
+etc., should be used in this instance, or, in fact, in any condition
+where the skin is broken. The warmth and moisture
+produced by such a covering is congenial to the growth and
+development of hostile bacteria.</p>
+
+<p>The wet dressing, then, should be left uncovered so
+that evaporation may take place and a quantity of the
+solution used should be prescribed for the patient, so that
+the dressing may be moistened with it from time to time.
+The dressing without impervious covering is antiseptic and
+<span class="pagenum" id="Page_220">[Pg 220]</span>heat reducing because of the evaporation and frequent replenishment
+of the solution.</p>
+
+<p><b>The Dry Dressing.</b> Dry dressings in this sense consist
+in the application either of plain, dry, sterile gauze packed
+in the nail groove and unmoistened, or dusting the affected
+parts with some antiseptic powder to maintain asepsis in
+the wound and to bring about normal granulation.</p>
+
+<p>Of these two forms of dry dressing, that constituted
+by the plain dry gauze is productive of better results than
+are obtained by the dusting powders. A lesion caused by
+the nail penetrating the soft tissues of the nail fold, in the
+process of healing, necessarily discharges a certain amount
+of waste material produced in the tissue repair. In consequence,
+where a dusting powder is used, the serous discharge
+at times combines with the particles of the powder
+to form a crust which, in the confined areas of the nail
+groove, often becomes equally as irritating as was the ingrown
+nail itself.</p>
+
+<p>However, in some instances dusting powders may be
+used with impunity and many practitioners favor and report
+success in their use.</p>
+
+<p>Aristol (thymol iodide), dermatol (bismuth subgallate),
+bismuth subnitrate and boric acid (powder), preferably the
+first two named, may all be safely used in the treatment
+of ingrown nail cases. Aristol depends upon the liberation
+of iodine for its antiseptic action while the two bismuth
+salts, the subgallate and the subnitrate, combine marked
+astringent properties with their antiseptic qualities.</p>
+
+<p>After the powder is dusted into the affected groove, a
+thin layer of sterile gauze is packed lightly under the lateral
+edge of the nail and a cocoon dressing is placed over the
+whole.</p>
+
+<p>This form of dressing is applied until resolution of the
+inflammatory process and granulation of the wound has
+taken place.</p>
+
+<p><b>The Ointment Dressing.</b> All ointments are necessarily
+of fatty or oily consistency and, in consequence, when applied
+<span class="pagenum" id="Page_221">[Pg 221]</span>over a surface excreting a serous discharge, are liable
+to confine this discharge to the affected areas rather than
+allow it to be absorbed by the gauze dressing, and so drain
+the wound. For this reason the use of ointments on discharging
+surfaces is not particularly recommended. Many
+practitioners use them, however, and presumably with
+beneficial results.</p>
+
+<p>Two classes of ointments may be used in this connection:
+antiseptic and stimulating. Under these headings the
+following are suggested: sulphur, 10% (vaseline or lanolin
+base); ammoniated mercury (white precipitate), 5%; balsam
+of Peru, 10%; scarlet red (medicinal Biebrich),
+4%.</p>
+
+<p>The ointment is placed in the nail groove by means of a
+spatula, and sterile gauze is packed lightly under the nail,
+holding the ointment in place. This is covered with a cocoon
+dressing and is renewed until the parts regain their normal
+condition.</p>
+
+
+<h3 id="COMPLICATED_CASES">
+  COMPLICATED CASES
+</h3>
+
+<p><b>Proud Flesh.</b> The development of unhealthy, exuberant
+granulations is a common occurrence in connection
+with ingrown nail cases, especially when they have been
+allowed to progress before proper treatment has been
+inaugurated.</p>
+
+<p>In all cases the primary steps in the treatment are
+essentially similar to those described under “uncomplicated
+cases.” Proper asepsis and antisepsis are at all times
+to be strictly observed, and any ingrown portion of nail
+should in all cases be first removed before additional treatment
+is administered.</p>
+
+<p>The speedy and complete removal of the unhealthy
+granulations is at all times essential. This may be accomplished
+either by excision, by the actual cautery or by the
+use of escharotics. The operator must always remember
+that the presence of proud flesh in a wound not alone retards
+the normal healing process, but also prevents the
+<span class="pagenum" id="Page_222">[Pg 222]</span>wound from healing without the formation of an abnormal
+amount of new tissue. If, for instance, a mass of proud
+flesh the size of a pea were present in connection with an
+ingrown nail and allowed to remain without further treatment,
+the tissue would in time present a perfectly normal
+appearance. That is, the exuberant granules would sooner
+or later develop an epithelial
+covering which
+would be of like appearance
+to the normal surface
+of the skin. But in
+doing so, the tissues
+would still retain the
+shape and size of the
+original mass of exuberant
+granules and we
+would find a teat of tissue,
+the size of a pea,
+jutting out of the normal
+surface of the nail
+groove.</p>
+
+<p>Keeping in mind,
+then, that to obtain a
+speedy and normal
+healing action in a
+wound the proud flesh
+present must be eradicated,
+it should appeal
+to the operator that the
+quickest means for its
+removal must be the best. Two quick and complete methods
+for obtaining this desired result are found in (1), excision
+(by the use of the scalpel or curved scissors), and in (2), the
+actual cautery.</p>
+
+<figure class="figcenter illowe24" id="i_p222">
+  <img class="w100" src="images/i_p222.jpg" alt="">
+  <figcaption>
+    BEGINNING INGROWN TOE NAIL
+  </figcaption>
+</figure>
+
+<p><b>Excision.</b> Excision of the proud flesh cannot be resorted
+to in all cases, but in most cases at least the larger portion of
+the exuberant granulations can be removed in this manner.</p>
+
+<p><span class="pagenum" id="Page_223">[Pg 223]</span></p>
+
+<p>The condition in which the use of the curved scissors is
+particularly advocated as most efficient is that in which the
+mass of proud flesh is found in pendulous form, where its
+base is narrow and covers but a small area and where the
+mass expands into an enlarged extremity. In cases where the
+proud flesh is found generally throughout the nail groove,
+and in some instances under the lateral edge of the nail
+itself, the scissors or scalpel cannot be used with good effect,
+if at all. Then of course other means must be employed.</p>
+
+<p><b>Method of Procedure.</b> After the field of operation has
+been thoroughly sterilized and the ingrown portion of the
+nail has been located and removed, the exact situation and
+amount of proud flesh is ascertained. If at all practical, a
+sterile scissors (preferably of the curved variety) is inserted
+under the granulating mass and the whole is quickly snipped
+off at its junction with the normal integument. Where
+the mass is considerable, it will be found advisable to ligate
+the toe at its base by means of a few tight turns of adhesive
+tape or by the use of a rubber ligature. This precaution
+will lessen the resulting hemorrhage and it can be more
+readily controlled.</p>
+
+<p>Where the amount of proud flesh to be excised is small,
+the blood flow is easily arrested by digital pressure.</p>
+
+<p>It will generally be found conducive to the best results
+to anesthetize the parts by hypodermatic injections of
+novocaine or by means of the ethyl chloride spray. This is
+not necessary in every instance, however, as the advisability
+of producing anesthesia depends upon the amount of tissue
+involved and the nervous condition of the patient.</p>
+
+<p>After the exuberant granulations have been cut off,
+Monsel’s solution, adrenalin chloride or some other styptic
+is applied to the bleeding capillaries.</p>
+
+<p>It may be found advisable to apply silver nitrate, 50%,
+or even nitric acid, c.p., to the bleeding parts. This serves
+not alone to check the hemorrhage, but the escharotic action
+tends to destroy whatever remaining shreds of the proud
+flesh may still be present.</p>
+
+<p><span class="pagenum" id="Page_224">[Pg 224]</span></p>
+
+<p>The oozing arrested, the ligature is removed. The nail
+groove is packed firmly with sterile gauze (firmly, so as to
+further check the vascular supply to the parts) and a wet
+dressing of liq. aluminum acetate is applied. In the event of
+no further recurrence of the proud flesh, the case is treated
+in any of the ways described under “uncomplicated cases.”</p>
+
+<p><b>The Actual Cautery.</b> The electric cautery presents a
+quick and sure means by which proud flesh may be destroyed.
+Local anesthesia should first be induced by means
+of a hypodermatic injection of novocaine, 1%, or by use of
+a freezing spray, such as ethyl chloride. In most instances
+the use of the ethyl chloride will be found sufficient for the
+needs of the case although its anesthetic effect is quite superficial
+and transient. Novocaine, on the contrary, is both
+lasting and complete in its effect.</p>
+
+<p>The argument against the use of the actual cautery is
+one of humaneness rather than one of science. Regardless
+of the lack of sensation produced by the anesthetic, patients
+will rebel at the sight of a white hot cautery. The
+mental shock of seeing one’s flesh seared by a hot iron is
+pronounced, and at the present time no podiatrist can take
+liberties with the patient’s feelings as does the surgeon,
+without jeopardizing his reputation and diminishing his
+clientele. On the other hand, while the mental anguish of
+the patient may be greater during the use of the actual
+cautery, the subsequent suffering is much less than that following
+the application of an escharotic.</p>
+
+<p>After the use of the cautery, a wet dressing of liq.
+aluminum acetate or a solution of boric acid and alcohol,
+equal parts, may be applied and renewed until all acute inflammatory
+symptoms have subsided when a dressing may
+be employed to hasten granulation.</p>
+
+<p><b>Escharotics.</b> The use of caustics for the destruction of
+proud flesh is probably the most generally used method in
+vogue today. Nitric acid, caustic potash and silver nitrate,
+either in fused or in solution form, may all be used in most
+every instance.</p>
+
+<p><span class="pagenum" id="Page_225">[Pg 225]</span></p>
+
+<p>Inability for any reason to resort to the use of a curved
+scissors, the scalpel, or the cautery compels us to look among
+the caustics for an agent to accomplish the desired results.
+Keeping in mind the aforementioned fact, that the quickest
+means for proud flesh removal or destruction is the best, we
+naturally lean toward the strong corrosives as a means to
+bring about this end.</p>
+
+<p><b>Nitric Acid.</b> Nitric acid (aqua fortis), in all probability,
+is the most efficient member of this class of drugs, as
+its action is both energetic and penetrating. In cases where
+the exuberant granulations are found involving the entire
+nail fold and in no particular localized area, aqua fortis
+is found very useful. Usually one application is sufficient
+to destroy all vestige of the unhealthy tissue, but in extreme
+cases added treatment may be necessary.</p>
+
+<p>Care is taken to cover the surrounding healthy integument
+with some greasy substance (vaseline is generally
+preferred) to prevent the acid from coming in contact with
+it and avoiding the consequent bad effects. The acid is then
+applied by means of a cotton wound applicator (wooden
+applicators are preferred, as they are inexpensive and may
+be thrown away after being used) or a glass rod. The nail
+groove should be firmly packed with sterile gauze and a
+wet dressing of liq. aluminum acetate or of bichloride of
+mercury, ¹⁄₅₀₀₀, or a boric acid and alcohol solution, equal
+parts, should be applied over the affected parts. At the
+next examination, any remaining shreds of the unhealthy
+granulation are to be looked for and, if found, another but
+lighter application of the acid should be applied. It is wise
+to remove the eschar caused by the previous application so
+that deeper penetration and more efficient action from the
+drug may be obtained.</p>
+
+<p>This is continued until all remnants of the proud flesh
+are destroyed, when the toe should be dressed to induce
+speedy and healthy granulation.</p>
+
+<p><b>Caustic Potash.</b> Potassium hydroxide (caustic potash)
+may be used in place of nitric acid for the destruction of
+<span class="pagenum" id="Page_226">[Pg 226]</span>proud flesh. The preference for the latter seems to be due
+to the fact that wound’s caused by the action of nitric acid
+are prone to heal more rapidly than those due to the use
+of caustic potash; also because the action of aqua fortis
+can be more readily counteracted should the need for such
+action arise.</p>
+
+<p>Caustic potash should be used with care, the same precautions
+to protect the healthy tissue being taken as in the
+use of nitric acid. Apply caustic potash on a small cotton
+wound applicator, packing the nail fold with sterile gauze
+to be followed by a moist dressing of liq. aluminum acetate.</p>
+
+<p><b>Silver Nitrate.</b> The use of the silver stick or a strong
+solution of the salt to destroy any great amount of proud
+flesh is not advocated. In the first place the caustic action
+of silver nitrate is due solely to the nitric acid generated by
+its use, and so the aqua fortis should be used to obtain a
+speedier and more energetic removal of the unhealthy tissue.
+Secondly, silver nitrate coming in contact with the
+albuminous tissue, decomposes, oxidizing it and forming a
+metallic deposit on the surface which becomes an impermeable
+eschar. This hard crust not alone prevents the silver
+salt from penetrating into the tissues—the action of silver
+nitrate is thus called “self-limiting”—but also being unyielding,
+acts as a direct irritant to the denuded tissues.</p>
+
+<p>Silver nitrate is, however, particularly efficacious after
+the great amount of the proud flesh has been removed by
+means of excision; in this situation it acts as a styptic to
+arrest the capillary flow of the bleeding stump, and as a
+mild caustic to destroy the remaining shreds of the unhealthy
+granulation. It is also a beneficial application for
+hardening the tissues of the nail fold to prevent further
+recurrence of the ingrowing nail. This subject will be fully
+discussed under “Prophylaxis.” After excision of the
+proud flesh, silver nitrate should be used in solution of fifty
+per cent. and the toe dressed as has been previously
+described.</p>
+
+<p><b>Burnt Alum.</b> Burnt alum is still another remedy used
+<span class="pagenum" id="Page_227">[Pg 227]</span>in podiatry for the destruction of proud flesh. Its use is
+not now favored for that direct purpose, but there are some
+situations in connection with the treatment of the condition
+in which it may be used with good results. It is the
+least energetic of all the escharotics herein mentioned, and
+many prefer to class it rather as an astringent. The burnt
+alum is dusted in the nail groove directly on the mass of
+proud flesh and the groove is then packed with sterile gauze.
+Because of its extremely mild action, comparatively speaking,
+burnt alum will not accomplish its work of destruction
+with the rapidity nor the completeness of the other mentioned
+drugs; moreover it causes considerable irritation and
+pain to the patient. The modern practitioner is inclined to
+relegate this drug, as a caustic, to the shelf, to be used only
+in cases where a strong astringent action is desired.</p>
+
+<p><b>Liquor Ferri Subsulphate.</b> Monsel’s solution has been
+used to dry up unhealthy granulations because of its astringent
+action rather than on account of its caustic properties.</p>
+
+<p><b>Treatment of Acute Infective Inflammations.</b> Infection
+is in all probability more generally met with in connection
+with ingrown nail cases than in any other ailment
+primarily occurring on the foot. The state in which the
+toe may be found is dependent upon the length of time the
+case has progressed without proper treatment. Cellulitis
+may be circumscribed or diffused, and lymphangitis, both of
+the reticular or tubular variety, may be present.</p>
+
+<p>Following the usual antiseptic and aseptic precautions
+relative to the field of operation, the operator’s hands and
+the instruments, drainage of the suppurated areas must first
+be obtained.</p>
+
+<p>In the average case, an abscess cavity is usually found
+in or adjacent to the lateral nail fold, and in many instances
+the pus sac will be punctured during the removal of the
+ingrown portion of the nail. It is sometimes found necessary
+to remove an overlying portion of nail, other than the
+ingrown portion, to give free access to the suppurating
+process and to afford drainage for its purulent discharge.
+<span class="pagenum" id="Page_228">[Pg 228]</span>A sterile chisel of the straight variety is generally used to
+accomplish the removal of the ingrown portion of nail,
+care being taken that the cutting edge is inserted deep
+enough to penetrate only the nail and not to pierce the underlying
+soft parts.</p>
+
+<p>Some practitioners do not advocate the removal of
+portions of the nail and prefer rather merely to drill a hole
+through the nail body and excavate the pus through this
+channel. No doubt circumstances alter cases, but the writer
+would prefer having the septic tract wholly exposed so that
+thorough irrigation and proper treatment may be accomplished.</p>
+
+<p>Having given free drainage to the pus cavities, the
+parts should again be sprayed with alcohol, 60%. Hydrogen
+peroxide, which manifests its greatest efficacy in pus cases,
+should then be freely applied until ebullition ceases.</p>
+
+<p>In cases where the sinus is small and deep and an ordinary
+cotton wound applicator is too large for insertion
+into its recesses, a wooden applicator tipped with iodine
+(these applicators already prepared are now on the market)
+will be found fine enough for this accomplishment.</p>
+
+<p>There is also on the market a fine, hollow, flexible
+needle, with a bulbous extremity in which there is an opening,
+that fits any hypodermic syringe. Two or three drops
+of iodine are drawn into the barrel, the needle is inserted
+into the sinus, and its contents are evacuated by piston
+pressure. This enables the operator to get the drug down
+into the sinus so that it comes into direct contact with its
+deepest surfaces. This needle is made of a non-corrosive
+metal.</p>
+
+<p>The next point to be considered is the form of dressing
+to be used. If the case has progressed to a point where the
+operator feels the necessity of a surgeon’s advice, the latter
+should by all means be called in as a consultant. The writer
+feels, however, that in most instances the modern practitioner
+of podiatry is well equipped to successfully treat
+even severe cases of this nature.</p>
+
+<p><span class="pagenum" id="Page_229">[Pg 229]</span></p>
+
+<p>The affected nail groove is packed with sterile gauze
+and a large piece of the fabric, of several thicknesses, is
+placed over the whole inflamed area. This is saturated with
+a solution of mercuric chloride, ¹⁄₅₀₀₀, and is remoistened
+at intervals by the patient so that it is constantly wet. In
+some cases it may be wise to have the patient remain in the
+office several hours to make sure that the infected parts are
+kept constantly immersed in a solution of mercuric chloride,
+¹⁄₅₀₀₀. This treatment has been found to be extremely
+beneficial in reducing the inflammation so that a moist
+evaporating dressing, as described above, may be safely
+applied. Rest is another feature to be employed in the
+treatment of these cases. The patient should be instructed
+to refrain absolutely from the use of the affected parts
+until such time when the inflammatory conditions have subsided
+or are under control. The podiatry patient as a rule
+is loathe to have his or her energies in any way curtailed,
+but the mention of “blood poisoning” is usually sufficient
+stimulus to send the patient to bed when so ordered.</p>
+
+<p><b>Prognosis.</b> The prognosis in all cases of ingrown nail
+under proper treatment is favorable. The length of time
+elapsing before a cure is affected is of course dependent
+upon the condition of the toe and the general condition of
+the patient.</p>
+
+<p>In cases where the nail penetration is slight, and the
+inflammatory conditions are in their incipiency, one or at
+most two treatments will be sufficient to heal the ulceration
+and to restore the toe to its normal condition. Complicated
+cases necessarily take longer to relieve and longer to cure.</p>
+
+<p>The surgeon is still rather reluctant to believe that an
+ingrown nail can be cured without removal of the affected
+half of the nail, the lateral nail fold, and a portion of the
+matrix. This method of procedure in nearly every instance
+incapacitates the patient for fully two weeks and it is doubtful
+whether anything is gained (taking all matters into
+consideration) over the methods of ingrown nail treatment
+as here outlined.</p>
+
+<p><span class="pagenum" id="Page_230">[Pg 230]</span></p>
+
+<p>The surgical argument is based on the contention that
+unless the matrix underlying the affected nail be removed,
+the nail will again grow into the tissues. This is unquestionably
+so, but in a majority of cases, as explained previously,
+the trouble is not due to a misdirected growth of the
+nail, but rather to the tissues surrounding the free edge and
+lateral nail border crowding up, around and over the nail.</p>
+
+<p>It may then be safely stated that an ingrown nail properly
+treated and which has been subjected subsequently to
+proper prophylactic measures, is curable; not temporarily,
+but permanently.</p>
+
+
+<h3 id="PROPHYLAXIS">
+  PROPHYLAXIS
+</h3>
+
+<p>In considering the measures employed by which the general
+condition of the nail may be improved so as to prevent
+a further recurrence of the ingrowing tendencies, we
+will make, for simplicity’s sake, six divisions. Five of these
+relate to the nail itself and to the subjacent tissues, and
+one to the footgear and hosiery of the patient.</p>
+
+<p><b>1. Thinning the Nail Through Its Long Axis.</b> When
+the acute inflammatory symptoms have subsided and the
+ulcerated areas healed, in other words when the toe and the
+nail have returned to normal, measures should be taken to
+prevent the latter from becoming again ingrown. With a
+rotary file, the centre of the nail should be ground to a
+paper thinness through its long axis. What is accomplished
+by this procedure?</p>
+
+<p>The nail is normally convex on its outer surface and
+the apex of its dome is the centre of the nail body. This
+portion, being the greatest point of elevation, naturally receives
+the brunt of the pressure from the shoe. If the nail,
+then, is allowed to remain thick in the centre of its body,
+the shoe pressing upon it will find the nail unyielding and
+in consequence will cause its lateral borders to be forced
+down into the nail grooves. By thinning the body of the
+nail to such an extent that it becomes thin and flexible, the
+shoe presses upon a yielding surface, in consequence of
+<span class="pagenum" id="Page_231">[Pg 231]</span>which the nail “gives” or spatulates at its centre and the
+pressure upon its lateral borders is decreased if not prevented
+entirely.</p>
+
+<p>Having done away with any untoward pressure which
+might be brought to bear on the nail, we next turn to:</p>
+
+<p><b>2. Hardening the Nail Groove, and Shrinking the Flap.</b>
+In many cases, after all acute symptoms of the disturbances
+have subsided, we find that the flap of tissue adjacent to the
+once affected nail and forming the outer side of the groove,
+is greatly thickened and enlarged.</p>
+
+<p>This must be reduced in order that the new-forming
+nail will have sufficient room to develop to its normal width
+and we must also harden and toughen the nail groove so
+that it will present a surface that the nail, as it grows out,
+will not be able to penetrate, should it be so inclined.</p>
+
+<p>Silver nitrate is the most generally used and most
+efficient agent to carry out a treatment of this kind. Solutions
+varying in strength from 5% to 50% are recommended,
+and the selection depends on what is to be accomplished and
+the length of time which may be given to the treatment.</p>
+
+<p>By persistent use of silver nitrate solution, 50%, an
+enlarged and thickened nail flap may in time be reduced to
+normal. Applications about one week apart—in some cases
+ten days or two weeks to intervene—will usually work wonders
+in conditions of this kind. The groove should be thoroughly
+cleansed and dried and the silver solution should be
+applied on a small cotton wound applicator and painted well
+down under the nail and over the tissue in the enlargement.
+A dressing, usually cotton and collodion, is then applied
+and allowed to remain undisturbed until the patient’s return.
+The action of this solution is astringent and sedative.
+It is bound to reduce the chronic inflammatory symptoms
+that may be present and, acting as an astringent, it
+gradually shrinks the enlarged flap until the normal line of
+the lateral nail fold is reached.</p>
+
+<p>During the treatment, there is absolutely no pain nor
+inconvenience to the patient. Care should always be exercised
+<span class="pagenum" id="Page_232">[Pg 232]</span>that the silver solution be not applied if any hemorrhage
+has been caused in the removal of a previous eschar,
+as it is sufficiently caustic to cause ulceration should it come
+in contact with such a denuded surface. Packing of the
+nail groove will be discussed under the sub-heading “Packing.”</p>
+
+<p>Subsulphate of iron (Monsel’s solution) may be used
+in the treatment of cases of this nature, but its action as an
+astringent in this connection is so mild that it is of necessity
+a slow process to effect a complete cure.</p>
+
+<p>The solution, usually applied to the groove on gauze,
+is allowed to remain. In fact, the patient is often advised
+to procure a quantity of the drug and keep the gauze
+moistened.</p>
+
+<p>The patient should be seen at periods of about a week
+or ten days, when both the dressing and the eschar caused
+by the action of the iron salt are removed. Fresh gauze
+is packed under the nail and the treatment continued.</p>
+
+<p>Ferric chloride has much the same action in this connection
+as the subsulphate, but this drug has never been so
+popular, for the reason of its greater irritant qualities,
+few of which are to any degree manifest in Monsel’s solution.</p>
+
+<p>Ointments or collodion containing large percentages of
+salicylic acid—as high as sixty to seventy-five per cent.—are
+sometimes used to destroy an enlarged nail flap by
+strong disintegrative action. The ointment is usually prepared
+on a cerate base and sufficient wax is added to thicken
+the paste so that the tendency to melt and run over portions
+of the integument, where its action would be detrimental,
+is minimized.</p>
+
+<p>The ointment is applied in the groove and over the
+top surface of the mass to be destroyed and is allowed to
+remain for a few days when the disintegrated portion is
+removed and another application made. This action of
+salicylic acid, used in considerable strength, is at times
+painful and cannot be borne by every patient. The treatment
+<span class="pagenum" id="Page_233">[Pg 233]</span>is a good one, however, and is rapidly coming into
+the prominence and popularity it deserves. Salicylated
+collodion is similar in action to the ointments containing
+salicylic acid, and the same general procedure holds good
+for both applications. The collodion is applied on all surfaces
+of the mass, is covered with a cotton and collodion
+dressing and a second application is made upon the removal
+of the disintegrated portion.</p>
+
+<p>It is sometimes advantageous to alternate the silver
+nitrate treatment with that of salicylic acid. An application
+of the ointment or the collodion is made and upon removal
+of the disintegrated portion, the silver solution is
+applied. After the lapse of about two weeks, the salicylic
+acid is again applied and the treatment continued alternately
+in this manner until the desired result is obtained.</p>
+
+<p><b>3. Packing.</b> We here come to one of the most important
+procedures necessary to a successful prophylactic
+treatment of an ingrown nail. Whether the nail groove is
+to be packed loosely or tightly is a question of great import
+and should be given careful consideration by the
+operator. Often the comfort of the patient and always the
+ultimate outcome of the case is dependent on the proper
+packing of the nail groove as an after-treatment.</p>
+
+<p>There appears to be a great tendency to pack the groove
+full to overflowing with gauze, cotton, or what not, and,
+although there are some instances where a procedure of
+this kind is necessary, it is usually conducive to a great
+amount of pain to the patient and has a decidedly deleterious
+effect on the tissues under treatment.</p>
+
+<p>In general, it is wise to pack the groove as lightly as
+possible, using only a small pledget of gauze or cotton and
+taking care that the fabric is well under the nail and interposed
+between it and the tender areas underneath. It must
+be remembered that no matter what fabric be used for
+packing, it rapidly hardens and becomes more or less irritant
+to the tissues. Should the nail groove be packed to
+such a degree that at the time of dressing it is unyielding
+<span class="pagenum" id="Page_234">[Pg 234]</span>and hard, it is easily realized what the condition of this
+dressing will be in the course of a few days.</p>
+
+<p>The only time a nail groove might be tightly packed is
+in connection with the treatment of proud flesh when the
+tight packing tends to interrupt the circulation to the part
+and thus aids in retarding the growth of the superfluous
+granulations. Another instance when a groove may be
+packed tightly is in a case where no inflammation is present
+and when it is the desire of the operator to hold the softer
+tissues down and away from the edge of the nail so that
+sufficient room may be allowed for the nail to grow out and
+attain its normal width. A word in connection with this
+theory. Silver nitrate solutions, twenty-five to fifty per
+cent., applied to the groove hardens the tissue by means of
+the eschar developed on its surface and a tight packing to
+hold these tissues in place is an ideal combination for the
+prophylactic treatment of a previously acute ingrown nail
+case, when by such tight packing no noticeable inconvenience
+is caused to the patient. If cotton is used as a
+packing it should be rolled into a loose thin pledget, the
+finer “point” of which is inserted under the edge of the nail
+near its posterior fold, and the thicker end is packed under
+the nail at its distal portion. One thickness of gauze is
+generally sufficient and, at most, two thicknesses may be
+used, unless, of course, tight packing is required.</p>
+
+<p>In connection with this prophylactic treatment it may
+sometimes be wise to place a shield of felt or buckskin between
+the tender part and the adjacent toe to hold that
+member away from the affected areas and so that the medications
+applied may be allowed a chance to complete their
+therapeutic action undisturbed. This shield is not strapped
+but is merely placed between the toes, resting on the interdigital
+web, and is just high enough to reach the base of the
+nail and so does not come in direct contact with the area
+under treatment.</p>
+
+<p><b>4. Allowing the Nail to Grow Long.</b> The nail should
+be allowed to attain as great a length as possible, particularly
+<span class="pagenum" id="Page_235">[Pg 235]</span>at its lateral points, without interference with the continuity
+of the patient’s hosiery, and yet not long enough to
+cause pressure from the toe of the boot.</p>
+
+<p>This can be best accomplished by cutting the free edge
+of the nail in a concave manner. The lateral points are
+kept, if possible, long enough so as to extend to a point
+slightly beyond the distal end of the nail fold and the rest
+of the free edge is cut in a circular manner so that at its
+centre it is no longer than just sufficient to cover the anterior
+edge of the nail bed. This manner of cutting, combined
+with thinning the nail body through its central longitudinal
+axis, prevents any great amount of pressure from being
+exerted by the shoe upon the apex of the nail’s convexity.
+It will also, to a great extent, prevent the nail from cutting
+through the patient’s hosiery. If the whole nail is allowed
+to grow long, and its free edge to extend over the end of the
+toe, some leverage is bound to be brought upon this extended
+portion and in consequence there is a tendency to
+press the lateral edges of the nail into the grooves, which,
+of course, is to be avoided at all costs.</p>
+
+<p><b>5. No Lateral Cutting.</b> In connection with the length
+which the nail is allowed to retain, it is absolutely imperative
+that no lateral cutting be done. Some cases of ingrown
+nail have been observed in even very young children (in
+one instance a baby of fourteen months). The primary
+cause in every case was found to be the overzealous care
+on the part of the parents to prevent just the condition
+they had caused by injudiciously removing from time to
+time the lateral edges of the sufferer’s toe nails.</p>
+
+<p><b>6. Proper Boots and Hosiery.</b> In addition to the various
+means for preventing the recurrence of an ingrowing
+nail, great care should be exercised in the selection of the
+patient’s footgear.</p>
+
+<p>Shoes of sufficient width and length should of course
+be advocated so that at no time will the toes be cramped by
+any degree of pressure.</p>
+
+<p>The wearing of a pointed boot or slipper in which there
+<span class="pagenum" id="Page_236">[Pg 236]</span>is not sufficient width at the ends of the toes to allow those
+members proper latitude, should be discouraged. When
+footgear is worn in which this cramped condition of the
+digits is brought about, it will be generally found that the
+soft tissues lying adjacent to the lateral edges of the nail are
+crowded up alongside the latter and an enlarged and thickened
+flap, which is the cause of so much trouble, is formed.
+Lace boots are probably the most practical of any in that
+they may be firmly fastened about the ankles and over the
+instep, and thus prevent the foot from sliding forward and
+coming in contact with the toe of the boot. Pumps of all
+varieties are without a doubt the most detrimental footgear
+worn today—for they have absolutely no support or anchorage
+at the ankle and, in some cases, patients find themselves
+flexing the toes in the endeavor to retain the slipper on the
+foot.</p>
+
+<p>Hosiery, too, should be neither tight nor short, as a
+short stocking or sock may cause pressure upon the toe
+nails and so be the forerunner of trouble.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_237">[Pg 237]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_XV">
+    <span class="chap">CHAPTER XV</span>
+    <br>
+    DISEASES OF THE NAILS
+  </h2>
+</div>
+
+
+<p>The nails of the hands and feet are subject to various
+diseases. The chief of these are:</p>
+
+<blockquote>
+<p>
+  Onychocryptosis, or ingrown nail.<br>
+  Onychophosis, or calloused nail groove.<br>
+  Onychia, or inflammation of the matrix.<br>
+  Paronychia, or inflammation around the nail.<br>
+  Onychauxis, or club nail.<br>
+  Onychatrophia, or atrophy of the nail.<br>
+  Onychoptosis, or falling off of the nail.<br>
+  Onychorrhexis, or brittle nail.
+</p>
+</blockquote>
+
+<p>Some of these diseases of the nails are the result of a
+general systemic disturbance, but only the local treatment
+of such conditions becomes the province of the podiatrist.
+It is often necessary to distinguish between a local
+chiropodical condition and a local manifestation of some
+serious systemic disease; it is then necessary for the medical
+practitioner and the podiatrist to join hands in
+making a diagnosis for the proper guidance of both practitioners.</p>
+
+<p><b>Onychocryptosis</b>, or ingrown toe nail, is a common affliction
+of the nail, and is thoroughly described in a separate
+chapter.</p>
+
+<p><b>Derivation.</b> From the Greek, onyx, nail, and krypto,
+I hide or conceal.</p>
+
+<p><b>Onychophosis</b>, or calloused nail groove, is also one of
+the common types of nail lesions, and is discussed separately.
+This lesion is often mistaken for ingrown toe nail, and
+treatment, improperly directed, often causes bad results.</p>
+
+<p><span class="pagenum" id="Page_238">[Pg 238]</span></p>
+
+<p><b>Onychia or Onychitis</b> is an inflammation of the matrix
+with suppuration and final shedding of the nail.</p>
+
+<p><b>Derivation.</b> From the Greek, onyx, nail, and itis, inflammation.</p>
+
+<p><b>Etiology.</b> Onychia may be due to trauma, causing malformation
+of the nail, and subsequent inflammation, but is
+most usually due to bacterial infection. Removal of ingrown
+toe nails under septic conditions, or the entrance of
+bacteria through self-inflicted or other wounds offer opportunities
+for infective processes on a part of the body none
+too clean at best. Syphilis, tuberculosis and eczema are
+also often etiologic factors.</p>
+
+<p><b>Pathology.</b> Bacterial infection or trauma causes the
+nail matrix to become inflamed, with the accompanying
+pathologic changes that occur in all inflammatory processes.
+There is a gradual solution of the continuity between the
+nail proper and the matrix, and as the degenerative processes
+continue, namely the formation of pus and the solution
+of the tissues which comprise the matrix, the grooves
+in the nail matrix, which hold the corresponding ridges of
+the nail, are lost and the mechanical union of the two parts
+cease. The nail subsequently falls off. If the entire matrix
+has been destroyed, no new nail will grow, but this does not
+usually occur. Malformation of the new nail is quite common,
+due to partial destruction of the matrix.</p>
+
+<p><b>Diagnosis.</b> The matrix of the nail is inflamed and severe
+pain is felt when pressure is brought to bear on the
+nail plate. The nail bed and the nail grooves are often involved
+and the inflammation may continue to such an extent
+as to involve lymphatics and cause destruction of a
+large area of tissue.</p>
+
+<p>Pus forms at the root of the nail, and the nail itself
+gradually becomes loosened from its bed. In cases due to
+injury or local infection, one or two toes may be involved,
+but when the cause is of systemic origin, all of the nails,
+including those of the hand, may become infected.</p>
+
+<p><b>Treatment.</b> The treatment of simple onychia consists
+<span class="pagenum" id="Page_239">[Pg 239]</span>in protecting the part from further injury and irritation
+and it often becomes necessary to cut the shoe to accomplish
+this. In severer cases, shoes should not be worn until resolution
+commences.</p>
+
+<p>Wet dressings are valuable, Burow’s solution or boric
+acid solution being all that is necessary in mild cases.</p>
+
+<p>When pus manifests itself, it is necessary to remove the
+nail over the abscess and to establish free drainage. Wet
+dressings of bichloride of mercury (¹⁄₅₀₀₀) for 48 hours
+may be used, and when drainage is complete, the cavity may
+be swabbed with silver nitrate, 5 to 10%. Dry dressings of
+thymol iodide or boric acid powder will usually suffice to
+complete a cure.</p>
+
+<p>The parts should be packed with sterile gauze so as to
+keep the soft tissues separated from the nail and to prevent
+irritation and pressure. This packing should not be too
+tight otherwise pus absorption with subsequent infection,
+is likely to occur.</p>
+
+<p>In extreme cases, in which the surrounding tissues are
+involved and destruction has gone on to a greater extent, the
+entire nail must be removed, and the matrix destroyed by
+caustics or by curettage.</p>
+
+<p><b>Paronychia, or Paronychitis</b>, is an inflammation of the
+tissues around the nail, and may involve all the tissues of
+the distal phalanx, including the bone.</p>
+
+<p><b>Synonyms.</b> Felon, panaris, whitlow.</p>
+
+<p><b>Derivation.</b> From the Greek, para, beside, and onyx,
+nail.</p>
+
+<p><b>Etiology.</b> Paronychia is usually caused by local bacterial
+infection, due to treating the nail grooves with
+unclean instruments, or it may be of systemic origin. It is
+often associated with onychia and in these cases is due to
+a spreading of the inflammation of the matrix to the surrounding
+tissues. Pressure of an ill-fitting shoe or stocking
+or of a foreign body may be a cause, and ingrowing
+toe nail may later develop into a paronychia. Syphilis
+often causes this lesion.</p>
+
+<p><span class="pagenum" id="Page_240">[Pg 240]</span></p>
+
+<p><b>Pathology.</b> The pathology of paronychia is much the
+same as that of onychia. The tissues surrounding the nail
+become inflamed, either by bacterial infection or by trauma,
+and all the signs and symptoms of inflammation manifest
+themselves. Swelling is marked and pus may or may not
+be present. Tissue destruction continues unless proper
+treatment is given, and the bone is often involved, causing
+periostitis or osteitis.</p>
+
+<p><b>Diagnosis.</b> Simple paronychia may exist without any
+hypertrophy of the nail itself, and may be due to pressure
+of a shoe or to a chronic ingrowing toe nail. The great toe is
+most commonly affected. The inflammation may be only
+slight and superficial, or it may be quite severe with great
+pain and swelling, terminating in a general intercellular infection
+with suppuration. Nourishment is interfered with
+and the nail may be shed much the same as in onychia. Pain
+is of a throbbing type which is immediately relieved when
+the abscess cavity is opened and the pus drained.</p>
+
+<p><b>Treatment.</b> Like onychia, paronychia should be
+treated with wet dressings and stimulating medications.
+In cases in which there is no suppuration, the following ointment
+will give good results:</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl padl">
+℞ Acidi salicylici
+</td>
+<td class="tdr">
+grs. X
+</td>
+</tr>
+<tr>
+<td class="tdl padl">
+Ung. hydrarg. amm.
+</td>
+<td class="tdr">
+Oz. 1
+</td>
+</tr>
+<tr>
+<td class="tdc" colspan="2">
+M. ft. ung. Sig. Keep on affected part constantly.
+</td>
+
+</tr>
+</table>
+
+
+
+<p>The corners and lateral edges of the nail should be separated
+from the soft tissues by means of sterile gauze, or
+they may be removed. Pus should be drained, with the assistance
+of antiseptic wet dressings such as bichloride of
+mercury, ¹⁄₅₀₀₀, and if excessive granulations are present,
+they should be snipped off or destroyed with silver nitrate.
+If necessary, free incisions should be made, which will relieve
+the pain as well as assist in draining the pus.</p>
+
+<p>In chronic paronychia it often becomes necessary to
+remove the entire nail, including the root, and under local
+anesthesia, this is easily accomplished. Rest is essential in
+<span class="pagenum" id="Page_241">[Pg 241]</span>these cases, and after suppuration has ceased, stimulants
+such as balsam of Peru or ichthyol may be used to good
+advantage.</p>
+
+<p>In cases of paronychia, due to syphilis, it must be remembered
+that the treatment must be constitutional as well
+as local and the family physician of the patient should attend
+to the former feature
+of the treatment.
+Mercurial ointments,
+applied twice daily, are
+usually employed locally.</p>
+
+<figure class="figcenter illowe24" id="i_p241">
+  <img class="w100" src="images/i_p241.jpg" alt="">
+  <figcaption>
+    ONYCHOGRYPHOSIS
+  </figcaption>
+</figure>
+
+<p><b>Onychauxis</b>, or hypertrophy
+of the nail, is
+an overgrowth or enlargement
+of the nails
+of the fingers and toes.
+When the hypertrophy
+is accompanied by deformity,
+the condition
+is called onychogryphosis.</p>
+
+<p><b>Derivation.</b> From
+the Greek, onyx, nail,
+and auxe, increase.</p>
+
+<p><b>Etiology.</b> Enlargement
+of the nail is a result
+of hyperplasia of
+the papillæ of the matrix,
+the thickening occurring
+at the base, front, lateral edges or over the entire
+area of the nail depending on the part diseased.</p>
+
+<p>Pressure is no doubt a causative factor, and lack of
+care of the nails will also cause a thickening. Injury to the
+matrix will cause the nail to become hypertrophied, producing
+in most cases a true club nail (onychogryphosis).</p>
+
+<p>Chronic cutaneous lesions, such as eczema or psoriasis
+<span class="pagenum" id="Page_242">[Pg 242]</span>and other diseases such as syphilis, gout and rheumatism,
+and nervous diseases or injury to the nerves supplying the
+nails, may act as causes for onychauxis.</p>
+
+<p><b>Pathology.</b> Pressure or injury causes a widening of
+the nail fold which allows the formation of a thicker nail.
+The nail bed is irritated at the same time and a horny mass
+forms on it below the nail, which acts as a barrier to the
+forward movement of the nail cells, and by raising them
+up, determines more or less, the degree of deformity. The
+papillæ of the matrix become enlarged, and may be seen
+protruding above the normal structure, when the nail is
+removed.</p>
+
+<p>The thickened and deformed nail thus produced, is
+often the cause of other nail lesions, due to its pressure on
+the soft tissues. Bacterial infection is also common at this
+point, due to the fact that the mass of epithelial cells is
+a good breeding place for microorganisms.</p>
+
+<p><b>Diagnosis.</b> Onychauxis may be congenital or acquired,
+usually the latter. Simple hypertrophy of the nail is rarely
+found, but overgrowth with deformity is quite common.
+The nail becomes hardened, due to a closer cohesion of its
+component cells; its transparency is lost, and it assumes
+a dirty brown or even black color. The surface becomes
+rough, due to the presence of longitudinal and wavy transverse
+ridges.</p>
+
+<p>One or all of the nails may be affected; there may be a
+simple thickening or there may be a lateral overgrowth,
+which may result in paronychia. The inflammation may
+be slight or it may be severe and purulent. The nail, as it
+continues to become thickened, may assume various shapes
+resembling claws, talons, horns, etc. The big toe nail is the
+one most usually affected and often only the one foot is involved.
+This is indicative of a traumatic etiology.</p>
+
+<p>Tuberculosis patients have a moderate onychauxis in
+most cases, particularly on the nails of the fingers, while
+hypertrophy is often seen in the inflammatory lesions such
+as eczema, psoriasis, etc.</p>
+
+<p><span class="pagenum" id="Page_243">[Pg 243]</span></p>
+
+<p>Older persons are more liable to be affected with hypertrophy
+of the nail than younger persons, as there is a natural
+tendency to epithelial overgrowth in the aged.</p>
+
+<figure class="figcenter illowe15" id="i_p243">
+  <img class="w100" src="images/i_p243.jpg" alt="">
+  <figcaption>
+    ONYCHAUXIS
+  </figcaption>
+</figure>
+
+<p><b>Treatment.</b> To affect a cure in case of hypertrophy
+of the nails it is necessary to recognize the cause. Thus,
+in cases of onychauxis, in which the general systemic condition
+is at fault, treatment must be directed by the family
+physician along constitutional lines and includes the taking
+of tonics, arsenic, mercury, etc. If a cutaneous lesion is
+the etiologic factor, it becomes necessary to treat the case
+both generally and locally. If the cause be an external one
+alone, local treatment is sufficient. For these latter conditions,
+the treatment is divided into palliative and radical
+procedures.</p>
+
+<p>The <i>palliative</i> treatment consists in keeping the nail
+properly cut. For this purpose, the rotary file, or surgical
+drill, as it is called, is very efficient. Suitable burrs are
+used, and care is taken that the skin of the nail grooves is
+not injured. Infections are easily caused through the careless
+use of this instrument. After the nail has been thinned
+and is as nearly like a normal nail as is possible, the part
+<span class="pagenum" id="Page_244">[Pg 244]</span>should be cleansed with alcohol, and tincture of iodine (4%)
+should be applied. The grooves may be packed with sterile
+cotton and covered with collodion (cocoon dressing) which
+will avoid any tenderness that may be felt after the nail has
+been cut down. The hard nails may also be softened by the
+application of sodium sulphide or liquor potassae and when
+softened, may be scraped away.</p>
+
+<p>If thickened or club nails become very painful, it is
+often necessary to resort to <i>radical</i> measures, as this is
+the only permanent cure for this trouble. The entire nail
+must be completely removed under local anesthesia, and
+subsequently the entire nail matrix should be thoroughly
+scraped away by means of a sharp curette. The wound
+thus produced is kept in sterile dressings and is allowed
+to heal by granulation. It is quite common to find
+only a small area of the matrix that is vital, particularly
+in chronic cases of club nail, so that curettage is really a
+simple procedure. A complete cure should be effected in
+from two to three weeks, the patient being able to walk with
+a cut-out shoe two or three days after the operation.</p>
+
+<p><b>Onychatrophia</b>, or atrophy of the nails, is a condition
+in which the nails of the toes and fingers become smaller
+and often are shed from the grooves in which they are contained.</p>
+
+<p><b>Derivation.</b> From the Greek, onyx, nail, and atrophia, atrophy.</p>
+
+<p><b>Etiology.</b> Atrophy of the nails may be caused by any
+one of many factors, among which are the inflammatory
+skin diseases, nervous diseases, constitutional disorders and
+injuries.</p>
+
+<p>Injury to the nail matrix causes complete or partial
+cutting off of nourishment. If the nourishment is completely
+cut off, the nail matrix will disintegrate and cause the
+nail to be shed. New nails usually grow in these cases. If
+the injury is less severe, there is only a temporary arrest
+in the nail growth, and the nail becomes thin and small discolorations
+are seen in the nail substance.</p>
+
+<p><span class="pagenum" id="Page_245">[Pg 245]</span></p>
+
+<p>Inflammation of the soft tissues around the nail which
+is accompanied by suppuration, may cause atrophy and
+shedding of the nail. The nail will grow again as a rule,
+but often when the etiology is systemic, the new nails shed
+as soon as they are formed (onychia maligna).</p>
+
+<p>In nervous diseases, such as cerebral paralysis, tabes
+dorsalis, syringomyelia, leprosy, division of the nerves, etc.,
+from the vasomotor disturbances due to the nerve lesion,
+a bleeding may occur about the posterior nail fold, and
+atrophy of the nail may result. The nails, as a rule, usually
+grow again.</p>
+
+<p>In stasis of the blood stream in the extremities due to
+heart lesions, in venous congestion from emphysema, or in
+any lesion in which the circulation is impaired, the nails
+may undergo atrophy, particularly the nails of the fingers.</p>
+
+<p>Diseases causing scarring of the nail matrix, such as
+pustular syphilides, gummata and variola, give rise to a partial
+destruction of the matrix and a shedding of the nail.
+Subsequent scarring may completely destroy the matrix, so
+that no new nail can grow.</p>
+
+<p>In systemic diseases that cause wasting of the tissues,
+such as chronic tuberculosis, nephritis and diabetes mellitus,
+the matrix is usually under-nourished and the nails become
+discolored, soft and brittle, and often crumble.</p>
+
+<p>Chemical poisons, such as arsenic, silver and lead, may
+cause atrophy of the nails. Those who work with chemicals
+and are compelled to put their fingers in acids and in alkalies
+often develop brittle, opaque nails. In general toxemias,
+the affliction of the nail is caused by interference with
+the nail nourishment at the matrix.</p>
+
+<p><b>Pathology.</b> When the nourishment of the matrix has
+been interfered with, the cells do not develop as rapidly as
+they should, and the nail becomes thin and streaked. The
+lustre is lost and the nails become gray or yellow, and often
+also become brittle. If the grooves in the nail bed are destroyed,
+the mechanical attachment between it and the nail
+is lost and the nail is cast off. Infective processes cause
+<span class="pagenum" id="Page_246">[Pg 246]</span>complete or partial destruction of the matrix by solution,
+and this in turn causes complete or partial loss of nail.
+White spots (leuconychia), said to be due to the entrance of
+air under the nails, are often seen, and gradually move
+toward the distal end of the nail.</p>
+
+<p><b>Diagnosis.</b> Atrophy of the nails may be congenital or
+acquired, the former being rare and usually accompanied
+by imperfect development of the phalanges and scantiness
+of the hair throughout the body (alopecia universalis). Acquired
+atrophy in some form is the usual condition.</p>
+
+<p>The nails present various appearances. They may be
+thin, soft, brittle, lustreless or opaque, split very easily,
+may be streaked or even worm-eaten in appearance. One
+or all of these conditions may be present. Thinning and
+splitting of the free ends may accompany systemic diseases,
+and some chronic inflammatory (especially scaly) skin lesions.
+Some nails are thinned at the ends with a central fissure
+extending toward the root. Transverse thinning or
+furrows are met with in fevers. The nails are always affected
+when nutrition has been lowered, due to depression
+of the general health.</p>
+
+<p>In wasting diseases, such as chronic tuberculosis,
+diabetes, etc., the spoon-nail is observed. This is a condition
+in which the lateral and free margins are raised, leaving
+a spoon-like depression in the centre.</p>
+
+<p>Trauma, parasites, lowered nutrition and nervous diseases
+cause a crumbly, brittle nail. This is fairly common,
+and may be limited to one or more nails of the toes and
+fingers or it may be general. The atrophy may begin at
+either end, and extend forward or backward.</p>
+
+<p><b>Treatment.</b> Treatment of a local nature is worthless
+if the cause be systemic. Much like hypertrophy, the cure
+of atrophy depends on an exact determination of the etiology.
+Systemic treatment along proper lines will usually
+effect a cure. Local treatment consists in protecting the
+nails from irritation and sometimes even from water. The
+nails should be cut even and smooth and mollifying ointments
+<span class="pagenum" id="Page_247">[Pg 247]</span>and lotions are advisable. Cocoon dressings are
+very efficient for affording protection. In atrophy, due to
+local circulatory interference, balsam of Peru (50%), in
+castor oil, or even pure, will stimulate nail growth. This
+should be applied once a day and can be retained by cocoon
+dressing. As a soothing agent the following may be employed.</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl">
+℞
+</td>
+<td class="tdl">
+Acid. boric.
+</td>
+<td class="tdl">
+</td>
+<td class="tdr">
+</td>
+</tr>
+<tr>
+<td class="tdl">
+</td>
+<td class="tdl">
+Bismuth. subnitratis
+</td>
+<td class="tdl">
+aa
+</td>
+<td class="tdr">
+0.60
+</td>
+</tr>
+<tr>
+<td class="tdl">
+</td>
+<td class="tdl">
+Ung. aquae rosae
+</td>
+<td class="tdl">
+</td>
+<td class="tdr">
+</td>
+</tr>
+<tr>
+<td class="tdl">
+</td>
+<td class="tdl">
+Unc. zinci oxidi
+</td>
+<td class="tdl">
+aa
+</td>
+<td class="tdr">
+16.00
+</td>
+</tr>
+<tr>
+
+<td class="tdl" colspan="4">
+M. Ft. ung. Sig. Apply to the nails morning and night.
+</td>
+
+
+</tr>
+</table>
+
+<p><b>Onychoptosis</b>, falling off of the nail, and <b>Onychorrhexis</b>,
+brittle nail, are atrophies and have been discussed
+as such in the preceding sub-head.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_248">[Pg 248]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_XVI">
+    <span class="chap">CHAPTER XVI</span>
+    <br>
+    FISSURES, BLISTERS, AND BURNS
+  </h2>
+</div>
+
+
+<h3>FISSURES (<i>Fissura</i>)</h3>
+
+<p><b>Definition.</b> Fissura or fissures, as used in this sense,
+are cracks or clefts in the surface of the skin, some involving
+only the epidermic layers, some penetrating deep into
+the corium.</p>
+
+<p><b>Etiology.</b> Fissures occurring on the foot, due to
+trauma, are far in the minority as compared with those occurring
+as secondary lesions in hyperidrosis, uric acid diathesis
+and other systemic conditions. They are usually due
+to a too strenuous drying of the interdigital surfaces with
+a rough towel. They may also be caused in like locations by
+excessive walking, but the condition of the skin of the patient
+has much to do with their formation. If the skin be
+dry and a great amount of its elasticity is gone, these lesions
+are much more prone to develop than where the skin tension
+is practically normal. The interdigital toe webs are often
+cracked or fissured in spreading the toes too far apart, and
+this has been caused, at times, by the podiatrist working
+between the toes and stretching them to obtain room for
+his instruments or dressings.</p>
+
+<p><b>Treatment.</b> The natural treatment for a condition of
+this kind would be to obtain astringent action. This may
+be accomplished by a number of drugs, principal among
+which is silver nitrate. Tannic acid preparations are also
+frequently used, but they cannot compare in efficiency with
+the silver salt. A number of mild vegetable astringents of
+the same group are similarly employed by podiatry practitioners.</p>
+
+<p><span class="pagenum" id="Page_249">[Pg 249]</span></p>
+
+<p>If the fissure is superficial, involving only the epidermic
+layers, compound tincture of benzoin, painted freely over
+the parts, after they have been thoroughly cleansed and
+dried, will be found advantageous in inducing rapid healing.
+Dusting powders such as tannoform, bismuth subgallate,
+bismuth subnitrate and thymol iodide, may also be successfully
+employed in these
+cases, but where the
+fissure is deep, the
+edges angry and red,
+and the whole area is
+involved in the inflammatory
+process, none of
+these are, as a rule, of
+avail, and more radical
+methods must be employed.</p>
+
+<p>Nitrate of silver presents
+the most efficient
+means whereby astringent
+action may be obtained
+in the parts.
+Weak solutions, from
+1% to 10%, are most
+generally employed, but
+it is often found necessary
+to use stronger
+solutions, even as high
+as 50%.</p>
+
+<figure class="figcenter illowe15" id="i_p249">
+  <img class="w100" src="images/i_p249.jpg" alt="">
+  <figcaption>
+    FISSURED TOE WEB
+  </figcaption>
+</figure>
+
+<p><b>Technic.</b> The parts
+are first thoroughly cleansed and any callous around the
+edges of the fissure is carefully and completely removed.
+This is an essential procedure, for no lateral granulation
+will take place, nor can direct apposition be obtained if this
+callous be allowed to remain.</p>
+
+<p>Small particles of material from the hosiery or other
+foreign bodies should also be thoroughly removed. The
+<span class="pagenum" id="Page_250">[Pg 250]</span>recesses of a deep fissure present excellent places of lodgment
+for minute particles which are always to be found
+in footgear, and it is these bodies which produce infective
+processes. The above precautions having been observed,
+alcohol, 60%, should be freely applied and the parts thoroughly
+dried. Silver nitrate may then be painted deep down
+into the floor of the fissure, by means of a cotton wound
+applicator. This will produce some smarting, but it is transient
+and there will be no great amount of irritation. The
+silver solution should also be applied to the surfaces adjacent
+to the edges of the fissure, for it must be remembered
+that silver nitrate is sedative and this action is desirable in
+reducing the local inflammation.</p>
+
+<p>Where the fissure is deep and of long standing, it may
+be found necessary to resort to a 25% or 50% solution or
+even to the fused stick. When cases are observed where
+proud flesh has developed in the fissure, due to continued
+irritation, it is necessary to use the stronger solutions or
+the stick at once. The proud flesh may be in such form as
+to permit of surgical removal. Where this can be accomplished,
+the bleeding stump is usually cauterized with silver
+solution, 50%. If a surgical procedure is impractical, the
+fused stick may be used to cauterize the neoplasm and thus
+eradicate it.</p>
+
+<p>A dressing should be applied over the parts after the
+fissure has been treated. This may consist of several thicknesses
+of gauze, fashioned to fit between the toes, if the
+fissure be in that location; if the lesion be upon a plane
+surface, a square of gauze should be applied and held in
+place by adhesive strips.</p>
+
+<p>A cocoon dressing may be substituted for that of gauze,
+and in many instances will be found more practical. It has
+been found necessary at times to apply some ointment or
+grease over the fissured area to aid in softening the parts
+and rendering them more flexible. Massage, at intervals,
+with olive oil or mutton tallow, will also be found advantageous
+in bringing about this result.</p>
+
+<p><span class="pagenum" id="Page_251">[Pg 251]</span></p>
+
+<p>No dressing is applied over the parts after the use of
+compound tincture of benzoin, for this drug forms its own
+coating, which is practically impermeable. If a dusting
+powder be used alone, the parts are first thoroughly dried,
+whereupon the powder is dusted lightly into the fissure, and
+a wisp of cotton is placed over the part and held in place
+with collodion.</p>
+
+<p>Pure ichthyol has also been found efficient in these instances;
+a drop is placed in the fissure and is retained there
+by means of cotton or gauze.</p>
+
+<p>Astringent treatment, as described, should be continued
+until the fissure has entirely healed, and in the use
+of silver nitrate it will be found advisable to remove all
+remnants of the previous application before the drug is
+again used. The eschar is easily removed, but it must also
+be remembered that in some instances it may be advisable to
+allow the eschar to remain, and the wound to granulate
+under its protective covering.</p>
+
+<p>This article has been confined almost entirely to fissures
+occurring in the interdigital webs for the reason that these
+parts are their usual sites of occurrence. At times, however,
+they do form in other parts of the foot—on the heels
+along the sides of the foot, and on the ends of the toes. The
+treatment in any locality is similar. When infection is
+present it should be arrested; if proud flesh has developed,
+that must be eradicated; in all cases astringent treatment is
+necessary to a successful outcome.</p>
+
+
+<h3 id="BLISTERS_Bullae">
+  BLISTERS (<i>Bullae</i>)
+</h3>
+
+<p><b>Definition.</b> A blister is a collection of fluid in the skin
+beneath the outer epidermic layers, which latter are raised
+to form the upper wall of the sac, the base of the blister
+being formed by the mucous layers of the epidermis or by
+the corium.</p>
+
+<p><b>Etiology.</b> The cause of practically all blisters met
+with in podiatry is traumatism. Those occasioned by the
+<span class="pagenum" id="Page_252">[Pg 252]</span>friction brought to bear on the surfaces of the foot by a new
+or unyielding shoe predominate, but occasionally the podiatrist
+is called upon to treat these lesions arising from a
+burn. In discussing the subject of blisters under this heading,
+those of traumatic origin only will be considered. Those
+occasioned through burns, or superficial vesicular developments
+of specific origin will be discussed in chapters dealing
+with the disease or diathesis in connection with which
+they may develop.</p>
+
+<p><b>Pathology.</b> The pathologic process causing the formation
+of a traumatic blister is a simple one. Due to the constant
+rubbing of a shoe, the superficial epidermic layers are
+loosened up, one layer from the other, and, owing also to
+this external irritation, the serous elements of the blood
+are caused to leave the vessels and thence find their way
+into the intercellular spaces caused by this loosening. Collections
+of fluid of this nature are known as bullae or blisters.
+The so-called “blood blister” is of a similar origin
+except that the injury (in this case usually a severe trapping
+or pinching of the tissue) is sufficient to cause the
+rupture of one or more capillaries whose blood contents extravasate
+into the overlying epidermic layers.</p>
+
+<p><b>Usual Points of Location.</b> Blisters developing upon the
+pedal extremities are most common in the spring of the
+year when people begin to wear Oxford ties or other styles
+of low shoes. They occur principally upon the posterior
+surfaces of the heel at the upper extremity of the os calcis,
+or upon the tendo Achillis, just above this point, and are
+caused by the rubbing of the stiff heel of the shoe upon
+these parts.</p>
+
+<p>Bullae are also often found to develop over or immediately
+adjacent to the prominent extensor tendon on the
+dorsum of the hallux. In these locations the stiffness of
+the shoe in “breaking” over this point is found to be the
+irritant agent.</p>
+
+<p>Whilst the two foregoing locations are the most general
+sites of occurrence, they are, at times, also found to
+<span class="pagenum" id="Page_253">[Pg 253]</span>develop upon the plantar surfaces, and in some instances
+upon the ends or between the toes.</p>
+
+<p><b>Treatment.</b> The method of treatment to be accorded
+these cases depends upon the condition that the affected
+part may be in at the time of observation.</p>
+
+<p><b>Ordinary Conditions.</b> When the blister is found to be
+unbroken and no great degree of inflammation is present,
+the sac should be opened and its contents evacuated. This
+is best accomplished by means of a fine-pointed, sterile
+scalpel or bistoury. The blister is punctured through the
+unaffected epidermis immediately adjacent to its base, and
+thereupon gentle yet firm pressure is exerted until all the
+fluid contents are evacuated.</p>
+
+<p>Once the contents have been removed, thorough asepsis
+should be inaugurated. The parts should be swabbed with
+alcohol, 60%, and allowed to dry by evaporation, or be dried
+with a sterile wipe. In dressing these conditions it must
+be remembered that protection must be obtained as well
+as granulation induced. Recognizing these to be important
+factors in treatment, the choice of a proper dressing should
+be carefully made.</p>
+
+<p>The cocoon dressing (see “<i>Dressings and Bandaging</i>”)
+is practical in these cases, as the cotton serves to afford
+great protection to the parts and also to confine whatever
+medication is to be applied as a curative agent.</p>
+
+<p>Dressings of sterile gauze or surgeon’s lint may also
+be used, and consist of a square of gauze or lint applied
+over the part and held in place by means of adhesive strips.</p>
+
+<p>The cocoon dressing may or may not be reinforced by
+adhesive strapping, as the judgment of the operator determines.
+If strapping becomes necessary in this connection,
+half-inch or one inch width plaster is generally used.
+The strips (each about three or three and a half inches in
+length) are applied in the form of a triangle, binding down
+the edges of the dressing. It is also found advisable to
+avoid using too much collodion on the cotton. These dressings
+should never be hard; it is, therefore, preferable to
+<span class="pagenum" id="Page_254">[Pg 254]</span>bind down the edges and then merely paint the collodion
+in one narrow strip across and with the fibre of the cotton.
+If adhesive strapping is to be used for the adherence of
+gauze or lint, the one-half inch plaster is the most practical
+in almost every instance.</p>
+
+<p>The strips are each cut about three inches in length,
+unless the size of the gauze or lint squares makes it desirable
+to have them longer, and they are placed in rectangular
+fashion over each of the four sides of the dressing. It
+should always be the endeavor, when possible, to bind down
+the edges of the fabric to the skin, and to accomplish this
+the adhesive strips are made adherent, half on the dressing
+and half on the underlying skin. This serves to hold the
+dressing more firmly in place and also to prevent foreign
+matter from getting under its edges.</p>
+
+<p>Ointments are generally found to be the most advantageous
+applications in cases of ordinary bullae. There are
+several of these from which we may choose. Ammoniated
+mercury, 10%, and ichthyol, 10%, are probably the most
+generally used and are efficient.</p>
+
+<p><b>Broken Conditions.</b> In many instances the blister,
+through neglect and improper puncturing, has become
+broken and the affected epidermic layers are stripped off,
+being attached at one point only, or are entirely gone.</p>
+
+<p>The parts should be thoroughly cleansed with alcohol,
+60%, and all loosened epidermis removed. Never leave any
+flaps of skin about the edges of the denuded area, for they
+not alone serve as excellent places for the lodgment of
+hostile bacteria, but are also apt to curl up and, becoming
+thickened, may irritate the denuded surfaces by pressure.</p>
+
+<p>The lesion being thoroughly aseptic, a dressing should
+be applied. If infection be already present in the part, the
+treatment should consist of the application of wet dressings
+of mercury bichloride, ¹⁄₂₀₀₀, or weaker, until all inflammation
+has subsided. If no infection be present, a dressing
+which will be protective, healing and sedative should be
+placed over the parts. A shield is usually a necessary adjunct
+<span class="pagenum" id="Page_255">[Pg 255]</span>to every successful treatment in cases of this nature.</p>
+
+<p>It will always be found advisable to have the aperture
+of the shield sufficiently large, not alone to protect the denuded
+area, but also to include some of the surrounding integument.</p>
+
+<p>In locations about the os calcis region and along the
+surfaces of the tendo Achillis, an oval pad of a soft grade
+of felt is found to afford the best protection. In cases where
+the blister has developed over the extensor tendon on the
+dorsum of the great toe, a strip of white felt, about one
+inch long and one-half inch wide, placed parallel to the
+tendon, and of sufficient thickness to be higher than its
+elevation, is found to be the most practical means of shielding
+the affected area. An oval shield, if used in this latter
+instance, should have a groove fashioned on its under surface
+in which no adhesive is placed and which allows for
+the free play of the tendon in movements of the foot.</p>
+
+<p>The choice of an ointment, if one is to be used, should
+be carefully made, for asepsis is to be at all times maintained
+and granulation must be induced.</p>
+
+<p>Ammoniated mercury, 10%, and sulphur, 10%, are to
+be highly recommended as antiseptic ointments, and the
+latter, in particular, has tissue stimulating properties.
+Ichthyol, 10%, balsam of Peru, 5%, or scarlet red, 3%, may
+also be used, the latter two where the lesion shows signs
+of indolence and needs stimulation.</p>
+
+<p>At times a dry dressing, either of plain sterile gauze,
+or gauze, combined with a dusting powder, secures good results
+in these cases. Thymol iodide and bismuth subgallate
+probably lead the list in popularity but a very efficient
+substitute is found in a combination of equal parts of
+bismuth subnitrate and powdered calomel.</p>
+
+<p>The areas should be thoroughly dried before any dusting
+powder is applied. This is best accomplished by applying
+alcohol and allowing it to dry by evaporation, which
+may be hastened by blowing air upon the area. A practical
+means of applying dusting powder is afforded by compressed
+<span class="pagenum" id="Page_256">[Pg 256]</span>air. Under low pressure any powder may be blown
+from the nebulizer upon the parts in a thin and even coating.</p>
+
+<p>Both the ointment and the dry dressing should be
+changed in from twenty-four to thirty-six hours until complete
+granulation is observed and the structures of the denuded
+corium are entirely covered. Dressings which are
+allowed to become stale and which harden, are apt to act as
+irritant agents to the tender granulating surfaces and not
+only retard normal healing but further break down the
+tissues.</p>
+
+<p>Cocoon dressings may also be employed to apply either
+ointments or dusting powders, as just described for gauze.
+They will remain in place for much longer periods of time
+than will gauze or lint, but in these cases, as the dressing
+must be changed daily, this is not an important consideration.</p>
+
+<p><b>Prognosis.</b> The tissue lost in blister cases properly
+dressed and protected should be replaced rapidly and stimulation
+is seldom found necessary. The course is active
+but short. It is advisable to have the patient refrain from
+wearing the shoe which originally caused the disturbance so
+that no untoward irritation is brought upon the part during
+treatment. After the epidermis covering is complete, it will
+be found advantageous to paint the parts with silver nitrate,
+50%. The eschar so formed will act as a protective agent
+to the parts until the skin regains its normal strength.</p>
+
+
+<h3 id="BURNS">
+  BURNS
+</h3>
+
+<p>The podiatrist is not called upon to treat many burns
+on the foot, and when these conditions are present they
+are, as a rule, not extensive. The subject is so important,
+however, and so much progress has been made in recent
+years along the lines of burn treatments, that a thorough
+knowledge of this subject is of great interest to the modern
+practitioner.</p>
+
+<p><b>Definition.</b> A burn is a lesion caused by heat or by
+<span class="pagenum" id="Page_257">[Pg 257]</span>caustics. The lesion may be superficial in the tissue involvement
+or it may have penetrated to the deeper tissues
+and, if extensive, may cause permanent injury or death.</p>
+
+<p><b>Pathology.</b> Intense heat being applied to the surface
+of the body destroys the vascular supply, and so shocks
+the nervous sensibility of the part that the nerves are temporarily,
+sometimes permanently, paralyzed. This causes
+the tissue to slough and a more or less deep ulceration is
+formed. The edges are found to be a dark, angry red in
+color and the floor of the ulceration is usually a pale, unhealthy
+yellow or white. In small areas the pain is intense,
+while if large areas be involved to such an extent as
+to include the main trunks, the parts rapidly become anesthetized
+and gangrene ensues. Discharge from the ulceration
+is generally profuse.</p>
+
+<p>As the podiatrist will only come in contact with the
+smaller burns the discussion in this chapter is confined to
+their consideration.</p>
+
+<p><b>Treatment.</b> The burn, whether caused by direct heat
+or by chemical reaction, is at first aseptic and this asepsis
+must be maintained throughout the entire treatment. If the
+burn is very recent, an immediate application of carron oil
+(equal parts of linseed oil and limewater) will be found
+to relieve much of the pain, and to keep the tissues in fairly
+healthy condition. If this medication is not obtainable, a
+paste of sodium bicarbonate will also prove efficient. All
+air should be excluded as soon as possible, and many advocate
+the application of a simple grease smeared freely on
+the abraded surfaces. These are purely first aid procedures,
+however, and have no part in scientific treatment.</p>
+
+<p>After the acute pain has been reduced or entirely relieved,
+treatment should be instituted which will at once induce
+granulation and maintain asepsis. Strong germicides,
+particularly those with toxic properties, should be studiously
+avoided, for it must be remembered that the vitality
+of the part has been severely shocked, even in a superficial
+burn. Nothing must be done to retard the healing process.</p>
+
+<p><span class="pagenum" id="Page_258">[Pg 258]</span></p>
+
+<p>Ointment or dusting powder dressings are advocated
+in these cases, but the most efficient treatment lies in the
+use of one of the newer paraffin preparations (see <i>Dressings
+and Bandaging</i>). The method of application of these paraffins
+is as follows and is the original technic as formulated
+by Dr. de Sandfort, who is the originator of this method of
+treatment:</p>
+
+<p><b>Method of Use.</b> Paraffins are used warm, consequently
+in a liquid state (158°-176° F.).</p>
+
+<p><b>Heating.</b> Place a piece of the material in a bowl, tin
+cup, or other convenient receptacle, set in any vessel containing
+a little water, which should be kept on the point of
+boiling for ten minutes.</p>
+
+<p><b>Precautions to Be Taken.</b></p>
+
+<p>1. Care should be taken to prevent the splashing of the
+boiling water into the container holding the paraffin. When
+the water begins to boil, reduce the temperature to avoid
+drops of water being thrown into the wax. It must be
+remembered that these compounds, completely devoid of
+water (anhydrous), do not burn the tissues at 176° F., while
+even the smallest quantity of water added would have the
+contrary effect.</p>
+
+<p>2. While the mixture is being heated, cut a piece of
+absorbent cotton of sufficient size to amply cover the burned
+area, and divide it into layers as thin as possible. At the
+same time, have ready the gauze and band, needed to bind
+and keep the waxen shell in place.</p>
+
+<p><b>The Dressing.</b> When the paraffin is in a liquid state,
+and is at a temperature of from 140° to 150° F., take a soft
+camel’s hair brush, dip it into the mass and spread it on
+the wound, without pressing; that is, as much as possible
+dabbing it on and not brushing it on. This operation is repeated
+until the glazing is complete, taking care to leave no
+spot uncovered. Immediately afterwards, place quickly on
+the first wax glaze one of the thin layers of absorbent cotton
+already prepared, as explained above, so that it becomes
+<span class="pagenum" id="Page_259">[Pg 259]</span>easily impregnated with the wax, and then, with the
+same dabbing movement, brush on several more applications
+of the paraffin.</p>
+
+<p>If the wound is extensive, the operation is done on
+small square surfaces, successively and close together
+(about 4 by 4 inches). These little surfaces become, by the
+application, part of one another. This proceeding is to
+avoid the first coat of glaze, because it is essential to form
+(on the whole surface of the wound) a shell uniformly
+warm which keeps its warmth a long time, thanks to the
+close attention of the wax with absorbent cotton. Two
+layers of cotton can be applied successively, saturated with
+the mixture, although this is not indispensable.</p>
+
+<p>When the application is complete, the dressing is finished
+by binding with ordinary gauze or cotton, kept in
+place by bands. If desired, gauze can be replaced in part
+by oiled silk, or even paper.</p>
+
+<p><b>Note.</b> In not following the precise instructions already
+given, grave errors can be committed. Thus, should the
+layer of absorbent cotton be applied directly to the wound
+and afterwards covered with the first layer of the paraffin it
+causes:</p>
+
+<p>1. A very painful burning sensation. These applications
+on a wound are very soothing, while cotton impregnated
+with the paraffin applied direct to the wound causes
+a distressing, burning sensation.</p>
+
+<p>2. At the moment of removing the dressing, a pulling
+and even tearing of the tissues is caused. If the wound
+has not been previously glazed by an application of a first
+layer of paraffin, as explained above, the cotton will adhere.</p>
+
+<p><b>Removing the Dressing.</b> For the first few days the
+waxen shell must not be left in place for more than twenty-four
+hours, on account of an abundant secretion of lymph,
+which takes place beneath it. The sero-purulent liquid flows
+under the wax covering (which proves that the waxen layer
+does not adhere to the tissues like collodion, with which paraffin
+has been wrongly compared) and exudes from under
+<span class="pagenum" id="Page_260">[Pg 260]</span>the edges of the dressing. After a few days, this exudation
+diminishes and the dressing can be left in place for forty-eight
+hours at a time and even longer.</p>
+
+<p>To remove the dressing, untie the bands and take off
+the ordinary gauze or oiled silk, thus exposing the “shell.”
+An incision is made in the “shell” by means of a blunt knife
+or scissors and it is easily peeled off. The dressing is removed
+more easily than a glove. The wound is afterwards
+bathed with boiled water and the cleansing is further perfected
+by washing with absorbent cotton soaked in boiled
+water. Then it is dried, either by a current of warm air
+or by a piece of cotton wool, care being taken not to rub,
+or cause the granulations to bleed. The new dressing is
+not applied until the surfaces are thoroughly dry.</p>
+
+<p><b>Important Recommendations.</b></p>
+
+<p>1. In washing the wounds, antiseptic solutions must not
+be used, unless extremely weak.</p>
+
+<p>2. Anxiety need not be occasioned by the grey aspect
+and fetid odor which emanates from the wound when the
+waxen shell is removed. In fact, after this washing, it is
+seen that beneath this purulent liquid, the tissues present
+an intense vitality and an excellent appearance. In order
+to properly proliferate the elements of healing, it even
+seems as if they have need to bathe in this purulent liquid,
+which might be termed auto-serotherapia.</p>
+
+<p>3. In application, the wax should be brushed on with
+strokes or daubs all directed the same way, and these should
+commence at the top of the part and be carried downward,
+never starting at the bottom and going upward.</p>
+
+<p>After several days of treatment, skin granulation will
+be observed, white spots appearing more especially at those
+points, where the sero-purulent liquid has remained in the
+greatest abundance.</p>
+
+<p>Care should be taken not to apply paraffin at a temperature
+of more than 105° F.</p>
+
+<p>Contrary to the usual practice, the abundant granulations
+must never be cauterized with nitrate of silver or any
+<span class="pagenum" id="Page_261">[Pg 261]</span>other caustic. In spite of their development, at times considerable,
+little by little they begin to be strangled by the
+regenerating elements of the skin, which finally replace
+them.</p>
+
+<p>In case of persistent atony of the wound or of excessive
+growth of granulations, the paraffin treatment can be
+interrupted every three or four days by a wet dressing
+(water slightly alcoholized) for a period of twenty-four
+hours. Paraffin treatment is afterwards resumed, which
+the patient often requests himself, on account of the comfort
+derived from the waxen shell.</p>
+
+<p>After some days of treatment, there appears sometimes
+on the healthy skin surrounding the wound an eruption
+of sudamina, caused by the perspiration confined under
+the waxen shell. To make it disappear, cover it with
+an ointment of oxide of zinc, then powder with talc,
+always continuing the paraffin application over the wound.</p>
+
+<p><b>Conclusions.</b></p>
+
+<p>1. Paraffin preparations instantly alleviate the pain.</p>
+
+<p>2. They constitute a warm shell, a heat retainer, under
+which the tissues, protected against outside contamination
+and maintained at a temperature always constant, rapidly
+heal.</p>
+
+<p>3. They become non-adhesive after a short period, thus
+rendering removal instantaneous, without pain, without
+hemorrhage and without tearing the tissues of neo-formation,
+thus permitting the integral healing of the tissues,
+without apparent scars, without contraction of the skin or
+of the tendons.</p>
+
+<p>4. Without causing persistent and incurable functional
+weakness.</p>
+
+<p><b>Important.</b> Heating these preparations in a bath of
+boiling water raises the temperature to nearly 212° F.,
+therefore, before applying to the wound, they should be
+removed from the water bath and allowed to stand for a
+minute or two so as to reduce the temperature below 105° F.</p>
+
+<p>If an ointment be used, a bland healing type should be
+<span class="pagenum" id="Page_262">[Pg 262]</span>chosen. Among these ichthyol ointment, 5% to 10%, is probably
+found to be as efficient as any, although zinc oxide,
+10%, balsam of Peru, 5%, and various sulphur ointments,
+3% to 10%, may be substituted with equal results.</p>
+
+<p>On a freely discharging surface, of course, an ointment
+is contra-indicated and a dusting powder must be resorted
+to or merely a dry aseptic gauze dressing applied. The
+dusting powders to be used are the two bismuth salts, subgallate
+and subnitrate, although the latter is found to be
+irritant at times; thymol iodide may also be used and its
+antiseptic and healing action makes for its general popularity
+in these cases.</p>
+
+<p>The ointment or dusting powder is covered with a cocoon,
+gauze, or lint dressing which is held in place by collodion
+or adhesive strips, respectively.</p>
+
+<p>The dressing should be changed daily until granulation
+is complete. Burns are stubborn lesions to heal and
+the podiatrist should not slight them in any way. They are
+prone to infective processes, and the least neglect is apt
+to cause the undoing of all that previous treatment has
+accomplished.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_263">[Pg 263]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_XVII">
+    <span class="chap">CHAPTER XVII</span>
+    <br>
+    BURSITIS
+  </h2>
+</div>
+
+
+<p>Bursae are closed sacs or pouches containing fluid,
+found in all parts of the body, covering and protecting exposed
+or prominent bony surfaces, and interposed between
+tendons and parts over which they play. They serve as
+protective cushions to prevent physiologic wear and tear.</p>
+
+<p>There are two varieties of bursae found in the human
+body: the bursae mucosae, those secreting a mucous or a
+gelatinous substance, and the bursae synovia, those secreting
+a thin, viscid substance, and which are similar in structure
+to synovial membranes.</p>
+
+<p>The principal form of bursae found in the foot is of
+the synovial type and for this reason the treatment of this
+variety is that discussed in this chapter. Bursae may be
+either deep-seated or subcutaneous and the latter variety
+are those which, through trauma, usually become inflamed
+and troublesome in the regions of the foot. The deeper
+seated bursae, however, often become involved in a pathologic
+process, and the podiatrist is called upon to treat
+these cases as well as those involving subcutaneous variety.</p>
+
+<p><b>Definition.</b> Bursitis is an inflammation of the bursa
+sac. The inflammation may be acute, subacute or chronic.
+Acute bursitis is a condition in which the general inflammatory
+symptoms are active, the course short, and in which the
+overproduction of synovial fluid has found an outlet and is
+discharging on the surface of the skin. Subacute bursitis
+is a condition in which the inflammation has not reached
+a true acute stage, but in which it is more in evidence and
+more active than in the chronic form. Chronic bursitis is
+a condition in which the inflammation is long standing
+<span class="pagenum" id="Page_264">[Pg 264]</span>and of an inactive nature and where no great amount of
+overproduction of synovia is in evidence. In chronic cases
+the walls of the sac itself are generally found thickened and
+leathery; where this condition occurs in the bursa over the
+first metatarsophalangeal joints it is often inadvertently
+called a “bunion”.</p>
+
+<figure class="figcenter illowe18" id="i_p264">
+  <img class="w100" src="images/i_p264.jpg" alt="">
+  <figcaption>
+    ACUTE BURSITIS
+  </figcaption>
+</figure>
+
+<p><b>Etiology.</b> Bursitis
+occurring in the foot is
+in nearly every instance
+due to trauma. A blow,
+a knock, a part being
+stepped on, or the continued
+pressure of an ill-fitting
+shoe, may be the
+exciting causes of this
+disturbance. Malalignment
+of a joint may
+be a secondary cause,
+such as would occur in
+hallux valgus. In this
+instance the deep-seated
+bursa would be affected.
+Bursitis would
+hardly develop from this
+alone, however, and the
+exciting cause is found
+in the pressure of footgear
+or some other injury
+to the part.</p>
+
+<p><b>Location.</b> As bursa
+sacs are only found covering a bony prominence, or interposed
+between the sheaths of tendons and muscles, or between
+these structures and the skin, serving in each capacity
+to prevent physiologic wear and tear, bursitis occurring in
+the foot will be found in these locations.</p>
+
+<p>The first and fifth metatarsophalangeal joints (metatarsophalangeal
+bursitis); the interphalangeal joints of
+<span class="pagenum" id="Page_265">[Pg 265]</span>the toes (interphalangeal bursitis); the posterior and outer
+surfaces of the os calcis (retrocalcaneal bursitis); and the
+tarsometatarsal region on the dorsum of the foot (dorsal
+bursitis) are the principal sites of occurrence. The base
+of the fifth metatarsal is also a spot over which bursal
+inflammation will occasionally develop.</p>
+
+<p><b>Pathology.</b> The pathology of bursitis is primarily that
+of any inflammation. Due to trauma, the parts are subjected
+to a severe irritation which causes an engorgement of blood
+in that location. Serous infiltration of the tissues takes
+place and the functional activity of the sac is increased. Materials
+from the blood for the production of synovia, are secreted
+in abnormal amounts, and in consequence the sac becomes
+distended from the superabundance of fluid. In time
+this fluid must find some outlet, for synovia is secreted so
+rapidly that the lymphatic system cannot absorb the excess.
+This outlet must naturally develop toward the point of least
+resistance, which, in these cases, is outward toward the
+periphery. The tissue is broken down to a small extent
+and a minute sinus is formed which permeates the tissues
+and opens upon the surface of the skin. From the peripheral
+opening the excess of fluid is thrown off, and when this
+stage is reached the distension in the part is naturally lessened
+and the patient is fairly comfortable.</p>
+
+<p><b>Symptoms.</b> <i>Objective Symptoms.</i> The parts will be
+found considerably swollen, red and hot. Loss of function
+is noted and fluctuation is present.</p>
+
+<p><i>Subjective Symptoms.</i> Pain on slightest pressure and
+at times upon forced movements; impaired function; heat,
+and a feeling of fullness or distension in the part.</p>
+
+<p><b>Characteristics.</b> The characteristics of bursitis,
+whether acute or chronic, are so plain that no error in diagnosis
+should ever be made. However, many of these cases
+are mistaken for suppurated helomata, probably through the
+fact that both are conditions in which a discharge is present.
+Why this error should be made is a mystery, for while it is
+true that there is an exudation in both instances, the characteristics
+<span class="pagenum" id="Page_266">[Pg 266]</span>of the discharges are so different that only a
+careless or inexperienced person could mistake one for the
+other. The important characteristics are:</p>
+
+<p>(1) The distension in the bursa sac proper causes a
+swelling of the parts adjacent and superjacent so that the
+whole area over and around the affected part will be found
+enlarged and puffy. Fluctuation is present and often the
+sac itself may be grasped in the fingers, so distended are
+its walls.</p>
+
+<p>(2) Removal of the overlying calloused area, should one
+be present, brings to view the sinus opening, in the acute
+stage. The tissues are blanched in appearance and are
+leathery and hard to digital or instrument touch. The opening
+of the sinus is usually very small and its edges are circumscribed
+and even. The sinus itself has the appearance
+of a healthy granulating surface and at no time is there
+apparently any membranous lining. Probing will determine
+that the sinus follows an almost vertical course with
+no sub-borrowings or offshoots in any direction. There is
+no loss of tissue upon the surface of the skin, such as would
+be found in connection with an heloma involved in a suppurative
+process, except at the opening of a canal.</p>
+
+<p>(3) Digital pressure exerted laterally and anterio-posteriorly
+usually is rewarded by the oozing of a thickish,
+viscid, almost colorless fluid from the sinus opening. There
+is nothing in the appearance of this fluid that should lead
+one to mistake it for pus. Very often this fluid oozes from
+the part of its own volition, due probably to the pressure of
+the excess fluid in the sac beneath. The fluid causes no active
+decomposition of hydrogen dioxide and the ebullition caused
+by the contact is almost negative. This constitutes one
+more point of differentiation between the changed synovial
+fluid discharged from an acute bursitis and a pyogenic exudation.</p>
+
+<p><b>Treatment.</b> The treatment of bursitis varies according
+to the degree of inflammation, and the general conditions
+present. We may divide the treatment into three
+<span class="pagenum" id="Page_267">[Pg 267]</span>classes: the radical operative, the non-radical operative,
+and the palliative. The first mentioned is a purely surgical
+procedure, complete in itself, and consists in the removal
+or curettage of the inflamed sac. The last two are usually
+combined and are procedures which are generally practised
+by the podiatrist.</p>
+
+<p><b>The Radical Operative Treatment.</b> Under proper
+aseptic conditions an incision is made in the overlying tissues
+and the sac is removed in its entirety; the parts are
+then sutured, and a few days rest and elevation of the foot
+brings complete union. This method may be varied in that
+the sac is not removed, but a free incision is made into it
+and the parts thoroughly curetted. One other of the purely
+surgical procedures is to make a free incision into the sac
+to accomplish thorough drainage. This latter procedure is
+generally practised in cases of infected bursitis.</p>
+
+<p>Inasmuch as the non-radical operative and the palliative
+methods of treatment are purely podiatry procedures
+and are usually combined, they will be discussed as one
+subject.</p>
+
+<p><b>The Non-Radical Treatment.</b> There are several methods
+by which bursitis in its various stages may be successfully
+treated. They vary in some details but all agree on
+two most important points: rest and the absence of pressure.</p>
+
+<p>A bursitis developing over a bony prominence upon the
+foot, usually occurs in connection with some form of superficial
+callosity or an heloma. The inflammation of the sac
+may be due to the neglect of a growth of this nature, or,
+as previously explained, to some distinct injury to this part.</p>
+
+<p>To successfully treat a condition of this nature it is
+found necessary at all times to accomplish the removal of
+the excrescence. This is done in the usual manner by either
+the shaving or dissection method. These growths must be
+removed for several reasons:</p>
+
+<p>(1) To remove all hardened and thickened epidermis so
+that no further irritation from that source will be present.</p>
+
+<p><span class="pagenum" id="Page_268">[Pg 268]</span></p>
+
+<p>(2) To allow the operator a chance to effect drainage
+for the overproduction of bursal fluid.</p>
+
+<p>(3) To allow the medications used to come in direct
+contact with the underlying tissues without the necessity of
+penetrating several layers of epidermis and expending their
+action upon and through them.</p>
+
+<p>Under proper aseptic conditions, the superficial thickened
+epidermic layers are removed and the excess fluid
+is allowed to drain off. It will often be found that the callous
+forms a “plug” which extends down into the surface
+opening and prevents this excess fluid from being thrown
+off. Once this drainage is accomplished, other procedures,
+dependent upon conditions present, should be utilized for
+the alleviation and cure of the bursitis.</p>
+
+<p><b>Rest.</b> By far the most effective means of bringing
+about a speedy cessation of the inflammation occurring in
+the bursa sac is to procure absolute rest for the part involved.
+It has been noted that in a number of cases when
+no medical or surgical treatment has been afforded, inflammations
+of this nature resolve themselves speedily upon
+complete rest. There is nothing remarkable or supernatural
+about this for inasmuch as the bursa is only used during
+the movements of a part, it is easily understood why a
+trouble of this nature will clear up rapidly if the part is
+kept immobile.</p>
+
+<p><b>Removal of Pressure.</b> There are many cases of bursal
+inflammation which occur in people who are not able to lay
+up and give complete rest to the affected part. The next
+most effective measure in these cases is the judicious and
+proper use of shielding. In applying a shield to a case of
+this nature it should always be remembered that the parts
+affected are usually swollen to a considerable extent around
+the tissues immediately overlying the sac itself. For this
+reason a shield such as would be employed for the protection
+of an heloma in a like situation, is not practical. This
+is more particularly the case where the bursitis is located on
+one of the interphalangeal joints of the toes. In this location
+<span class="pagenum" id="Page_269">[Pg 269]</span>an individual shield which is to rest on the affected
+toe alone cannot be applied, for the whole area overlying
+the inflamed sac will be found swollen and leathery and the
+tissues anterior and posterior, as well as those covering
+the interdigital surfaces of the toe, are ordinarily more or
+less involved in the general inflammation. In this instance,
+then, we must resort to some sort of shielding which will
+take the shoe pressure from the part, and yet which will be
+distributed over the whole digital surface and not on the
+diseased toe alone. A dorso-digital oval or crescent shield
+(see chapter “Shields and Shielding”) answers the purpose
+and is entirely effective in most instances.</p>
+
+<p>Probably the most practical method of removing all
+pressure from the inflamed areas is to have a circular portion
+of leather immediately overlying the part removed
+from the shoe and another softer piece adhered over the
+opening. The appearance of this will be inconspicuous
+and the small pouch thus formed allows the patient to wear
+a shoe, affording comfort, which, however, exerts no pressure
+upon the lesion. It is wise to remove a piece of leather
+considerably larger than the circumference of the affected
+part, otherwise the edges of the aperture cut in the shoe
+may become depressed and press upon and irritate the
+already inflamed areas.</p>
+
+<p><b>Strapping.</b> Enlarging upon the theory of rest, inasmuch
+as complete absence of movement aids materially in
+reducing the local irritation, strapping is a practical means
+of immobilization.</p>
+
+<p>This procedure, although used in these situations, is not
+so practical in bursitis occurring over the first and fifth
+metatarsophalangeal joints, or over the interphalangeal
+joints, as it is in other locations upon the foot.</p>
+
+<p>Adhesive strapping is applied in such manner and at
+such tension as to accomplish almost complete immobilization,
+and for this reason it will be readily seen that this
+method cannot be used in cases where the added pressure
+will produce additional irritation. Several lengths of adhesive
+<span class="pagenum" id="Page_270">[Pg 270]</span>plaster are placed over the part and adhered tightly
+to the surrounding integument so that very little or no
+movement is allowed in the affected part.</p>
+
+<p>Strapping, to prevent movement, is particularly effective
+when the bursitis has occurred in the os calcis region
+between that bone and the tendo Achillis (retrocalcaneal
+bursitis). The foot is placed in plantar flexion and a long
+strip of 1¹⁄₂ or 2 inch plaster is anchored at the centre of
+the upper part of the calf and is then carried down over
+the heel on the plantar surface of the foot. This strip is
+then reinforced by transverse straps applied over the heel
+at the insertion of the tendon.</p>
+
+<p>Aside from these general methods of procedure thus
+discussed, the podiatrist must resort, in a majority of cases,
+to local treatment which will hasten the ultimate resolution
+of the inflammatory process. These local methods of treatment
+are conveniently divided into six groups:</p>
+
+<blockquote>
+<p>
+  1. Hydrotherapeutic measures.<br>
+  2. Moist and wet dressings.<br>
+  3. Unguent dressings.<br>
+  4. Counter-irritation.<br>
+  5. Massage.<br>
+  6. Electricity.
+</p>
+</blockquote>
+
+<p><b>Hydrotherapy.</b> Hydrotherapeutic measures may be
+resorted to in the treatment of bursal inflammations and
+either thermal extreme may be used with equal results. As
+one person will react to one extreme more readily than to
+the other, the choice of heat or cold usually depends upon
+the individual case.</p>
+
+<p><b>Hot Applications</b> are probably most practical in these
+instances in the form of compresses. Several thicknesses
+of gauze, saturated in water, as hot as can be borne, are applied
+over the affected areas, the hot water being replenished
+as soon as the compress commences to cool. Hot applications
+act as mild poultices and their action is similar
+to them in a limited and modified form. They tend to hasten
+<span class="pagenum" id="Page_271">[Pg 271]</span>resolution of the inflammatory process by accelerating absorption.
+It is unwise, however, to continue hot applications
+for too long a period; it is found preferable to have
+the patient apply hot compresses for periods of one hour
+duration two or three times a day, allowing the part complete
+rest in the intervals.</p>
+
+<p>Hot compresses, applied continuously for some hours,
+are apt to bring about an over-stimulation in the parts to
+such an extent as to produce a slough. To be effective, it
+must be remembered that the compress must be kept hot
+for the entire period of application. This may be accomplished
+by immersion in hot water, by moistening intermittently,
+or by keeping the compress covered with some heat-confining
+covering. In the latter instance, oiled silk is in
+all probability the most practical agent, but even the use
+of an impervious covering does not relieve the patient of
+the necessity of remoistening the compress with hot water,
+at frequent intervals.</p>
+
+<figure class="figcenter illowe15" id="i_p271">
+  <img class="w100" src="images/i_p271.jpg" alt="">
+  <figcaption>
+    INFECTED BURSITIS
+  </figcaption>
+</figure>
+
+<p><b>Cold Compresses</b>, as here advised, are either applications
+of cold water on a compress of gauze or some similar
+material, kept constantly wet, the use of ice bags or packs,
+or a cold water drip. The surfaces of the foot, particularly
+<span class="pagenum" id="Page_272">[Pg 272]</span>if the bursitis be on the toes, are so small, however, that as
+a general rule, ice bags or packs are not practical. The cold
+produces anemia of the parts by contracting the calibre of
+the blood vessels, and forcing the blood from the capillaries.
+They also tend to anesthetize the nervous sensibility and
+are in that way also pain reducing. There is one bad feature,
+however, in the use of cold as a hydrotherapeutic agent.
+The resulting reaction, which is generally bound to occur,
+gives the patient considerable annoyance and is apt in time
+to increase the infiltration and distension in the part.
+Again, should the patient have any tendency toward chilblains,
+the moist cold is almost always sure to develop the
+tendency into a reality.</p>
+
+<p><b>The Poultice</b> is the older and now obsolete method of
+applying moist heat to a part. The stimulative action of
+this form of application is at times so severe as to cause
+deleterious effects upon the diseased tissues. A cataplasma
+should never be used where a distinct loss of tissue is in
+evidence, in the presence of pus, or where the vitality of the
+parts is considered to be subnormal, either from the age or
+condition of the patient, or because of the diseased condition
+of the part.</p>
+
+<p>The most generally used materials in this connection
+are flax-seed, and slippery elm, and the most practical manner
+for preparing a poultice for use in podiatry is to make
+several small bags (about two or three inches square) from
+cheesecloth or some like material. These are filled half full
+with the meal and are dropped into a vessel containing
+boiling water. The bags and their contents are allowed to
+boil for eight or ten minutes and are then applied to the
+part as hot as can be borne. This method does away with
+the rather “messy” procedure of laying a cloth on the part
+and then applying the warm mass by means of a spatula,
+spoon or like implement; also the poultice, so made, may
+be used again and again. The usual method of procedure
+in using poultices, when recommended, is to have the patient
+apply them continuously for about an hour during some
+<span class="pagenum" id="Page_273">[Pg 273]</span>part of the day. It is found much more effective to have
+moist heat applied for a longer period at one time than
+to apply three poultices a day, one in the morning, one at
+noon, and the last at night. The patient removes one bag
+as soon as it starts to cool and replaces it with another
+taken hot from the boiling water. This form of treatment,
+of course, tends at first to increase the overproduction of
+synovial fluid, and proper drainage must at all times be
+preserved so that this excess may be carried off.</p>
+
+<p><b>Baking.</b> With the development of the modern baking
+apparatus, this method of applying heat to a part has come
+into use in cases of subacute or chronic bursal inflammations.
+The heat applied by this means is dry, in contradistinction
+to that obtained from hot applications of water
+and from poultices. As the synovial bursae are of similar
+structure to the true synovial membranes of the joint cavities
+and capsules, they are subjected to similar ailments. It
+stands to reason, therefore, that if baking is beneficial in
+several forms of arthritis, it is also beneficial in some forms
+of synovial bursitis. Some podiatrists have baking apparatuses
+installed in their offices; where this is not the case it
+is recommended that, when such treatment is thought advisable,
+the patient be sent to some hospital or institute where
+this treatment can be administered. Baking serves as a
+hyperemic agent (to bring an abnormal supply of blood to
+the part) and in this way to aid in the more rapid absorption
+of the exudates in the affected region.</p>
+
+<p><b>Moist and Wet Dressings.</b> In conditions of acute bursitis,
+an efficient means of reducing the inflammatory symptoms
+is found in the use of wet dressings. Moist dressings
+(those with mackintosh protection) should not be used in
+these cases when the skin is broken, when there is any suspicion
+of a discharge, or where infection is present.</p>
+
+<p>The agents which may be used with such wet dressings
+are mercury bichloride, liq. aluminum acetate, saturated solution
+of boric acid and alcohol, equal parts, and lead and
+opium wash.</p>
+
+<p><span class="pagenum" id="Page_274">[Pg 274]</span></p>
+
+<p><b>Mercury Bichloride</b> may be used as a wet dressing in
+all cases of acute bursitis, but more particularly where infection
+is present. It should never be used with mackintosh
+covering, for even without the confinement thus afforded,
+its action serves to macerate the skin to a great extent.
+The solution may be used either hot or cold and in no instance
+stronger than ¹⁄₄₀₀₀. This strength solution should
+only be resorted to in cases where the infection is acute and
+has progressed to some extent, weaker solutions, ¹⁄₅₀₀₀ or
+¹⁄₁₀₀₀₀, being found efficient in a majority of cases. Mercury
+bichloride, on account of its toxic properties, should
+not be used after the infective process has been reduced,
+and there are many arguments in favor of an efficient substitute
+for it even in the initial instance. However, no solution
+which is practical for use in these cases can be depended
+upon for beneficent results as surely as corrosive
+sublimate. In chronic bursal inflammations, corrosive sublimate
+is contra-indicated.</p>
+
+<p><b>Liq. Aluminum Acetate</b> can be used in place of bichloride
+of mercury in many cases of acute bursitis. The solution
+is decidedly astringent, and while this action is to be
+desired at times, nevertheless it has been found detrimental
+in the treatment of some cases of acute bursitis, because
+when it penetrates through the sinus into the bursal sac it
+has been found to create a decided irritation upon these
+deeper tissues. Liq. aluminum acetate, therefore, is shunned
+by many in the treatment of these cases, but aside from this
+one detrimental feature, the action of the acetate is efficient
+and is productive of good results. The drug may be used
+plain, or diluted with sterile water to reduce its irritant,
+astringent qualities. A dressing of liq. aluminum acetate,
+like bichloride, should never be confined in a mackintosh
+covering, as it will macerate the skin, quickly and thoroughly.
+This solution is particularly effective in subacute
+cases where no infection is present when its astringent
+action goes far to reduce the infiltration in the parts. It
+should be applied cold.</p>
+
+<p><span class="pagenum" id="Page_275">[Pg 275]</span></p>
+
+<p><b>Boric Acid-Alcohol Solution</b> may be used in all cases
+of acute or subacute bursal inflammations. It is efficient
+in septic cases and its quality of rapid evaporation aids
+materially in reducing the inflammatory symptoms, independent
+of the therapeutic action of the component drugs.
+This solution, on account of its rapid evaporation, must be
+renewed more often than either of the foregoing, but while
+this demands more attention on the part of the patient, it is
+immeasurably better for the general condition of the disease.
+The one disadvantage in having the patients attend
+to the moistening of the dressing is that often they will fail
+to carry out instructions properly; but a condition of this
+nature, properly attended, will respond as quickly to the
+boric-alcohol application as to aluminum acetate or to mercury
+bichloride, and with none of the irritant or toxic tendencies
+of both of these. This solution is applied cold.</p>
+
+<p><b>Lead and Opium Wash</b> may be used in the treatment
+of bursal inflammations, usually in the subacute or chronic
+stages. In cases where the integument is broken, avoid the
+use of this medication on account of the irritant qualities
+of the lead it contains. Prolonged applications are apt to
+develop a dermatitis, and if the skin is broken, local lead
+poisoning will not only be more pronounced, but will be
+manifest in a shorter space of time. Lead and opium wash,
+hot, is an advantageous application in the treatment of
+chronic bursal inflammations, the heated applications being
+continued for about thirty minutes at a time, at intervals
+of two or three hours. It should always be remembered in
+using this wash that it exhibits marked irritant qualities
+upon prolonged application.</p>
+
+<p>The choice of a moist dressing to be used in subacute
+or chronic cases, especially the latter, should be carefully
+made. Boric acid, saturated solution, is an efficient and
+safe drug to use under rubber, fish skin, or oiled silk covering
+but, as before mentioned, mercury bichloride and liq.
+aluminum acetate are contra-indicated in this connection.</p>
+
+<p><b>Unguent Dressings.</b> Ointment dressings are used in
+<span class="pagenum" id="Page_276">[Pg 276]</span>this instance under the same rules and considerations which
+govern their application in all other conditions. No ointment
+should be applied on any inflamed bursa where there
+is a discharge of any nature. The operator must never
+forget that the base of all ointments is either oily or fatty
+and a serous discharge, coming from any surface, cannot be
+absorbed by the fabric used as a dressing if even a thin
+unguent film is interposed.</p>
+
+<p>Certain classes of drugs, however, which are known to
+be beneficial in certain stages in the treatment of bursitis,
+can be readily applied in unguent form and for this reason
+the question of using them may be profitably discussed here.
+The action demanded of drugs to be used in the treatment
+of bursal inflammations are antiphlogistic, analgesic and
+antiseptic. The latter action is particularly demanded in
+cases where surfaces denuded of epidermis are found.
+Some stimulant action is at times desired and drugs which
+have properties of this nature may also be included in this
+armamentarium. The following named ointments may be
+used, therefore, with beneficial results in certain stages of
+bursal inflammations: ichthyol, sulphur, menthol, balsam of
+Peru, scarlet red and salicylic acid.</p>
+
+<p><b>Unguentum Ichthyoli</b>, 3% to 10%, is used in all cases
+where an emollient action is desired. The stimulating action
+of the drug in this form is negative, but it can be relied upon
+to reduce acute inflammatory symptoms. Ichthyol may be
+combined best with either lanolin or vaseline as a base; the
+former is preferred inasmuch as it does not become
+rancid when exposed to a variety of conditions as does
+the latter. Lanolin being a wool fat product is supposed
+to have a beneficent action upon certain pathologic conditions
+of the skin, and so it is used as the base of many
+ointments.</p>
+
+<p><b>Unguentum Sulphuris</b>, 10%, may be used in many conditions
+of subacute or chronic bursitis. Its antiseptic action
+makes it a desirable choice for use when the integument
+is broken or when a distinct antiseptic action, in addition
+<span class="pagenum" id="Page_277">[Pg 277]</span>to the general action of sulphur as an antiphlogistic,
+is sought.</p>
+
+<p><b>Unguentum Balsamum Peruvianum</b> is used in these instances,
+principally when some loss of tissue in the part is
+noticeable and where stimulation is required to accelerate
+granulation. Peruvian balsam is sometimes combined with
+ichthyol (5% of each) in ointment form. In this combination
+the ointment has marked stimulative and antiphlogistic
+qualities. Balsam of Peru is used in strengths of from 3%
+to 10% in a vaseline base.</p>
+
+<p><b>Scarlet Red</b> is a highly efficient stimulative ointment.
+It is used alone, with zinc oxide or with borated vaseline,
+and should never be applied in too thick a coating. The
+parts should first be made thoroughly aseptic and dried,
+and then scarlet red applied on gauze in a thin even coat.
+Care should be taken that the application of scarlet red does
+not cause over-stimulation to the parts, and thus prove detrimental
+to the general condition of the lesion.</p>
+
+<p><b>Unguentum Acidi Salicylici</b>, 2% to 5%, may be used to
+good advantage where the parts overlying the thickened
+sac are found to be somewhat calloused. One application of
+an ointment of this strength will serve to disintegrate this
+overlying thickening, thus making the parts flexible and
+soft. A stronger ointment than this should never be used
+in these cases, as salicylic acid is a strong epidermic disintegrant
+and will cause decided irritation if used in greater
+than 5% strength. In such cases salicylic acid may also be
+combined with collodion in the same percentage, 5 grains of
+ext. cannabis indica being added as an anodyne. Unguentum
+salicylic should never be used when the skin is broken or
+the tissues show any tendency to thinness. All ointments
+used in the treatment of bursitis are applied and kept in
+place by the use of a cocoon dressing. If a shield is to
+be used, it is first applied; the ointment is then placed
+in the shield aperture and the cotton and collodion dressing
+is made to cover the whole. The ointment should be
+renewed at frequent intervals in order that the dressing
+<span class="pagenum" id="Page_278">[Pg 278]</span>may not become hardened, and thus become an irritant.</p>
+
+<p><b>Counter-Irritation.</b> Counter-irritation means literally
+an irritation which is developed to act against a previous
+irritation. It would seem, theoretically, that in cases of
+bursitis, this form of treatment is particularly advantageous.
+A bursal inflammation is a fairly deep-seated condition
+which should readily respond to a counter-irritation
+developed on the surface overlying the trouble. Counter-irritant
+agents should be used only in subacute and chronic
+cases, more particularly in the latter; for it is found that
+this form of treatment applied to an acute bursal inflammation
+tends to intensify rather than reduce the symptoms.</p>
+
+<p>In treating such cases we have a number of counter-irritants
+which may be used with consistently good results:
+iodine, capsicum, turpentine and mustard, are the most important
+and most commonly used.</p>
+
+<p>Iodine is today, in all probability, the most generally
+used agent to induce counter-irritation in podiatry. Its
+present popularity as a germicide, however, has over-shadowed
+its action as a counter-irritant.</p>
+
+<p>To obtain the maximum counter-irritant action from
+tincture iodine (U. S. P. 7%) it should be applied in a heavy
+coat at frequent intervals until such time as the inflammatory
+symptoms have entirely subsided. The continued use
+of iodine after this has been accomplished should be avoided
+as the tincture is irritant and mildly corrosive, and numbers
+of patients will be found whose skin will not stand its
+activities. Churchill’s tincture of iodine (about 16%) has
+been advocated for general use as a counter-irritant, but
+its action in many cases will be found too irritant for ordinary
+use.</p>
+
+<p>The theory of counter-irritation, simplified, is that a
+drug applied at a spot more or less distant from an inflamed
+area will cause an irritation in this new locality
+and thus aid the original condition, inasmuch as it will draw
+away the excess blood in the original part and allow the
+vessels to contract to normal calibre and the circulation
+<span class="pagenum" id="Page_279">[Pg 279]</span>there to become normal. Realizing this, it is readily understood
+why tincture of iodine should not be used as a counter-irritant
+in acute cases. With a discharging sinus to contend
+with, applying iodine over its opening at the periphery
+might be the cause of a severe irritation in that location
+which would further increase the tissue loss and thus prove
+a detriment to the general condition.</p>
+
+<p><b>Capsicum</b> is generally applied in these conditions in the
+form of a plaster. It should never be used in acute cases
+as its greatest efficacy is apparent in those cases with
+chronic characteristics. Capsicum plaster is applied and
+renewed as necessary, until the symptoms of the deep inflammation
+have subsided. Shields are usually employed
+to remove the pressure while a chronic case is under treatment,
+and this removal of all irritation which the shoe might
+produce aids materially in the relief and cure of these conditions.</p>
+
+<p><b>Turpentine</b> may be massaged into the parts for the purpose
+of counter-irritation although its action is at times
+severe; it should never be used where the skin is broken
+or where a discharge is present. It is not so desirable an
+application as either of the foregoing for it is found impractical
+to give proper massage to the comparatively small
+areas which are affected in bursal inflammations.</p>
+
+<p><b>Mustard</b> has been recommended for use in cases of
+chronic bursitis, either in the form of a moderate local application
+or in a general foot bath. It is decidedly energetic
+in action, and should be used with great discretion and care.
+Every skin will not stand the action of mustard and for this
+reason it is not advocated as a general counter-irritant
+agent. Upon the failure of any of the other drugs mentioned
+under this heading, however, it may be tried, and if
+properly used, may prove conducive to good results.</p>
+
+<p><b>Massage.</b> Massage is at times a potent factor in aiding
+absorption in chronic cases. There is no question but
+that the stimulation afforded by this procedure is efficient
+and will aid materially in returning the tissues to normal.</p>
+
+<p><span class="pagenum" id="Page_280">[Pg 280]</span></p>
+
+<p>Some cases of bursitis which occur upon the foot, however,
+are confined to such limited areas that massage is impractical.</p>
+
+<p>Several drugs which are reputed to have great powers
+of penetration are recommended as agents which can be
+safely massaged into the parts and even if the action
+claimed for them is overestimated, their use at least serves
+to reduce the friction upon the surface tissues.</p>
+
+<p>Many of the so-called “petrogen compounds”—drugs
+in combination with petroleum (mineral oil)—are recommended
+for use in these cases, and are undoubtedly of some
+benefit. Petrogen iodine, 10%, and petrogen camphor, 5%,
+(Wyeth) are the two most generally used, and have been
+found to be productive of good results.</p>
+
+<p>The compound is applied to the parts and then rubbed,
+first lightly, then gradually increasing the pressure, by the
+fingers and palm of the hand. It is found advantageous to
+massage the parts at first with a circular movement, confining
+the energy to the areas immediately overlying the enlarged
+sac. After about five minutes, the pressure is increased
+and considerable of the surrounding integument is
+included in the massage. The direction of the finger movements
+is then changed from a rotary one to a series of long
+strokes under considerable pressure, first toward the diseased
+sac, following as nearly as possible the blood supply
+to the part, and then away from the sac, following the outgoing
+vessels. This serves first, to increase the vascular
+supply, and then to aid in its quick removal, and reduce
+the congestion in the part. With this, the lymph activity
+is also increased so that it helps to absorb the waste products
+more rapidly.</p>
+
+<p>Massage should be recommended as a daily treatment
+and should be continued until all signs of infiltration have
+disappeared. Perseverance is necessary, for in chronic
+bursal inflammation, the changes are not noticeable nor
+should they be expected to be rapid.</p>
+
+<p><b>Electricity.</b> Many forms of electrical application are
+<span class="pagenum" id="Page_281">[Pg 281]</span>recommended in the treatment of chronic bursal inflammations.
+Among those most commonly employed are the high
+frequency, and the faradic currents. Vibration, induced by
+electric impulses, is also recommended and is employed generally
+by the podiatrist.</p>
+
+<p><b>High Frequency Current</b>, more popularly known or
+rather misnamed “violet ray,” is generally found efficient
+and is more generally used than any other form of electric
+application. This current serves to produce active stimulation
+in the parts and by this means tends to accelerate all
+functional activities and to hasten absorption. Whether
+the more popular priced and small sized high frequency
+machines on the market today really do create any but a
+very superficial stimulation, is a question, and for this reason
+a machine of greater power is recommended. The parts
+are treated daily, the glass electrode being applied for about
+eight or ten minutes at a time.</p>
+
+<p><b>Faradic Current</b> is also recommended for daily use being
+applied by means of a moistened sponge electrode. The
+treatment is from five to ten minutes duration. Stimulation
+is obtained by this treatment which, as in the case of
+the high frequency current, aids the general absorption in
+the affected areas.</p>
+
+<p><b>Vibration</b> used in these cases may be produced by electricity
+direct, or through a modern air compressor, controlled
+by electricity. Vibration is only recommended in
+chronic cases; it increases the functional activities of the
+part. It should be applied daily.</p>
+
+<p>Bursitis is a stubborn condition in any form, and can
+only be relieved and finally cured by scientific and rational
+treatment. The operator should bear in mind that rest and
+the absence of shoe irritation will do as much or even more
+for the general improvement of the condition than can be accomplished
+by drugs. Surgical procedure is certainly to be
+recommended in cases where no improvement is shown
+<span class="pagenum" id="Page_282">[Pg 282]</span>under palliative methods, even though this requires a cessation
+of activity on the part of the patient, and means the
+transfer of the patient to the care of a practitioner of
+surgery.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_283">[Pg 283]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_XVIII">
+    <span class="chap">CHAPTER XVIII</span>
+    <br>
+    CHIMATLON
+  </h2>
+</div>
+
+
+<p>Chimatlon, or pernio, is an inflammation of the skin
+and of the deeper structures which is the result of exposure
+to reduced temperatures. The severity of the condition
+depends upon the length of the exposure as well as
+upon the degree of temperature. If the skin alone is involved
+and there is no loss of tissue, chimatlon mild, or
+chilblains, is the term applied to the lesion; where there
+is an involvement of the deeper structures the condition
+is called chimatlon severe, or frost bite. In many instances
+it becomes difficult to distinguish between a severe chilblain
+and a mild frost bite. However, for the sake of scientific
+study, in all cases in which the deeper tissues are involved
+and suppurative processes affecting these structures
+manifest themselves, the condition should be considered as
+chimatlon severe, for these cases are usually due to prolonged
+exposure to low temperatures.</p>
+
+
+<h3 id="CHIMATLON_MILD">
+  CHIMATLON MILD
+</h3>
+
+<p><b>Derivation.</b> Chimatlon, from the Greek, meaning the
+severity of winter.</p>
+
+<p><b>Synonyms.</b> Chilblains, Dermatitis Congelationes, Erythema
+Pernio.</p>
+
+<p><b>Definition.</b> Chimatlon mild, or chilblains, is a local
+inflammation of the skin due to exposure to cold and dampness.</p>
+
+<p><b>Etiology.</b> Chilblains are primarily due to exposure to
+cold in varying degrees. When the part is exposed to a
+decreased temperature, the vasomotor nerves become affected
+<span class="pagenum" id="Page_284">[Pg 284]</span>and the cutaneous circulation is impaired. This interference
+with the blood flow produces congestion, leading
+to inflammation, which latter is followed by a serous discharge
+or even by the production of pus. Dampness hastens
+the affection of the vasomotor nervous system of the
+skin, and where this organ is very sensitive, in the presence
+of moisture, only a moderate decrease in the temperature
+is necessary to produce all the symptoms of severe chilblains.</p>
+
+<p>The parts of the body most usually affected are the
+hands and feet; the distance of the extremities from the
+heart is probably the reason for this impairment under the
+other abnormal conditions. Where the horny layer of the
+skin is thin, it receives its nourishment normally, regardless
+of the distance from the heart; but on the hands and feet
+the skin is thicker and is imperfectly nourished and a decrease
+in temperature, in the presence of moisture, results
+in local inflammation.</p>
+
+<p>Females are more disposed to chimatlon mild than
+males, and young people more than old. Aside from cold
+as an etiologic factor, there is also the predisposition which
+is equally as important in the production of chimatlon mild
+and should be considered in every case. Imperfect circulation
+in the limbs, due to varicose veins and arterial disturbances,
+caused by a deranged nervous system, are often
+causes of chilblains and must be given consideration.</p>
+
+<p>Any part of the body exposed to the air may become
+affected, particularly the ears and nose. Several cases of
+chimatlon mild of the skin over the throat have been recently
+reported, due to walking against a strong wind, with
+the throat bared to the weather.</p>
+
+<p><b>Symptoms.</b> The symptoms in the mild form of chimatlon
+vary with the severity of the exposure. In very mild
+cases the only perceptible symptoms are a tingling or slight
+itch, and the part feels cold and clammy to the touch. The
+most common cases show the parts colored dark blue or
+purple, immediately after exposure and during the reaction.
+<span class="pagenum" id="Page_285">[Pg 285]</span>The parts are inflamed and there is severe itching coupled
+with pain. After reaction has set in, the color of the lesions
+varies from a scarlet to a purple. There is no sharp line of
+demarcation between the affected and the surrounding area,
+but there is a gradual blending between the discolored and
+the normal tissues. There is considerable congestion, the
+parts are swollen and after a complete reaction, heat manifests
+itself. These symptoms may soon subside or they may
+persist for many months. In general, they are of a transient
+nature, but the parts remain permanently weakened
+and congested, and are easily affected from the slightest
+cause.</p>
+
+<p>In the more severe types of chilblains, blebs are formed
+which, when opened, exude serum or even pus. The blebs
+are commonly found at the ends of the toes, and sometimes
+the entire distal end of the digit is covered by one lesion.</p>
+
+<p>No pain is felt immediately after exposure, but as reaction
+commences, shooting pains develop, and if the reaction
+is severe, these pains become almost unbearable.
+Itching is present to a marked degree, and after reaction is
+complete, dull pains and burning are noticed until the
+affected parts become normal.</p>
+
+<p><b>Pathology.</b> The immediate effect of cold upon the skin
+is to constrict the small blood vessels and to retard the
+stream within them. Under quite severe or prolonged exposure
+there may ensue a destruction of the minute vasomotor
+nerve terminals in the arterioles, which control their
+constriction and dilation. This nerve function is thereafter
+permanently affected and the muscular coat of the vessels
+in the parts impaired, atrophies from disuse. It is this
+degree of chimatlon which is classified as chimatlon mild, or
+chilblains. (Destruction of tissue beyond this, is classified
+as chimatlon severe or frost bite).</p>
+
+<p>In winter there is a natural conservation of heat, by the
+constriction of the superficial capillaries; the blood supply
+to the skin is diminished and heat radiation is thus controlled.
+This reduction in the peripheral blood pressure
+<span class="pagenum" id="Page_286">[Pg 286]</span>especially affects the feet and other parts remote from the
+heart.</p>
+
+<p>Later on besides this natural deficiency in the blood supply,
+there is in chimatlon mild a deficiency of freely circulating
+blood, due to the blood vessels relaxing. The reverse
+condition may seem to be proven by the heightened color but
+in reality this redness is due to too much blood in the tissues.
+There is however, congestion; the blood entering the tissues
+has but little motion, the pulse wave is lost in the relaxed
+vessels and the stream is in consequence a sluggish one.
+The reduction in the supply of fresh blood is probably the
+direct cause of the pain; the lack of oxygen brought to the
+parts and the retention of excrementitious chemical substances,
+act as irritants to the sensory nerve terminals.
+Persons suffering with chilblains have feet which are generally
+cold to the touch in spite of their being surcharged
+with blood. The blood in them is rendered sluggish and the
+heat is not retained long, nor is there a sufficiently rapid
+supply of fresh blood to replace it.</p>
+
+<p>In summer time, when the general peripheral circulation
+is at its maximum, vascular conditions are equalized
+throughout the entire body surface and are congenial to
+conditions in affected areas.</p>
+
+<p>All the peripheral vessels are dilated and the blood
+pressure within them is increased to facilitate heat radiation
+and the maintenance of a cool body. “The season is
+congenial to persons who suffer with chilblains in winter
+because the pathologic condition is compensated by the
+physiologic vasodilatation and heightened blood pressure.”
+(Maximilian Stern, M.D.)</p>
+
+<figure class="figcenter illowe24" id="i_p287">
+  <img class="w100" src="images/i_p287.jpg" alt="">
+  <figcaption>
+    CHIMATLON MILD FROM THE JACOBI ATLAS
+  </figcaption>
+</figure>
+
+<p><b>Diagnosis.</b> Chimatlon mild is a true inflammation of
+the skin with or without bullous formation and serous or
+purulent exudation. The color varies from a light scarlet
+to a deep purple and the lesions blend gradually with
+the surrounding normal tissue. The part feels cold and
+clammy to the touch, this being a characteristic symptom in
+spite of the heightened red color. The blood present in the
+<span class="pagenum" id="Page_287">[Pg 287]</span>parts is sluggish so that its temperature is below normal.</p>
+
+<p>Chilblains of the metatarsophalangeal joint of the great
+and fifth toes may be mistaken for bursitis. The chief
+difference between the two conditions is found in the history
+of the case,
+which in chilblains
+shows exposure,
+while in
+bursitis the lesion
+is usually
+accompanied by
+hallux valgus.
+The usual sites
+of chimatlon
+mild of the foot
+are the heel, the
+tips of the toes,
+the great and little
+toe joints
+and the webs between
+the toes.
+The pains of
+chilblains are
+transient and of
+a shooting variety,
+and are
+present with the
+shoe on or off,
+while those of
+bursitis are constant
+and dull,
+and are present
+only when the
+shoe is worn.
+Where inflammatory
+processes
+have continued
+<span class="pagenum" id="Page_288">[Pg 288]</span>so that the deep tissue are involved, the pains are of
+a throbbing nature in both lesions, so that other symptoms
+must be observed to determine upon a proper diagnosis.</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdc">
+<span class="smcap">Chimatlon Mild</span>
+</td>
+<td class="tdc">
+<span class="smcap">Bursitis</span>
+</td>
+</tr>
+<tr>
+<td class="tdl">
+History of exposure
+</td>
+<td class="tdl">
+No history of exposure
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Hallux valgus not usually present
+</td>
+<td class="tdl">
+Hallux valgus usually present
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Pains of shooting variety
+</td>
+<td class="tdl">
+Pains dull and steady
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Pains present at all times
+</td>
+<td class="tdl">
+Pains absent with shoes off
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Intense itching
+</td>
+<td class="tdl">
+No itching
+</td>
+</tr>
+</table>
+
+
+<p>The lesions of chimatlon are irregular in shape and may
+involve the entire forefoot, including both the dorsal and
+the plantar surfaces. The heel over the tendo Achillis, as
+well as the skin on the sole and lateral surfaces over the os
+calcis, are common sites of chilblains. These lesions are
+usually deeply colored, the redness gradually diminishing
+as the periphery is reached.</p>
+
+<p>The blebs which have formed, may exude serum or even
+pus, and these lesions may be easily differentiated from the
+blebs of pompholyx and eczema by carefully noting the
+history of the case, the age of the patient and the general
+appearance of the foot and leg.</p>
+
+<p><b>Prognosis.</b> The ultimate cure of chilblains is uncertain.
+Cases of a mild type often respond immediately, while others
+persist indefinitely. The painful symptoms are readily
+relieved, but the lesion itself often continues until the change
+of season, when the warmer weather brings about a cure.
+This is due to the changes that occur in the cutaneous circulation
+during warmer weather. Recurrence is the rule in
+those who have poor circulation from anemia or other
+causes.</p>
+
+<p><b>Treatment.</b> The treatment for chimatlon mild consists
+in bringing about a gradual reaction. This should be commenced
+immediately after exposure, and is accomplished by
+rubbing the parts with snow or cold water. It must be
+remembered that the reaction must be gradual. If the parts
+<span class="pagenum" id="Page_289">[Pg 289]</span>exposed are rapidly warmed, the reaction will be equally
+rapid, and serious results may follow. After reaction has
+been established, the treatment varies with the severity of
+the resulting inflammation.</p>
+
+<p>When the skin has been broken and blebs or bullae are
+present, the lesions must be healed first. For this purpose
+ointments are most desirable. The parts should be thoroughly
+cleansed with an antiseptic such as phenol (1-40)
+or bichloride of mercury (1-2000), and by removing serum
+or pus present, with hydrogen peroxide. The surface of the
+lesion may then be dressed with any of the following:</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl">
+℞
+</td>
+<td class="tdl">
+Ichthyol
+</td>
+<td class="tdr">
+8.00
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Petrolatum q. s. ad.
+</td>
+<td class="tdr">
+32.00
+</td>
+</tr>
+<tr>
+<td class="tdl" colspan="3">
+M. ft. ung. Sig. Apply over affected parts twice daily.
+</td>
+</tr>
+<tr><td colspan="3"></td></tr>
+<tr>
+<td class="tdl">℞
+</td>
+<td class="tdl">
+Acid. carbol.
+</td>
+<td class="tdr">
+0.60
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Acid. boric
+</td>
+<td class="tdr">
+2.00
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Petrolatum q. s. ad.
+</td>
+<td class="tdr">
+32.00
+</td>
+</tr>
+<tr>
+<td class="tdl" colspan="3">
+M. ft. ung. Sig. Apply on chilblain once daily.
+</td>
+
+</tr>
+<tr><td colspan="3"></td></tr>
+<tr>
+<td class="tdl">
+℞
+</td>
+<td class="tdl">
+Spirit. terebinthinae
+</td>
+<td class="tdr">
+2.00
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Acid. boric
+</td>
+<td class="tdr">
+2.00
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Petrolatum q. s. ad.
+</td>
+<td class="tdr">
+32.00
+</td>
+</tr>
+<tr>
+<td class="tdl" colspan="3">
+M. ft. ung. Sig. Apply on chilblain once daily.
+</td>
+</tr>
+</table>
+
+
+<p>Wet dressing of Burow’s Solution, diluted with equal
+parts of distilled water, applied for a few days, produces
+satisfactory results in lesions where there is marked inflammation
+and swelling.</p>
+
+<p>In severe ulcerative processes that do not granulate
+readily, a strong stimulant, such as balsam of Peru or some
+iodine preparation, should be used until the entire area is
+healed.</p>
+
+<p>After the skin has been healed, or in cases where the
+skin has not been broken, the treatment varies with the
+severity of the lesion. In very mild cases, massage followed
+by an application of the compound tincture of benzoin,
+which, because it furnishes an occlusive coating and acts as
+<span class="pagenum" id="Page_290">[Pg 290]</span>a support for the skin, is often sufficient. The liquor alumini
+acetatis (Burow’s Solution) may be used as an astringent
+wet dressing to reduce the swelling and inflammation. The
+part may also be painted with a four per cent. solution of
+silver nitrate at frequent intervals, to be then covered with
+raw cotton; or nitric acid, diluted with aqua cinnamoni, 15
+minims to the ounce, may be painted over the unbroken skin.</p>
+
+<p>A very satisfactory liniment which has been used extensively
+to relieve the pain and reduce the inflammation in
+this condition consists of the following:</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl">
+℞
+</td>
+<td class="tdl">
+Guaiacol
+</td>
+<td class="tdr">
+8.
+</td>
+</tr>
+<tr>
+<td class="tdl">
+</td>
+<td class="tdl">
+Spts. terebinth.
+</td>
+<td class="tdr">
+28.
+</td>
+</tr>
+<tr>
+<td class="tdl">
+</td>
+<td class="tdl">
+Ol. olivae q. s. ad.
+</td>
+<td class="tdr">
+64.
+</td>
+</tr>
+<tr>
+<td class="tdl" colspan="3">
+M. ft. lin. Sig. Rub on affected parts at bedtime.
+</td>
+
+</tr>
+</table>
+
+
+<p>The itching, which is a marked symptom of chimatlon
+mild, can readily be controlled by the application of camphorated
+soap liniment. Its action is almost instantaneous.</p>
+
+<p>Ichthyol has proven to be a valuable agent in the treatment
+of chilblains; it may be used with collodion, or as an
+ointment, the following being found satisfactory:</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl">
+℞
+</td>
+<td class="tdl">
+Ichthyol
+</td>
+<td class="tdr">
+8.
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Lanolin q. s. ad.
+</td>
+<td class="tdr">
+32.
+</td>
+</tr>
+<tr>
+<td class="tdl" colspan="3">
+M. ft. ung. Sig. Spread on gauze or lint and apply.
+</td>
+
+</tr>
+</table>
+
+
+<p>It must be borne in mind that the apparent cure of an
+acute lesion of chimatlon mild, is not in reality an absolute
+cure, and thorough precautions must be taken to prevent recurrence.
+Stimulation of the cutaneous blood supply and
+the vasomotor nervous system is essential, and for this
+purpose, massage and the alternate hot and cold foot baths
+are advisable. The latter treatment should be used at least
+once daily and if possible, twice a day. The feet should be
+kept in hot water for thirty seconds and then plunged into
+cold water and kept there for fifteen seconds. This is repeated
+for an entire ten minute period.</p>
+
+<p>Electricity, in the form of the faradic or the high frequency
+<span class="pagenum" id="Page_291">[Pg 291]</span>currents, may be used to assist in the stimulation
+of the action of the skin. These treatments should be given
+for ten minutes, three times a day.</p>
+
+<p>The hygiene of the foot is all important, and this should
+be explained at length to the patient. The feet should be
+protected by wearing woolen or cashmere stockings, the
+latter being preferred, and should be used from early in the
+fall until late in the spring. Hose of this kind prevent heat
+radiation, so necessary for those who suffer from chilblains;
+they also absorb excretory moisture, all of which prevents
+recurrence of the lesions. It is necessary to conserve the
+body heat as much as possible, and warm underclothing,
+covering the entire body, should be worn; the patient should
+be instructed to take some form of general exercise. Footgear
+should be wide enough to allow freedom of the toes
+and the shoes should be made of either calf skin or vici kid.
+The wearing of silk stockings and patent leather shoes must
+be discouraged if good results are to be expected.</p>
+
+<p>Where the skin is not broken, Dr. Charles T. St. Clair
+of Bluefield, West Virginia, advises as follows: “coal oil
+(kerosene) applied night and morning to old itching frost bites
+of the feet gives almost immediate relief. It should be
+applied with a cloth and cotton soaked in the kerosene and
+allowed to evaporate, which it will do in a few minutes. If
+the sock is put on and the person goes to bed with the foot
+still wet with the oil, it may burn the skin.”</p>
+
+
+<h3 id="CHIMATLON_SEVERE">
+  CHIMATLON SEVERE
+</h3>
+
+<p><b>Derivation.</b> Chimatlon, from the Greek, meaning the
+severity of winter; severe, with extremely bad effects on the
+tissues.</p>
+
+<p><b>Synonyms.</b> Frost bite, pernio, dermatitis calorica.</p>
+
+<p><b>Definition.</b> Chimatlon severe is a local inflammation
+of the skin and deeper structures, produced by exposure to
+extreme cold, and is a result of complete or partial paralysis
+of the vasomotor nerves.</p>
+
+<p><b>Etiology.</b> The one cause for the severe form of chimatlon
+<span class="pagenum" id="Page_292">[Pg 292]</span>is prolonged exposure to an extreme degree of cold. The
+decrease in atmospheric temperature lowers the temperature
+of the parts exposed, thereby causing complete or
+partial paralysis of the vasomotor nerves and producing
+congelation of the blood vessels. When the congelation is
+complete the parts are deprived of their nourishment, and
+finally become devitalized.</p>
+
+<p><b>Symptoms.</b> Immediately after exposure, numbness develops
+and all sensation is gradually lost. The parts are
+congealed and if there is complete freezing, they present a
+white, blanched appearance. The tissues affected may be
+so completely frozen, that upon thawing, they are either
+found to be absolutely dead, or their vitality so greatly impaired
+that there is very little reaction and gangrene may
+result in a very short time. If the area is not completely
+frozen, the reaction is rapid, the tissues become purple,
+swollen and very painful. The parts may become gangrenous,
+in which case the line of demarcation and separation
+between the gangrenous and the healthy tissues evidences
+itself. The affected tissue is at first white but gradually
+becomes blue and finally black. The fluids in the tissues
+rapidly evaporate and the odor of decaying flesh is very
+apparent.</p>
+
+<p>If the parts do not become gangrenous, the symptoms
+that present themselves are those of inflammation. The
+tissues become swollen and assume a deep purple color,
+which, as the circulation is restored, becomes lighter and,
+after inflammation has subsided, gradually disappears.
+Blebs may form and there may be an exudation of serum
+or even of pus.</p>
+
+<p><b>Pathology.</b> The changes that occur in chimatlon severe
+are much the same of those of the milder type, the former
+however, causing complete destruction of tissue, or the development
+of gangrene. The cold causes a constriction of
+the blood vessels and the stream within them is retarded.
+The minute nerve terminals in the smaller arteries, which
+control the dilation and constriction, are destroyed and their
+<span class="pagenum" id="Page_293">[Pg 293]</span>function is lost. The vessels now contract and in extreme
+cases remain so. Where the exposure has not been severe
+enough to cause complete death of the vessels, there is a
+dilation after the contraction, with a very slow movement
+or even complete stasis of the blood stream.</p>
+
+<p>Gangrene or necrosis will manifest itself in extreme
+cases almost immediately, and often after reaction has
+commenced, the tissues may be cast off. At the line of
+demarcation between the normal and the dead tissues, the
+changes that accompany inflammation take place.</p>
+
+<p><b>Diagnosis.</b> The diagnosis of frost bite is not very
+liable to be confused with any other condition, in that the
+history shows exposure to an extremely low temperature.
+The disease known as “Trench Foot,” when it first manifested
+itself, during the world war, was considered a form
+of chimatlon, but since research work has been done along
+the lines of the new disease, it has been found to be quite
+another condition. Trench Foot will be discussed following
+this chapter.</p>
+
+<p>The color of the part is characteristic. Immediately
+after exposure, the tissues are blanched, and as reaction
+progresses, the color deepens from a light scarlet to a deep
+red purple or black, depending on the length of the exposure
+and the severity of the condition. As reaction advances,
+the gangrenous tissue is separated from the normal
+tissue by a distinct slough, which, as previously stated, is
+known as the line of demarcation.</p>
+
+<p>The milder cases of frost bite and the severer cases of
+chilblains are often confused, particularly in cases of the
+former when the loss of tissue has been avoided. The
+confusion, although of no great moment (inasmuch as the
+treatment of both lesions is identical), may be avoided by
+remembering that frost bite develops quickly and that the
+parts have been exposed to a very low temperature, while
+chilblains develop more slowly, are less painful and do not
+require exposure to a very great decrease in temperature
+for their causation.</p>
+
+<p><span class="pagenum" id="Page_294">[Pg 294]</span></p>
+
+<p><b>Prognosis.</b> When the part has been completely frozen
+and the circulation to the parts has ceased, there is no possibility
+of saving the tissues. However, in cases seen immediately
+after exposure, in which proper treatment is
+commenced at once, it is often possible to save large areas
+that would otherwise be lost. Amputation is the only cure
+in cases where gangrene has developed. The ulcers which
+result after the dead tissue has been removed, respond very
+slowly, requiring from one to four months to heal.</p>
+
+<p>Recurrence is the rule, due to the fact that the vasomotor
+nerves never regain their normal vitality, and persons
+who have had frost bite will develop symptoms from
+the least imaginable cause.</p>
+
+<p><b>Treatment.</b> In all cases of frost bite, even when the
+parts seem hopelessly frozen, the first treatment should
+consist of bringing the parts back to normal temperature
+by a gradual reaction. This should be carried out as thoroughly
+as possible, for it often is the means of saving large
+areas of tissue. A case in which the entire forefoot is
+involved may be thus saved so that only one or two toes are
+lost. Such a patient would be able to walk comfortably,
+whereas if no care were taken with the preliminary treatment,
+the patient might become a hopeless foot cripple.</p>
+
+<p>A gradual reaction is brought about by rubbing the
+parts with snow or cold water. The affected parts may be
+placed in a vessel containing cold water, or they may be
+wrapped in cloths wrung out in cold water. The final result
+depends largely upon the length of time elapsing between
+the exposure and the inauguration of the first treatment.</p>
+
+<p>If the parts are completely frozen, gangrene will soon
+manifest itself. If the affected part is only partly frozen,
+a gradual reaction can be brought about by the above-described
+means and if the subsequent inflammatory reaction
+is gradual, gangrene may be averted or at least limited.
+Cold water dressings should be continued for some time
+after reaction has occurred, and should be maintained until
+the certainty of the avoidance of gangrene is fixed. The line
+<span class="pagenum" id="Page_295">[Pg 295]</span>of demarcation and separation will be indicative of this fact.</p>
+
+<p>When all of the gangrenous tissue has separated, the
+remaining ulcer should be treated just as though it had
+arisen from any cause. In cases of gangrene of the toes and
+feet, complete or partial amputation should be practised
+as soon as the lines of demarcation and separation are well
+established. When gangrene has been avoided in frost bite,
+the treatment consists in stimulating the affected area.
+Various medicaments are useful, among which may be mentioned
+oil of turpentine, balsam of Peru, tincture of iodine,
+ichthyol and strongly carbolized ointments.</p>
+
+<p>If the frost bite is of the bullous, pustular, vesicular or
+escharotic type, soothing agents such as ichthyol, Burow’s
+solution, etc., should be applied to the affected parts.</p>
+
+<p>Wrapping the affected parts in dry salt has been suggested
+by a western chiropodist, who claims to have obtained
+excellent results by the use of this agent.</p>
+
+<p>In cases where gangrene has been averted, the following
+have proved of great value:</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl">
+℞
+</td>
+<td class="tdl">
+Acid, carbol.
+</td>
+<td class="tdr">
+1.
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Acid, boric
+</td>
+<td class="tdr">
+2.
+</td>
+</tr>
+<tr>
+<td class="tdl">
+</td>
+<td class="tdl">
+Petrolat, q. s. ad.
+</td>
+<td class="tdr">
+32.
+</td>
+</tr>
+<tr>
+<td class="tdl" colspan="3">
+M. ft. ung. Sig. Apply every morning.
+</td>
+</tr>
+<tr><td colspan="3"></td></tr>
+<tr>
+<td class="tdl">
+℞
+</td>
+<td class="tdl">
+Ichthyol
+</td>
+<td class="tdr">
+8.
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Lanolin q. s. ad.
+</td>
+<td class="tdr">
+32.
+</td>
+</tr>
+
+<tr>
+<td class="tdl" colspan="3">
+M. ft. ung. Sig. Apply on lesions once daily.
+</td>
+
+</tr>
+<tr><td colspan="3"></td></tr>
+<tr>
+<td class="tdl">
+℞
+</td>
+<td class="tdl">
+Ichthyol
+</td>
+<td class="tdr">
+8.
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Aquae q. s. ad.
+</td>
+<td class="tdr">
+32.
+</td>
+</tr>
+<tr>
+<td class="tdl" colspan="3">
+M. Sig. Paint over the affected area.
+</td>
+
+</tr>
+</table>
+
+
+<p>In frost bite, after the gangrenous tissue has been removed,
+the resulting ulcer may be treated with a stimulant.
+For this purpose balsam of Peru, iodine, ichthyol and other
+agents have proven successful. These ulcers do not respond
+readily, because of the decrease in vitality of the surrounding
+tissues, and patience is essential for a final cure. The
+<span class="pagenum" id="Page_296">[Pg 296]</span>patient must be told that the lesion will require a long time
+to heal.</p>
+
+<p>Hernance (Therapeutic Gazette, 1895) draws the following
+conclusions from the study of thirty cases: “1. Ichthyol
+is the drug that gives most relief to pain and is as good a
+protector as any other application. 2. Acetanilid ointment
+is the best dressing when the parts are raw and ulcerated,
+preventing suppuration and promoting granulation. 3. In a
+certain number of cases one can do nothing but keep the
+parts clean and wait until nature throws off the diseased
+tissue.”</p>
+
+<p>Massage is a very good therapeutic agent for chimatlon
+severe, and should be applied twice a day, if possible. This
+will help stimulate the circulation and tone up the faulty
+nerve endings. Electricity should also be used wherever
+possible, the high frequency and the faradic currents being
+the best. Applications directly to the affected parts for
+ten minutes, once or twice a day, will aid materially in bringing
+about a rapid cure.</p>
+
+<p>The prevention of the recurrent attacks may be accomplished
+by treatment commenced in the early fall, and including
+massage, proper shoes, cashmere stockings, and
+other prophylactic measures. This treatment is essential,
+particularly for those who are anemic and under-nourished.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_297">[Pg 297]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_XIX">
+    <span class="chap">CHAPTER XIX</span>
+    <br>
+    DISEASES OF THE SWEAT GLANDS
+  </h2>
+</div>
+
+
+<h3>HYPERIDROSIS</h3>
+
+<p><b>Derivation.</b> From the Greek <i>hyper</i>, in excess, and
+<i>hidros</i>, sweat.</p>
+
+<p><b>Synonyms.</b> Idrosis; ephidrosis; hydrosis; sudatoria;
+polyidrosis; excessive sweating, sudorrhea.</p>
+
+<p><b>Definition.</b> Hyperidrosis is a functional disorder of
+the sweat glands (usually of the hands and feet) characterized
+by the excessive excretion of sweat. The condition may
+be limited to certain areas or it may be distributed over the
+entire body.</p>
+
+<p><b>Etiology.</b> When hyperidrosis is general it is caused
+by faulty innervation. The cause in localized forms is
+doubtless varied from that of pure idiosyncrasy to grave
+systemic disturbances. In instances there seems to be an
+inherited tendency to this disturbance. Excessive drinking
+of water or tea will produce hyperidrosis pedum in some
+people. Localized sweating may follow some debilitating
+diseases for a period of time. Anything that causes a depression
+of the nervous tone, may be an etiologic factor.
+Neurasthenics often display this symptom. Physical or
+mental excitement will cause profuse sweating in many
+individuals.</p>
+
+<p><b>Pathology.</b> The normal sweat excretion is closely related
+to the nervous system, hence pathologic excretion
+must have some nervous cause. It is most probable that
+any disease or injury that affects the function of the sympathetic
+nervous system, is the direct cause of excessive sweat
+excretion. Examination of sections of the glands fails to
+show any increase in size or in the epithelium of the gland.</p>
+
+<p><span class="pagenum" id="Page_298">[Pg 298]</span></p>
+
+<p><b>Symptoms.</b> Hyperidrosis may occur as a result of a
+general disease such as rheumatism, tuberculosis, malaria,
+etc., or it may be idiopathic and persist for a long period.
+The latter phase is of most interest to the podiatrist. The
+disease is quite common. The sweating may be immediate
+or profuse, and is always more marked in regions where
+excessive sweating is normal, such as the hands, feet,
+axillae, etc. It is more pronounced in hot weather, but is
+excessive even in cold weather, and is increased by the least
+exertion. In hot weather it is frequently accompanied by
+miliaria, intertrigo, or acute eczema.</p>
+
+<p>On the feet, hyperidrosis is often disgusting, and may
+become exceedingly troublesome. The excretion is excessive
+and the feet are constantly damp or wet and clammy.
+The stockings become moist and the shoe may become water-soaked.
+Sweating is most profuse on the soles and between
+the toes. The skin is soggy and macerated and, in severe
+cases, the sole and surrounding areas are reddened, puffy
+and irritated, with ill-defined vesicular or flattened bullous
+lesions. In ordinary hyperidrosis of the feet, the sweat is
+not offensive immediately after it is exuded, but rapidly
+becomes so, unless the footgear is changed frequently.
+Bromidrosis is often associated with hyperidrosis.</p>
+
+<p><b>Prognosis.</b> As a rule, localized cases are obstinate, but
+with continued treatment, good results will follow. It is
+often necessary to change the treatment from time to time.
+Relapses are not uncommon.</p>
+
+<p><b>Treatment.</b> The treatment of hyperidrosis is divided
+into two groups, local and general. Excessive general
+sweating following fevers and debilitated conditions of the
+system should receive general treatment at the hands of the
+physician. When nervous disorders produce sweating in
+limited areas, they also require specially directed general
+treatment. In localized sweating of indefinite cause, under
+the advice of the physician, it is often advisable to administer
+general tonics, and remedies such as ergot, belladonna,
+gallic acid, etc., may be locally applied. Precipitated
+<span class="pagenum" id="Page_299">[Pg 299]</span>sulphur, taken internally, one dram twice daily, is the resort
+of many physicians in such cases and the treatment has
+given satisfactory results.</p>
+
+<p>While constitutional treatment should be used in every
+case of hyperidrosis pedum, the external treatment is more
+positive in result and therefore is more essential. This
+external treatment consists of the application of ointments
+and powders, with frequent washing and the use of lotions.
+Astringent lotions, used for the purpose of hardening the
+skin may be chosen from the following:</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl">
+Alum powdered
+</td>
+<td class="tdl">
+1 ounce.
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Water
+</td>
+<td class="tdl">
+1 pint.
+</td>
+</tr>
+<tr>
+<td class="tdc" colspan="2">
+or
+</td>
+
+</tr>
+<tr>
+<td class="tdl">
+Zinc sulphate
+</td>
+<td class="tdl">
+2 drams.
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Water
+</td>
+<td class="tdl">
+1 pint.
+</td>
+</tr>
+<tr>
+<td class="tdc" colspan="2">
+or
+</td>
+
+</tr>
+<tr>
+<td class="tdl">
+Formalin
+</td>
+<td class="tdl">
+3 drams.
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Alcohol
+</td>
+<td class="tdl">
+1 pint.
+</td>
+</tr>
+</table>
+
+
+<p>The feet should be thoroughly cleansed and dried.
+Lotions applied two or three times daily, should be allowed
+to dry on the foot. This may then be followed by a dusting
+powder of the following:</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl">
+Acid salicylic
+</td>
+<td class="tdr">
+15
+</td>
+<td class="tdl">
+grains.
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Boric acid
+</td>
+<td class="tdr">
+1
+</td>
+<td class="tdl">
+ounce.
+</td>
+</tr>
+</table>
+
+
+<p>The local application of belladonna in the form of the
+diluted tincture, the liniment or the ointment, has given
+excellent results in some cases, but great care should be
+exercised in their use, as belladonna may produce toxic
+effects, through absorption.</p>
+
+<p>Many cases have responded readily to the alternate
+foot bath (See Chapter, <i>The Care of the Foot</i>). After the
+alternate foot bath, the feet are thoroughly dried, and in
+severe cases, the lotion of formalin and alcohol may be used,
+or in ordinary cases, grain alcohol is applied. When the
+<span class="pagenum" id="Page_300">[Pg 300]</span>lotion has dried, the feet are dusted with the following
+powder:</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl">
+℞
+</td>
+<td class="tdl">
+Acid salicylic
+</td>
+<td class="tdl">
+
+</td>
+<td class="tdr">
+15
+</td>
+<td class="tdl">
+grains
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Alum powdered
+</td>
+<td class="tdl">
+
+</td>
+<td class="tdr">
+
+</td>
+<td class="tdl">
+
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Lycopodium
+</td>
+<td class="tdl">
+aa
+</td>
+<td class="tdr">
+1
+</td>
+<td class="tdl">
+ounce
+</td>
+</tr>
+<tr>
+<td class="tdl" colspan="5">
+M. Sig. Dust on feet morning and night.
+</td>
+
+</tr>
+</table>
+
+
+<p>Diachylon ointment, freshly prepared, is the best
+remedy among the unguents. It is prepared as follows:</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl">
+℞
+</td>
+<td class="tdl">
+Lead plaster
+</td>
+<td class="tdr">
+1
+</td>
+<td class="tdl">
+ounce
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Oil of lavender flowers
+</td>
+<td class="tdr">
+15
+</td>
+<td class="tdl">
+grains
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Olive oil, q.s. ad.
+</td>
+<td class="tdr">
+3
+</td>
+<td class="tdl">
+ounces
+</td>
+</tr>
+<tr>
+<td class="tdl"  colspan="4">
+M. Sig. Apply on gauze and bandage.
+</td>
+
+</tr>
+</table>
+
+
+<p>Another ointment which has astringent properties and
+which has been used with some success is:</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl">
+℞
+</td>
+<td class="tdl">
+Tannic acid
+</td>
+<td class="tdr">
+2
+</td>
+<td class="tdl">
+drams
+</td>
+</tr>
+<tr>
+<td class="tdl">
+</td>
+<td class="tdl">
+Petrolatum
+</td>
+<td class="tdr">
+1
+</td>
+<td class="tdl">
+ounce
+</td>
+</tr>
+<tr>
+<td class="tdl"  colspan="4">
+M. Sig. Spread on gauze and bandage.
+</td>
+
+</tr>
+</table>
+
+
+<p>Before these ointments are applied, the parts should be
+thoroughly washed with soap and water, dried, and the
+ointment spread on gauze and held in place with a bandage.
+The application should be removed after twelve hours, the
+parts rubbed dry with a towel, and the ointment reapplied.
+This should be continued for a week or two, when, if results
+have not followed, other forms of treatment should be used.</p>
+
+<p>The X-rays have a drying influence upon the skin, but if
+this treatment is used, great caution should be exercised,
+as the rays are likely to have a very harmful influence upon
+the tissues generally.</p>
+
+<p>At the suggestion of a prominent chemist and physician,
+a series of experiments were performed with oxygen
+gas and vanadium chloride solution for the treatment of
+hyperidrosis, which proved more or less successful. The
+solution of vanadium chloride (1-20,000) was applied to the
+foot, and the oxygen gas was slowly sprayed on the foot,
+<span class="pagenum" id="Page_301">[Pg 301]</span>from a large gas container. This treatment lasted for ten
+minutes and was applied twice a week. In one particular
+case, which had resisted the ordinary methods of treatment,
+the use of this remedy was of great benefit to the patient.
+After several weeks, the case showed marked improvement,
+but the inability of the patient to continue treatment prevented
+further trials. In many other ordinary cases of
+hyperidrosis, the results were excellent, while in others
+there was no marked improvement&#x2060;<a id="FNanchor_6_6" href="#Footnote_6_6" class="fnanchor">[6]</a>&#x2060;. The use of formalin
+and alcohol solution in conjunction with the oxygen treatment,
+has proven very effective. The lotion is used at night,
+immediately before retiring.</p>
+
+<p>Stillians, in the Journal of the American Medical
+Association, states that a 25% solution of aluminum chloride
+in distilled water, dabbed gently on the part every second
+or third day and allowed to dry, will cause a rapid amelioration
+of the excessive sweating; three such applications are
+usually sufficient. If the condition recurs, the treatment
+may be repeated.</p>
+
+<p>Potassium permanganate solution, 5 parts to 1,000, has
+been found efficient as a wash for the feet. More active,
+and therefore to be used with more care, are “chromic acid”
+solutions, as:</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl padl">
+Chromium trioxide
+</td>
+<td class="tdr">
+2.5
+</td>
+</tr>
+<tr>
+<td class="tdl padl">
+Water
+</td>
+<td class="tdr">
+50.0
+</td>
+</tr>
+<tr>
+<td class="tdl"  colspan="2">
+Sig. Use as a paint once a week.
+</td>
+
+</tr>
+</table>
+
+
+<p>Less active, but more pleasant than the foregoing, is:</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl padl">
+Tannic acid
+</td>
+<td class="tdr">
+5.
+</td>
+</tr>
+<tr>
+<td class="tdl padl">
+Alcohol
+</td>
+<td class="tdr">
+100.
+</td>
+</tr>
+<tr>
+<td class="tdl padl">
+Water, q. s. ad.
+</td>
+<td class="tdr">
+200.
+</td>
+</tr>
+<tr>
+<td class="tdl"  colspan="2">
+Sig. Use as a wash twice a day.
+</td>
+
+</tr>
+</table>
+
+
+<p>The lotions and washes should be used in conjunction
+with drying powders, such as have been already mentioned.</p>
+
+<p>The use of the various solutions of aluminum chloride,
+or of chromium trioxide, may, in some cases, cause a mild
+<span class="pagenum" id="Page_302">[Pg 302]</span>dermatitis, perhaps with itching. This may be relieved by
+the application of protective dressings to prevent scratching,
+and the application of ointments, such as cold cream
+containing 12 per cent. boric acid, or a calamine lotion. Itching
+may be relieved by adding 0.5 per cent. phenol to the
+calamine lotion.</p>
+
+
+<h3 id="BROMIDROSIS">
+  BROMIDROSIS.
+</h3>
+
+<p><b>Derivation.</b> “<i>Bromos</i>,” a stench; and “<i>hidros</i>,” sweat.</p>
+
+<p><b>Synonym.</b> Osmidrosis.</p>
+
+<p><b>Definition.</b> Bromidrosis is a functional disorder of the
+sweat glands, characterized by a sweat excretion which has
+an offensive odor.</p>
+
+<p><b>Etiology.</b> The etiology of bromidrosis is much the
+same as that of hyperidrosis, occurring in those who are
+anemic, chlorotic and nervous and in those who are compelled
+to stand for long periods. Eating certain foods and
+drugs will give peculiar odors to the perspiration, among
+which are garlic, onions, assafetida, and sulphur. The
+cause of the odor of the sweat in bromidrosis pedum is the
+decomposition of the fatty acids of the sweat, as well as the
+presence of the bacterium fetidum, which is found on the
+feet, especially between the toes.</p>
+
+<p><b>Pathology.</b> Immediately after the sweat is excreted,
+it is not offensive, but soon becomes so, due to the presence
+of microorganisms and the decomposition of the fatty acids.</p>
+
+<p><b>Symptoms.</b> The sweat has a disagreeable odor and is
+usually associated with hyperidrosis, but not necessarily so,
+as it may occur in persons having a normal sweat excretion.
+When the excretion is excessive, there are the usual symptoms
+of hyperidrosis, viz., puffiness, tenderness, sogginess
+and possibly blebs or vesicles. The odor is offensive, stale,
+penetrating and peculiar and often is sufficient to make the
+sufferer unfit for society.</p>
+
+<p><b>Treatment.</b> The treatment is essentially the same as
+for hyperidrosis, coupled with absolute cleanliness and frequent
+change of footgear. Shoes should be allowed to stand
+<span class="pagenum" id="Page_303">[Pg 303]</span>in the air for at least twenty-four hours after having been
+worn, so that several pairs are required. Constitutional
+treatment is the same as for hyperidrosis as is also the
+external treatment. The feet should be washed in boric
+acid solution, and the powder used freely in the socks and
+on the feet.</p>
+
+<p>The feet may be painted once every three weeks with
+a 5 to 10 per cent. solution of chromic acid, or they may be
+washed every other day in one per cent. solution of potassium
+permanganate, and in the interval the following
+powder proves efficacious:</p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl">
+℞
+</td>
+<td class="tdl">
+Acid salicylic
+</td>
+<td class="tdr">
+10
+</td>
+<td class="tdl">
+grains
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Tannoform
+</td>
+<td class="tdr">
+2
+</td>
+<td class="tdl">
+drams
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Zinc oxide
+</td>
+<td class="tdr">
+
+</td>
+<td class="tdl">
+
+</td>
+</tr>
+<tr>
+<td class="tdl">
+
+</td>
+<td class="tdl">
+Talc
+</td>
+<td class="tdr">
+aa 3
+</td>
+<td class="tdl">
+drams
+</td>
+</tr>
+<tr>
+<td class="tdl"  colspan="4">
+M. Sig. Dust on feet morning and night.
+</td>
+
+</tr>
+</table>
+
+
+
+<h3 id="ANIDROSIS">
+  ANIDROSIS
+</h3>
+
+<p><b>Derivation.</b> <i>a</i>, without; and <i>hidros</i>, sweat.</p>
+
+<p><b>Synonym.</b> Decrease or absence of sweating.</p>
+
+<p><b>Definition.</b> Anidrosis is a functional disorder of the
+sweat glands characterized by a diminution or suppression
+of sweat.</p>
+
+<p><b>Etiology.</b> Anidrosis is rare as an idiopathic condition,
+occurring generally in diabetes and fever, also in some skin
+diseases such as ichthyosis and pityriasis rubra pilaris; also
+in the parts affected by anesthetic leprosy, scleroderma and
+keloids. Localized sweat suppression follows injury to the
+nerves.</p>
+
+<p><b>Symptoms.</b> The skin seems to be abnormally dry, and
+this dry skin may be a form of ichthyosis or may predispose
+to eczema. When the sole of the foot is dry and the skin
+shows clefts, which contain helomata miliare, and has a yellowish
+color, diabetes may be suspected. There may be but
+slight diminution of sweat excretion, or total absence.</p>
+
+<p><b>Treatment.</b> In congenital cases, nothing is of much
+<span class="pagenum" id="Page_304">[Pg 304]</span>avail. In the acquired cases, applications of hot water or
+vapor baths externally, and general tonics, the free drinking
+of water and the use of warm clothing, are indicated.
+Pilocarpin or jaborandi may be given internally, but this
+must be on the prescription of a physician. Massage with
+oil or the application of galvanic or faradic electricity have
+proven of benefit. Hot alkaline baths, preceding the massage
+with oil, are also at times beneficial.</p>
+
+<p>In addition to the above there are a number of rare
+granular perversions which occasionally are seen by the
+podiatrist and of which but brief mention need here be
+made:</p>
+
+<p><i>Chromidrosis.</i> A condition in which the sweat is
+colored, usually black. When this condition arises from
+accident, the sweat may be colored green. Red sweat, which
+occasionally occurs in the axillae, is due to the action of
+bacterium prodigiosum.</p>
+
+<p><i>Sudamen.</i> A collection of sweat in the upper layers of
+the epidermis, due to obstruction of the sweat ducts, which
+gives rise to an eruption of numerous pinhead, transparent
+vesicles. Occurs during the course of fevers and is usually
+of but short duration.</p>
+
+<p><i>Uridrosis.</i> Characterized by the excretion of urine constituents
+through the sweat glands. Usually the result of
+suppression of urine by reason of impaired kidney function,
+whereupon the sweat glands assist in the elimination of the
+urinary deposits. There is a urinous odor to the skin.</p>
+
+<p><i>Hematidrosis.</i> Characterized by hemorrhage from the
+sweat glands. A very rare condition.</p>
+
+<p><i>Phosphoridrosis.</i> In this very unusual disease the
+sweat glands exude a phosphorescent sweat, said to be due
+to a species of photobacterium following the ingestion of
+phosphorus or of food stuffs containing phosphorus.</p>
+
+<p><i>Miliaria.</i> A mild inflammatory affection caused by obstruction
+of the sweat ducts, characterized by the occurrence
+of small papules and vesicles at their mouths.</p>
+
+<p><i>Hydrocystoma.</i> A condition characterized by the
+<span class="pagenum" id="Page_305">[Pg 305]</span>formation upon the face of firm, pinhead sized vesicles, due
+to sweat gland obstructions.</p>
+
+<p><i>Hydradenitis Suppuration.</i> An inflammatory disease
+of the sweat glands followed by deep-seated, shot-like
+nodules, which suppurate and leave scars.</p>
+
+<p><i>Seborrhea.</i> A lesion of the fat-producing glands characterized
+by an increased and altered secretion of sebum resulting
+in an oily or scaly condition of the skin.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_306">[Pg 306]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_XX">
+    <span class="chap">CHAPTER XX</span>
+    <br>
+    ULCERS
+  </h2>
+</div>
+
+
+<p><b>Definition.</b> An ulcer is a lesion of a cutaneous or
+mucous surface, caused by a molecular disintegration of the
+superficial parts, usually attended by more or less suppuration.
+A wound, or superficial loss of tissue due to traumatism,
+is not primarily an ulcer, but may become such if
+the healing process is arrested or the wound becomes infected
+with pyogenic microorganisms.</p>
+
+<p>The following ulcers frequently come under the observation
+of the podiatrist:</p>
+
+<p><b>Simple Ulcer</b>, a local non-constitutional lesion attended
+with no marked pain or inflammation.</p>
+
+<p><b>Indolent or Callous Ulcer</b>, a chronic lesion, with hard,
+elevated edges and few or no granulations and showing no
+tendency to heal.</p>
+
+<p><b>Varicose Ulcer</b>, localized destruction of the skin over a
+varicose vein, usually of the leg, due to mechanical pressure,
+to nutritive disturbances, or to bacterial action.</p>
+
+<p><b>Perforating Ulcer of the Foot</b>, malum perforans pedis,
+a round, deep, trophic lesion of the sole of the foot, following
+disease or injury (in any part of its course from the
+centre to the periphery) of the nerve supplying the parts.</p>
+
+<p><b>Syphilitic Ulcer</b>, due to syphilis in late secondary or in
+tertiary stages.</p>
+
+<p>Before describing the characteristics of the various
+forms of lesions just mentioned, together with their differential
+diagnosis, treatment, etc., it is deemed advantageous
+to briefly discuss the general etiology and pathology of all
+ulcers.</p>
+
+<p><b>Etiology.</b> One or several factors may be concerned in
+<span class="pagenum" id="Page_307">[Pg 307]</span>the etiology of ulcers, which are grouped under: (a) predisposing
+causes; (b) exciting causes. The first group includes
+local as well as general causes.</p>
+
+<p><b>Predisposing Causes.</b> Age can hardly be considered as
+a very important factor, except that old age is accompanied
+by retrogressive tissue changes, hardening of the arteries,
+impaired circulation, etc., and one would therefore expect
+the statistics to show a greater proportion of ulcers during
+the later years of life.</p>
+
+<p>As regards sex, ulcer is more common among men than
+women in the ratio of about three to one. Alcoholism, syphilis,
+and traumatism may in some measure explain why
+ulcers are more common in men than women. Occupation
+seems to have little to do with the etiology beyond the fact
+that it may predispose to various forms of infection, and it
+is due to this element that we have the most important factors
+in the causation of ulceration. Varicose ulcer is always
+associated with varicose veins in the lower extremity,
+and these may be described as veins whose valves are incompetent.
+The most obvious cause of the breaking down
+of the valves is hard work, that is the lifting or carrying of
+heavy loads, as in the case of laborers, freight handlers,
+and longshoremen. The great strain occasioned by work
+of this kind lays a heavy load upon the veins of the legs.
+Whether the valves become useless through stretching of
+the vein walls, or are directly broken, is immaterial. The
+occupations which involve standing for long periods without
+moving the legs are, in a lesser degree, a source of
+valvular incompetence, and this is not from excessive back
+pressure but from stasis due to lack of muscular movement.
+Among women, the venous engorgement of the legs, so often
+seen in pregnancy, may, after the birth of several children,
+result in varicosity.</p>
+
+<p>Many of the constitutional diseases such as gout,
+anemia, diabetes, syphilis, and tuberculosis, which lower the
+vitality of the tissues, and other conditions, such as valvular
+disease of the heart, general obesity, and arterial hardening
+<span class="pagenum" id="Page_308">[Pg 308]</span>which prevent proper circulation, predispose to the formation
+of ulcers when there is in addition some exciting cause.</p>
+
+<p>Embolism, which cuts off the nutrition of the part, may
+also act as a local cause. Certain vasomotor disturbances,
+such as occur in frost bite and in Raynaud’s disease, may
+produce small areas of localized gangrene which subsequently
+become the seat of an ulcer.</p>
+
+<p>Interference with the return of venous blood from a
+part predisposes to ulceration. Where phlebitis and periphlebitis
+occur, especially in the smaller venous radicles,
+small abscesses often form, the adjacent skin becomes involved,
+and an ulcer results; or the rupture of the diseased
+wall of one of the small veins may become infected, and
+ulcer develops.</p>
+
+<p>Perforating ulcer of the foot is a frequent complication
+of tabes dorsalis. Myelitis, and other pathologic conditions
+of the nervous system may also, either through trophic
+changes or by reason of impaired sensation, bear a distinct
+relationship to ulcerative processes.</p>
+
+<p><b>Exciting Causes.</b> Traumatism is one of the most frequent
+causes of ulcer formation. Its degree may, of course,
+vary greatly, and whether it will produce an ulcer depends
+upon one or more of the predisposing causes already mentioned.
+Infection by any of the staphylococcus or streptococcus
+group of organisms as well as by the tubercle bacillus
+will produce ulcers; malignant ulceration also occurs.</p>
+
+<p><b>Pathology.</b> The pathology will vary according to the
+conditions causing the ulcer, although in the non-specific
+forms of ulcer the phenomena of congestion, exudative and
+necrotic inflammation, together with reparative inflammation
+or granulation, will only be in evidence. In the development
+of an ulcer the degenerative process predominates;
+in the healing stage, the reparative. When the ulcer
+develops from without, as when infection enters the skin
+through an abrasion, congestion first occurs. This is
+rapidly followed by the emigration of leucocytes, by a diapedesis
+of red blood cells which rapidly disintegrate, and
+<span class="pagenum" id="Page_309">[Pg 309]</span>by an exudation of serum and fibrin. At the same time
+there is a proliferation of the epithelial cells and also a
+proliferation of the connective tissue cells of the corium.
+The tissue next becomes softened by the exudate between
+the cells. Then, as a result of the pressure of the exuded
+serum, of the crowding by the leucocytes, and of the cutting
+off of the blood supply, and also in some measure through
+the effects of the toxins furnished by the bacteria, there
+occurs necrosis of the cells, which are thrown off from the
+surface with the products of exudation, until there is formed
+an ulcer with its base consisting of spheroidal and a few
+epithelioid cells developed from the connective tissue cells
+by proliferation.</p>
+
+<p>When an ulcer in its complete stage of development is
+examined, the surface is found to be covered with a layer
+formed by the overproduction of new round cells, together
+with the exudate of fibrin, serum, and the cellular elements
+of the blood. When the discharge from the ulcer is profuse,
+this may be constantly washed away. When the ulcer is
+sluggish, it may be in a condition of coagulation necrosis.
+In this latter condition a croupous material covers the base
+of the ulcer, and below this is a more or less distinct layer,
+largely composed of cellular elements, with very little cellular
+substance, the cells being spheroidal and epithelioid in
+character and mingled with polynuclear leucocytes. As we
+go deeper, the amount of intercellular substance increases,
+and a number of transparent fibres and fusiform cells are
+found. In this layer of granulation tissue are also the newly
+formed blood vessels, the most superficial branches being
+vertical to the surface, and developing by a process
+of budding from the endothelial cells of the capillaries
+deeper down. This layer is paler in color than the layer
+made up of the cellular elements, but may contain pigment
+from the disintegration of the red blood cells. It gradually
+merges into a layer of cicatricial connective tissue which
+lies beneath the ulcer.</p>
+
+<p>A section of a chronic ulcer would show an enlargement
+<span class="pagenum" id="Page_310">[Pg 310]</span>and prolongation of the papillæ, with a marked proliferation
+of the epithelial cells covering them. This is most pronounced
+in the condition known as callous ulcer, where the
+edges may, by proliferation, be considerably raised about the
+level of the surrounding skin, and often overhang the base
+of an ulcer. Under proper treatment the reparative process
+proceeds faster than the degeneration of the cells and the
+ulcer begins to heal by granulation. Small sprouts or buds
+of protoplasm protrude from the capillaries below or in the
+base of the ulcer, developing from the cells in their walls.
+These are hollowed out by the blood pressure and form new
+blood vessels which anastomose with others. Nuclei form in
+the protoplasm and thus endothelial cells develop. At the
+same time small spheroidal cells, developing from the connective
+tissue cells, become grouped around the blood vessels.
+These are closely crowded together at first, being
+separated by only a small amount of fluid intercellular substance.
+Some of the round cells then become larger and
+fusiform or branched. The larger cells are known as epithelioid
+cells. Some of the fusiform and branched cells, called
+fibroblasts, develop the new delicate fibrillar intercellular
+substance, while others form the connective tissue cells.
+Gradually the fibrous intercellular substance increases in
+amount, while the cells become fewer and flattened, and
+cicatricial tissue is formed. The contraction of this cicatricial
+tissue constitutes an important element in the healing
+of an ulcer.</p>
+
+<p>During the process of granulation, more of the round
+cells are produced than are necessary. These die and
+are thrown off in the discharge. Healthy granulations
+should be small, even, and of a reddish pink color. Where
+the growth of the blood vessels proceeds more rapidly than
+the development of the cells and the formation of connective
+tissue, there is produced a soft, pale, flabby condition known
+as exuberant granulations, or proud flesh. On the other
+hand, both the cells and the blood vessels may develop very
+slowly, forming indolent or sluggish granulations. In order
+<span class="pagenum" id="Page_311">[Pg 311]</span>that the ulcer may heal it must eventually become covered
+with epithelium, and this can develop only from the epithelium
+at the edges of the ulcer. Under favorable conditions,
+when the granulations reach the level of the surrounding
+skin, the epithelium begins to spread in a thin bluish white
+line from the edges out over the surface, until the latter is
+entirely covered, when the ulcer is healed.</p>
+
+<p><b>Simple Ulcers.</b> By far the greatest number of ulcers
+coming under the observation and within the province of
+the podiatrist are of the simple variety. Heavy calloused
+areas which are neglected are apt to become so irritant as
+to cause the softer tissues underneath to break down and
+ulcerate, and a similar condition very often occurs in connection
+with helomata, particularly heloma molle.</p>
+
+<p>Constitutional diseases, either trophic or specific, may
+be predisposing causes of these conditions but the exciting
+cause is surely traumatism.</p>
+
+<p>Simple ulcerations are most generally found upon the
+plantar surfaces of the feet, under the heads of the first or
+fifth metatarsal bones. As has been previously mentioned,
+however, the interdigital surfaces are also prone to these
+conditions. In this latter location the amount of perspiration
+excreted in the locality undoubtedly has much to do
+with the lowering of the vitality of the skin covering the
+part, and renders it susceptible to disintegrative processes.</p>
+
+<p><b>Treatment.</b> All the overlying callous must be immediately
+removed so that the parts may be properly cleansed
+and so that drainage may be maintained. This may be done
+with a sharp sterile scalpel, but sufficient care should be
+exercised so that no hemorrhage is caused. After the
+hardened tissue has been cut away, all necrosed tissue adhering
+to the floor and edges of the ulcer should be removed.
+A spray of alcohol, 60%, may then be employed to obtain
+thorough asepsis and after the parts are thoroughly dried, a
+dressing is applied in keeping with the conditions present.</p>
+
+<p><b>Wet Dressing.</b> If infection is present, or if the parts be
+considerably inflamed, due simply to the traumatic irritation,
+<span class="pagenum" id="Page_312">[Pg 312]</span>a wet dressing of mercury bichloride, ¹⁄₄₀₀₀, liq.
+aluminum acetate, or alcohol and boric acid, equal parts,
+should be employed for a sufficient time to reduce all infective
+or other inflammatory symptoms. Bichloride of
+mercury should not be used for a prolonged period of time
+in these cases, for its corrosive action will prevent new
+granulations and thus retard healing. The aluminum
+acetate and alcohol, boric acid combination may be used
+without fear of toxic irritation. If simple inflammation is
+present in the parts, Goulard’s extract may be employed to
+reduce the acute symptoms, but care must be exercised and
+the parts watched so that no lead dermatitis shall develop
+from the drug.</p>
+
+<p>It is unwise under any condition to prolong the use of
+wet dressings beyond a time when they are thought to be
+necessary. The constant moisture is not conducive to
+prolific or to healthy granulation and for this reason these
+applications are best discontinued as soon as possible.</p>
+
+<p><b>Boroglycerine</b>, a combination of boric acid and
+glycerine, applied to a simple ulceration, particularly one
+of the indolent type, is found to stimulate granulation and
+thus aid materially in the healing process. It is applied on
+sterile gauze and allowed to remain unchanged for from
+twenty-four to forty-eight hours.</p>
+
+<p><b>Dry Dressings.</b> Dry dressings, either of plain aseptic
+gauze or of dusting powders, are found effective in the
+treatment of simple ulcerations. The choice of the dusting
+agent is, of course, dependent upon the conditions present,
+but it should combine astringent and antiseptic properties.</p>
+
+<p><b>Thymol Iodide</b>, while not astringent, is a general
+favorite for most simple ulcerations. Contrary to the action
+of most powders, this combination of iodine and thymol induces
+a discharge rather than prevents it. This is due to
+the action of its constituent thymol and is desirable in dry
+ulcerations where more or less coagulation is present. This
+powder, known best by its trade name, aristol, has an
+energetic, antiseptic action due to the liberation of iodine
+<span class="pagenum" id="Page_313">[Pg 313]</span>and is used practically to the exclusion of all other iodine
+powders. It is principally used as an iodoform substitute,
+having none of the disagreeable odor of this drug.</p>
+
+<p><b>Bismuth Subgallate</b>, a combination of gallic acid and
+bismuth, is an efficient powder for use in these conditions.
+Its action is markedly astringent and it can be depended
+upon for antiseptic action as well.</p>
+
+<p><b>Bismuth Subnitrate</b> is also an astringent and antiseptic
+powder which may be substituted for the other bismuth salt
+in these conditions. The molecules of this powder are very
+fine and there is a tendency for it to cake so that when used,
+the dressing should be changed at regular and short intervals;
+the parts should be thoroughly cleansed of the dried
+powder from previous application before the new dressing
+is applied.</p>
+
+<p><b>Zinc Powders</b>, such as the oxide and the stearate, are
+also applicable in cases of simple ulcer. Zinc oxide may be
+combined with various other powders and numerous such
+combinations are now in the market. Zinc stearate is used
+alone and can be depended upon for a mild astringent action,
+although not comparable with either bismuth subgallate or
+subnitrate.</p>
+
+<p><b>Ointment Dressings.</b> The use of ointments is contra-indicated
+in the presence of a discharging surface and for
+this reason drugs in fatty or oily bases are not generally
+used in all stages of ulcer regeneration. Several ointments
+may be used, however, either for antiseptic or stimulative
+action after the acute discharge, if present, has subsided
+or if no great amount or exudation is present.</p>
+
+<p><b>Ung. Hydrargyri Ammoniati</b>, white precipitate of mercury,
+will be found useful where antiseptic action is
+desired.</p>
+
+<p><b>Ung. Acidi Borici</b>, an antiseptic ointment, is also used
+in this connection.</p>
+
+<p><b>Ung. Acidi Tannici</b>, twenty parts of tannic acid, twenty
+parts glycerine, sixty parts cerate, is an astringent ointment
+efficient in these cases.</p>
+
+<p><span class="pagenum" id="Page_314">[Pg 314]</span></p>
+
+<p><b>Ung. Eucalypti</b> is used as an antiseptic and stimulant
+application for indolent ulcers.</p>
+
+<p><b>Ung. Zinci Oxidi</b> is a soothing and mildly astringent
+ointment which can be used advantageously.</p>
+
+<p><b>Ung. Balsam of Peru</b>, a 3% to 10% ointment of Peruvian
+balsam in vaseline or lanolin, is both antiseptic
+and stimulant.</p>
+
+<p><b>Scarlet Red</b>, an ointment prepared from medicinal scarlet
+red (Biebrich), may be used in strengths from 1% to 8%
+as a stimulant and healing application.</p>
+
+<p>In the use of all ointments it is advisable to place only
+a thin film of the mass over the parts. Avoid the tendency
+to use a large quantity of any ointment.</p>
+
+<p>A shield may, at times, be used in connection with the
+application of the dry or of the ointment dressing. These
+appliances, however, particularly if made from a thick
+material, tend to arrest the circulation to the localized area,
+and, as free blood flow is to be desired at all times, the
+shield should be omitted in cases in which an ointment
+dressing is being used, unless it is sure that circulation is
+not being thereby impeded.</p>
+
+<p>Squares of sterile gauze held in place by adhesive strips
+or by a soft cocoon dressing, are practical means of
+retaining a powder or an ointment to the part. In choosing
+the latter form of dressing, never use a great amount of
+collodion in binding down the cotton fibre. If applied too
+freely, it is absorbed by the cotton and is apt to come in
+contact with the ulcerated surface itself. The dressing, if
+applied over a discharging area, should be absorbent, and
+this possibility is nullified when it is hardened by collodion.</p>
+
+
+<h3 id="INDOLENT_OR_CALLOUS_ULCER">
+  INDOLENT OR CALLOUS ULCER.
+</h3>
+
+<p>This form of ulcer occurs principally on the leg, but
+occasionally is found on the foot and ankle. Callous ulcers
+vary in size from a five cent piece to the entire circumference
+of the part attacked.</p>
+
+<p>The surface is usually smooth and glistening and of a
+<span class="pagenum" id="Page_315">[Pg 315]</span>dirty yellow color, with perhaps a few badly formed granulations.
+The edges are hard and sharply cut and elevated
+considerably above the surface, while the surrounding skin
+may be inflamed over the margin and is either covered with
+sodden cuticle or is congested. The skin surrounding the
+part is often deeply pigmented from chronic congestion, the
+pigmentation starting in separate papillæ as maculae,
+which gradually coalesce. The discharge is purulent or
+serous and may be so abundant and irritating as to cause
+eczema of the skin. The base is adherent to the underlying
+tissues and this constitutes one of the main difficulties in
+healing, as contraction is thus prevented. If the ulcer is
+situated above a bone, such as the tibia, chronic periostitis
+may result. Such ulcers are sometimes very painful from
+pressure on cutaneous nerves, or from a localized cellulitis
+associated perhaps with inflammation of veins and lymphatics.
+Thrombosis not infrequently occurs in both sets of
+vessels, leading to chronic edema of the feet.</p>
+
+<p><b>Etiology.</b> <i>General Causes</i>: (a) Various devitalizing
+fevers and diseases such as typhoid, scorbutus, diphtheria,
+chronic nephritis, etc. (b) Mineral poisoning, such as is
+produced by phosphorus. (c) Anemia and debilitating conditions
+brought on by starvation, improper food, poor
+hygiene, overwork, lack of sleep, etc.</p>
+
+<p><i>Local Causes</i>: (a) Old scar tissue, the contraction of
+which has cut off the circulation. (b) Continuous pressure,
+from splints, lying in bed, etc. (c) Local destruction of the
+tissues such as is produced by extremes of heat and cold.
+(d) Local irritation or injury of tissues from violence.
+(e) Various diseases of the skin, for example, pemphigus.</p>
+
+<p><b>Symptoms.</b> These ulcers are most commonly found on
+the inner side of the lower third of the leg. They show
+great variety in size, shape and appearance, of base, edges,
+and surrounding area, and in accordance with these differences,
+many different names are applied to them. They may
+be round, very irregular, or funnel-shaped, as in perforating
+ulcer of the foot. When the granulations are large,
+<span class="pagenum" id="Page_316">[Pg 316]</span>irregular, and bleed easily, they are spoken of as exuberant
+or fungating; when pale, soft and flabby, as weak or edematous;
+when small and growing slowly, as indolent. Sometimes
+the base is covered with a grayish or yellowish-white
+necrotic layer formed of fibrin and necrotic cellular elements.
+When this is removed, no granulations appear, but
+instead it presents a smooth, shining base resembling
+mucous membrane. This form is known as the croupous
+ulcer. The edges also vary greatly. They may be irregular
+or sharply cut, moderately thickened, or very much so, due
+to chronic congestion and edema, with enlargement of the
+papillæ and proliferation of the epithelial cells. When this
+is a prominent feature, the name callous ulcer is applied.
+The edges may be adherent to the deeper structures, thus
+preventing contraction and healing; they may be rounded,
+elevated, undermined, or overhanging.</p>
+
+<p>The discharge from an ulcer is usually slight in
+amount, serous in character, and contains very few pus
+cells. The surrounding area may be swollen, red, congested,
+pigmented, edematous, eczematous, or the ulcer may
+be surrounded by smaller sores, by vesicles, or by masses
+of varicose veins. As a rule, there is an absence of severe
+pain accompanying leg ulcers, unless there is an exposure
+or involvement of some nerve filaments; but frequently,
+after the patient has been on his feet for a long time, there
+is a dull, aching pain in the part, due to chronic congestion
+which causes tension in and about the ulcer.</p>
+
+<p><b>Differential Diagnosis.</b> The diagnosis of a chronic indolent
+or callous ulcer can be easily made by the character
+of the granulations and by the location of the ulcer itself.
+The history points usually to an injury or infection and the
+situation of the sore is at the site of the previous injury or
+infection. The base is shallow, inflamed and often of a
+grayish-yellow color, with no thickening or elevation of its
+edges. The surrounding area is usually round and inflamed.
+A varicose ulcer is differentiated by the history of
+varicose veins or phlebitis, by its occurrence at the lower
+<span class="pagenum" id="Page_317">[Pg 317]</span>third of the leg and by the undermined thickened and
+irregular-shaped edges. A syphilitic ulcer is diagnosed by
+the history of lues; by its usual occurrence at the upper
+third of the leg; by a dirty sloughing and deep base; by
+punched out, thin, dense, firm and undermined red edges;
+and by scars of a dusky red color. A tuberculous ulcer, by
+the history of previous glandular bone or lung disease; soft,
+pale, edematous granulations; thin undermined edges; involvement
+of glands and other signs of tubercular sinuses,
+bone disease, etc. A perforating ulcer, by the history of
+the case; the appearance of the ulcer upon the sole of the
+foot or in the vicinity of the heel; the presence of a sinus
+leading to necrosed bone; the pale, flabby granulations; all
+these signs should make the diagnosis easy.</p>
+
+<figure class="figcenter illowe18" id="i_p318">
+  <img class="w100" src="images/i_p318.jpg" alt="">
+  <figcaption>
+    CHRONIC ULCER OF THE FOOT<br>
+
+    (BEFORE OPERATION)
+  </figcaption>
+</figure>
+
+<p><b>Treatment.</b> This naturally depends upon the stage at
+which the ulcer is seen and the conditions present. If there
+is considerable inflammation, accompanied by marked cellulitis
+and pain, wet dressings are indicated. Two distinct
+therapeutic actions may be derived from the wet compress,
+depending upon whether or not an impervious covering is
+employed. These actions are antiphlogistic and hyperemic,
+and these in turn may be either antiseptic or astringent.
+The wet dressing, without a covering, is cleansing and heat
+reducing, because of evaporation. There should be frequent
+replenishment of the solution where there is considerable
+discharge, or where it is desirable to reduce
+inflammation. A wet dressing with an impervious covering
+is contra-indicated in the presence of pus, the warmth and
+moisture of such a dressing, being congenial to the growth
+and to the multiplication of bacteria. For the relief of pain
+and for the reduction of inflammation, wet dressings are
+the most effective form of treatment because (1) they are
+aseptic; (2) they permit free drainage; (3) no new granulations
+are disturbed in changing the dressing.</p>
+
+<p>A great many different solutions are used and among
+these are: (1) sterile water; (2) ordinary saline solution
+(a teaspoonful of salt to a pint of water); (3) saturated
+<span class="pagenum" id="Page_318">[Pg 318]</span>solution of boric acid (prepared by dissolving a teaspoonful
+of boric acid in a pint of water); (4) Thiersch’s solution
+(prepared by dissolving 15 grains of salicylic acid and 90
+grains of boric acid in a pint of water); (5) Burow’s solution
+(prepared by dissolving 675 grains of alum and 270
+grains of lead acetate in a pint of water); (6) solution of
+bichloride of mercury (varying in strength from 1 to 3,000
+to 1 to 10,000); (7) lead and opium wash (U. S. P.); (8)
+Dakin’s solution (hypochlorite of soda).</p>
+
+<p>After the reduction of the inflammation, the next step
+is the cleansing and sterilization of the ulcer. Before
+healthy granulations can form, the removal of sloughs and
+the cleansing of the base must be accomplished as thoroughly
+as possible. Many means toward this end may be
+effective. A one-half to two per cent. creolin or lysol emulsion
+<span class="pagenum" id="Page_319">[Pg 319]</span>is very useful for those dirty ulcers from which a profuse,
+foul discharge escapes. A one per cent. solution of
+formalin is of great value for smaller ulcers, especially
+those due to tuberculous disease. The destruction and removal
+of sloughs may be hastened by cauterization with the
+solid stick of nitrate of silver. The use of certain ferments,
+such as brewer’s yeast, papoid, or protonuclein, may help to
+clean up a chronic ulcer. The most frequent means employed
+for the cleansing and sterilization of the ulcer, previous
+to the application of some stimulating dressing, is
+washing the part with tincture of green soap and water.
+Peroxide of hydrogen can next be used, then sulphuric
+ether, and finally ninety-five per cent. alcohol. Where there
+is an accompanying eczematous condition, the scales can
+best be removed with benzine.</p>
+
+<figure class="figcenter illowe18" id="i_p319">
+  <img class="w100" src="images/i_p319.jpg" alt="">
+  <figcaption>
+    CHRONIC ULCER OF THE FOOT<br>
+
+    (AFTER OPERATION)
+  </figcaption>
+</figure>
+
+<p>Having reduced the inflammation and succeeded in
+cleansing the ulcer, the next thing to consider is the means
+by which granulations may be stimulated. This may be
+accomplished by applications in the form of powders, solutions,
+ointments and grafts.</p>
+
+<p>Dusting powders are employed either as antiseptics
+or as astringents or for both purposes. Their use in this
+<span class="pagenum" id="Page_320">[Pg 320]</span>instance is limited, and they are employed only where the
+secretion is scanty. Among the various powders used are:
+aristol, dermatol, boric acid, orthoform, calomel, protonuclein,
+alum, zinc oxide, etc. Thymol iodide, or aristol, is
+a superior antiseptic powder and enjoys the advantage
+over iodoform of being inodorous. Iodoform should be
+used only in tuberculous conditions; calomel only in syphilitic
+cases. Dermatol, or bismuth subgallate, combines the
+astringent and mildly antiseptic qualities of bismuth and
+gallic acid. Boric acid is mildly antiseptic. Zinc oxide
+and alum are both astringent. Scarlet red, five per cent.,
+with boric acid, ninety-five per cent., is indicated when the
+granulations are sluggish.</p>
+
+<p>Among the various solutions used are silver nitrate in
+various strengths, zinc and copper sulphate, ichthyol, balsam
+of Peru, and calamine. Silver nitrate, zinc and copper
+sulphates are employed for their astringent action. Balsam
+of Peru, fifty per cent., with castor oil, fifty per cent.,
+is used for its stimulating action.</p>
+
+<p>Ointments are used in the treatment of ulcers either to
+stimulate the granulations or to soften thick epidermis.
+Ointments should never be employed where there is a profuse
+discharge. Many different kinds of ointments are used,
+prominent among them being: balsam of Peru, in a ten
+per cent. strength for the stimulation of the granulations;
+boric acid and ichthyol, in the same strength; Lassar’s
+paste (which consists of salicylic acid, one dram; starch
+and zinc oxide, each one ounce, and vaseline to make four
+ounces). This latter ointment is especially indicated when
+there is an eczema present. An ointment which has given
+good results is scarlet red, 1% to 5%. Scarlet red (Biebrich)
+was originally prepared as a dye for wool and silk, and is so
+named because of the fact that it was first manufactured in
+the town of Biebrich. Its application to granulating surfaces
+induces healing, not by the formation of scar tissue,
+but in every case by producing a high grade of normal skin
+which very soon becomes freely movable on the underlying
+<span class="pagenum" id="Page_321">[Pg 321]</span>tissue. The return of sensation in the healed area takes
+place from the periphery inward, instead of upward from
+the underlying tissue. Usually the dressing should be left
+undisturbed for from twenty-four to forty-eight hours, then
+reapplied, as indications warrant. In removing the dressing,
+if it be adherent to the granulations, peroxide of hydrogen
+should be used to loosen it. The skin about the granulating
+surface is best cleansed by benzine, as this removes all
+traces of scarlet red better than any other solution. The
+following formulas are recommended:</p>
+
+<p>Scarlet red (medicinal Biebrich) fifteen grains; ungt.
+acidi borici, q. s. ad three ounces (one per cent.).</p>
+
+<p>Scarlet red (medicinal Biebrich), forty-five grains;
+ungt. zinci oxidi, q. s. ad three ounces (three per cent.).</p>
+
+<p>Scarlet red (medicinal Biebrich), seventy-five grains;
+balsam of Peru, seventy-five minims; petrolati, q. s. ad three
+ounces (five per cent.).</p>
+
+<p>The first is indicated where scarlet red is desired over a
+large area and for a long time; the second, where an astringent
+action is required because the granulations are profuse;
+the third, where the granulations are sluggish and require
+stimulation.</p>
+
+
+<h3 id="VARICOSE_ULCER">
+  VARICOSE ULCER.
+</h3>
+
+<p><b>Etiology.</b> To chronic ulcers of the leg, associated with
+varicose veins, especially of the smaller venous radicles, the
+name varicose ulcer has been given. The usual development
+of this variety of ulcer is as follows: persons who suffer
+from varices of the leg usually complain, for some time before
+the external manifestation of the disease, of a dull,
+aching pain in the limb, with a sense of weight, fullness and
+fatigue. In a more advanced state of the disease the ankles
+swell after a day’s hard work, and the feet are constantly
+cold; an embarrassed state of circulation is denoted by
+these symptoms and the deep-seated veins begin to swell.
+After a time, which varies with the idiosyncrasy and occupation
+of the patient, small, soft, blue tumors are seen at different
+<span class="pagenum" id="Page_322">[Pg 322]</span>points of the leg, most of them disappearing on pressure,
+but returning when it is removed, or when the patient stands
+up. Each little tumor is caused by a vein, dilated at the point
+at which it is joined by an intramuscular branch. Around
+many of these tumors a number of minor vessels of a dark
+purple color are clustered; these are the small superficial
+veins which enter the dilating vein and in which the passage
+of the blood is retarded. An increasing area of veins gradually
+becomes involved and a number of irregular, knotty,
+consolidated tumors are developed, grouping themselves
+around the point at which the dilatation first began. The
+external and internal saphenous veins are those primarily
+affected, but long tracts of tortuous veins may extend up the
+leg and thigh. Dangerous and even fatal hemorrhage may
+ensue from the bursting of a varix through the skin. The
+vessels may become filled with clots and permanently obstructed,
+and ulceration with thrombosis or phlebitis may be
+the sequel. The capillaries become engorged with blood,
+and hence the assimilation changes are retarded and sometimes
+altogether checked. Gradually the entire circulation
+of the part is arrested. The vitality of the superficial structures
+becomes permanently impaired; consequently they are
+unable to resist the effects of slight injuries and repair fails
+to take place after a portion has been destroyed, and an open
+sore or ulcer is established.</p>
+
+<p><b>Symptoms.</b> The varicose ulcer is usually single, oval,
+round or irregular in outline, and is most often seen on the
+lower third of the leg near the internal or external malleolus.
+The edges are thick, everted, and swollen. The swelling
+is largely due to edema and is found to pit on pressure.
+The floor is generally covered with rather large granulations
+which bleed freely when touched. In a varicose ulcer
+the destruction of tissue often begins at the margin of a
+congested area and advances toward the centre. The size
+varies from the small ulcers, less than one-half inch in
+diameter, formed by the breaking down of an area of periphlebitis
+around a small vein, to those several inches in
+<span class="pagenum" id="Page_323">[Pg 323]</span>diameter. Several ulcers may be present on one limb. The
+granulations, as a rule, are weak and flabby. The discharge
+is thin, serous, mixed with débris, and may be blood-stained.
+The skin surrounding a varicose ulcer is often of a brownish
+blue color, due to a deposit of pigment. The recognition of
+varicose ulcers is usually easy; but the mere presence of
+enlarged veins, it should
+be noted, is not pathognomonic,
+because they may
+exist along with ulcers of
+other origin—the luetic,
+trophic, etc. The most frequent
+complication is
+phlebitis; cellulitis is also
+seen. This latter may
+sometimes be so severe
+as to necessitate operation.
+Complications such
+as necrosis of bone, involvement
+and ankylosis
+of the ankle joint, together
+with atrophy and
+contracture of muscles
+and adhesions of tendons
+(perhaps giving
+rise to various deformities
+of the feet, such as
+flat foot or even club-foot)
+are extreme and
+unusual complications.</p>
+
+<p>Where the varicose ulcers have persisted for a long
+time and refuse to heal, it is always advisable to apply the
+Wassermann test in order to exclude the possibility of
+syphilis. In doubtful cases it is also advisable to test by the
+Noguchi luetin skin reaction.</p>
+
+<figure class="figcenter illowe24" id="i_p323">
+  <img class="w100" src="images/i_p323.jpg" alt="">
+  <figcaption>
+    VARICOSE ULCER
+  </figcaption>
+</figure>
+
+<p><b>Treatment.</b> In these cases of varicose ulcers it is impossible
+to effect a cure until the chronic congestion of the
+<span class="pagenum" id="Page_324">[Pg 324]</span>limb is relieved and the blood supply of the part approaches
+normal. Often all that is necessary is a gauze,
+muslin, rubber or flannel bandage.</p>
+
+<p>A bandage, when applied with moderate, even pressure,
+has for its purpose the relief of congestion. In a great
+many cases rubber has an irritating effect upon the skin,
+and that kind of a bandage should therefore be cautiously
+used. When the granulations are almost on a level with the
+skin, and also where there is considerable thickening of the
+edges of the ulcer, the best means of keeping up an even
+pressure and causing absorption of the thickened margins,
+as well as of hastening epithelial growth, is to apply zinc
+oxide adhesive plaster in strips, one-half to one inch in
+width. These strips should overlap to the extent of about
+one-third of their width, should extend about three-fourths
+of the way around the limb, and should be evenly and
+smoothly applied. They should be started about one inch
+below the ulcer and should run from two to three inches
+above it.</p>
+
+<p>In order to effect a permanent cure, varicose veins
+must be operated upon, and a number of operations have
+been devised, as follows: the ligation of the internal saphenous,
+as advised by Trendelenburg; the multiple percutaneous
+ligations of Schede; the total extirpation of the internal
+saphenous, as recommended by Mayo; the dissection after
+the method of Madelung; and the spiral of Rindfleisch.</p>
+
+<p><b>Perforating Ulcer of the Foot.</b> This type of ulcer usually
+occurs where pressure and irritation are greatest and
+is therefore commonly found on the plantar surface of the
+foot under the heads of the first and fifth metatarsal bones,
+and on the under surface of the great toe. Occasionally,
+however, they develop on the dorsal surfaces or ends of the
+toes, in cases such as hammer toe.</p>
+
+<p><b>Etiology.</b> There are various theories relative to the
+causation of lesions of this nature. One claims injury to be
+the sole cause; another attributes it to arteriosclerosis and
+capillary thrombosis; still another charges it to chronic
+<span class="pagenum" id="Page_325">[Pg 325]</span>peripheral neuritis and alteration in the nerve terminals.
+One writer states that traumatism is an important factor in
+their development, conceding, however, that various systemic
+conditions must necessarily enter into the etiology,
+among them, locomotor ataxia and injuries to the spinal
+cord, diabetes and injuries to the peripheral nerves. This
+latter, known as the
+“mixed theory,” is the
+one most generally accredited
+and is in all
+probability most correct.</p>
+
+<p>This type of ulcer is
+found more frequently in
+males than in females
+and it occurs almost exclusively
+in adult life
+(between 40 and 60
+years). Occupation is a
+predisposing factor, and
+work demanding long
+periods of standing or
+walking unquestionably
+has much to do with the
+development of a perforating
+ulcer, all other
+conditions being equal.</p>
+
+<figure class="figcenter illowe24" id="i_p325">
+  <img class="w100" src="images/i_p325.jpg" alt="">
+  <figcaption>
+    POST-OPERATIVE DIABETIC ULCER
+  </figcaption>
+</figure>
+
+<p><b>Characteristics.</b> The
+ulcer is usually found to
+be irregularly circular in
+shape, with a tendency to
+progressive development, involving the deeper soft tissues,
+finally attacking the periosteum and the bone itself, causing
+necrosis. The superficial edges of the ulceration are heavily
+calloused and the lesion shows little or no tendency to heal.
+One of the most marked characteristics is the entire loss of
+sensation. Many cases have been observed where the
+patient feels no pain, even when the lesion is deeply probed.</p>
+
+<p><span class="pagenum" id="Page_326">[Pg 326]</span></p>
+
+<p><b>Symptoms.</b> At times, particularly in diabetic patients,
+a purulent blister is the initial lesion, but in most instances
+these lesions develop under a heavy callous, the centre of
+which breaks down into an indolent superficial ulceration,
+discharging a thin, discolored, odorous pus, but never in
+great quantities.</p>
+
+<p>The fact that changes in the peripheral nerve supply
+usually take place in the development of perforating ulcer
+probably accounts for the absence of pain, as above mentioned,
+and also explains the progressive degeneration
+which takes place, allowing the ulcerative process to progress
+into the deeper tissues.</p>
+
+<p><b>Treatment.</b> The systemic disturbances which may be
+present are important factors to be considered in the treatment
+of perforating ulcer, but local applications may be
+made and local conditions must be considered. If the ulcer
+be upon the plantar surfaces of the foot, walking and standing,
+which would bring continued pressure, must be avoided.
+Shoes must be well fitted and must not irritate the parts,
+and cleanliness must be obtained and maintained. All callous
+must be removed from the edges of the ulcer and proper
+drainage is of great importance. All necrosed tissue must
+necessarily be removed and any burrowing sinuses should
+be thoroughly opened. Artificial hyperemia, massage and
+electricity are found to be of benefit in improving the general
+circulation in the foot and leg.</p>
+
+<p>In the local treatment of the ulceration itself, prolonged
+application of strong germicidal solutions is to be avoided
+at all times. Cleansing with warm normal salt solution is
+recommended as a non-toxic and stimulant application.</p>
+
+<p>Dressings may be of plain aseptic or iodoform gauze
+packed lightly into the ulcer. These lesions are discouraging
+to treat, inasmuch as even after complete healing, relapses
+usually occur which leave the parts as bad or worse
+than the original lesion.</p>
+
+<p>Stimulant applications may be employed locally, with
+some success in connection with internal medications for the
+<span class="pagenum" id="Page_327">[Pg 327]</span>systemic disturbance present. Balsam of Peru or scarlet
+red (1% to 3%) are advocated in this connection.</p>
+
+<p>The prognosis in cases of perforating ulcer is bad, inasmuch
+as the progress of the lesion sooner or later involves
+sufficient tissue in the degenerative process to necessitate
+surgical interference—perhaps amputation of the foot. As
+has been previously
+mentioned, even when
+fully healed, relapse almost
+always occurs.</p>
+
+<p><b>The Syphilitic Ulcer.</b>
+The syphilitic ulcers do
+not properly come within
+the province of the podiatrist
+for treatment, but
+he should be able to
+recognize them. They
+may develop from pustules
+or begin as original
+lesions in the tertiary
+stages of the disease. Developing
+in this latter instance
+from gummata,
+they are immediately
+deep ulcers.</p>
+
+<p>The worst superficial
+ulcers of syphilis may
+develop early in the
+course of the general
+disease.</p>
+
+<figure class="figcenter illowe24" id="i_p327">
+  <img class="w100" src="images/i_p327.jpg" alt="">
+  <figcaption>
+    SYPHILITIC ULCER OF THE LEG
+  </figcaption>
+</figure>
+
+<p><b>Symptoms.</b> These ulcers vary in size from a quarter
+to a silver dollar and occur on the upper third of the leg,
+occasionally on the upper part of the middle third. During
+the early stages of the lesion it is surrounded by an inflamed
+area of skin at the ulcer and presents an even, “punched
+out” edge. Being a new growth, developed in the corium,
+the edges are usually more firm and dense than in other
+<span class="pagenum" id="Page_328">[Pg 328]</span>forms of ulcer. The floor of the lesion is of a dusky red or
+coppery color, and has a characteristic slough of a greenish
+color. The discharge is frequently bloody and is filled with
+broken-down tissue.</p>
+
+<p>If on account of the presence of enlarged veins, it is
+difficult to distinguish a syphilitic from a varicose or other
+type of ulcer, a positive Wassermann test will confirm the
+diagnosis.</p>
+
+<p>Being merely a local manifestation of a general infection,
+the systemic disturbance must be treated by a licensed
+physician. It is generally found that a lesion of this type,
+once healed, remains so.</p>
+
+<p><b>Treatment.</b> Treatment for syphilitic ulcers comprehends
+the use of mercurials as local applications. Mercury
+bichloride ¹⁄₁₀₀₀₀ may be employed with beneficent results
+in most cases where a profuse discharge is present. Where
+there is little or no discharge, calomel powder dusted into
+the ulcer will give good results.</p>
+
+<p>As in most cases where a syphilitic lesion has developed
+locally on the leg, the patient is or has been under a physician’s
+care, practically none of these cases come to the podiatrist
+for his treatment alone. Many times, however, he is
+called in by the physician to do local dressings under his
+direction, and it has even happened that the podiatrist has
+been the first to recognize the significance of the local lesion.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_329">[Pg 329]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_XXI">
+    <span class="chap">CHAPTER XXI</span>
+    <br>
+    CUTANEOUS MANIFESTATIONS OF
+    SUPER-ACIDITY
+  </h2>
+</div>
+
+
+<p>A surcharging of the blood with an abnormal amount
+of acidity leads generally to conditions which come under
+the domain of the physician. So-called rheumatism, gout
+and kindred ailments of all forms and varieties are every-day
+occurrences, and, being symptoms of systemic disturbances,
+should be treated by internal administration.</p>
+
+<p>The podiatrist, however, in his daily treatment of foot
+troubles is called upon to treat locally certain forms of skin
+disturbances due to hyper-acidity which manifest themselves
+upon the surfaces of the foot.</p>
+
+<p>Uric acid eczema is the general term employed to designate
+these annoying conditions and is synonymous with the
+older and now obsolete terms, lithemia and uric-acidema.</p>
+
+<p><b>Definition.</b> Uric acid eczema is a skin eruption due to
+a surcharge of uric acid in the blood and a precipitation of
+this acid in a certain part, so that the acid elements or
+urates are carried by the blood stream to the skin and there
+set up a dermatitis.</p>
+
+<p><b>Characteristics.</b> These manifestations may be found
+in all varieties and degrees from a mere dryness and hardness
+of the skin, in which the normal flexibility is gone, and
+in connection with which there is usually intense itching and
+burning, to the formation of deep fissures (usually found in
+the toe webs) and small ulcerative processes which may
+manifest themselves in any part of the foot and often present
+a stubborn resistance to all endeavors at healing.
+These symptoms may occur singly or, as in the most instances,
+in combination.</p>
+
+<p><span class="pagenum" id="Page_330">[Pg 330]</span></p>
+
+<p>These conditions are usually met with in the spring of
+the year and no doubt are brought about by a series of
+changes in habits and diet which occur at this time.</p>
+
+<p><b>Etiology.</b> During the winter months the average person
+takes but little physical exercise as compared to his
+activities during the warmer weather. The foot, being at
+the base of a column of blood which must be forced back to
+the heart, against gravity, is coming constantly in contact
+with cold surfaces. This, together with a lack of exercise,
+tends to stagnate the blood circulation in the pedal extremities.
+Coupled with these two conditions, during the winter
+months, people are inclined to over-eat and over-drink, the
+waste materials from which excesses are but improperly
+eliminated, due also, to a great extent, to insufficient exercise.
+Here, then, we have a stagnation of the blood current
+in the pedal extremities, a surcharging of the blood in the
+feet with certain urates, and a precipitation of these solid
+constituents, due to the cold surfaces with which those
+members constantly come in contact.</p>
+
+<p>This condition is present in the spring of the year
+when fresh vegetables and fruits begin to come into the
+market. A great many of these edibles, particularly strawberries
+and tomatoes, are markedly acid and when ingested
+tend to exaggerate the conditions in the blood already present.
+The result is generally a cutaneous eruption which
+may appear on any part of the body and which frequently
+occurs in the feet. (See chapter on Fissures and Burns.)</p>
+
+<p><b>Fissures.</b> Probably the most common condition met
+with from this cause is the cracking or fissuring of the toe
+web. This may be accompanied by itching and burning in
+varying degrees, but these latter complications are not
+always present. The skin between the digits is found to be
+blanched and macerated and often the superficial epidermic
+layers will become slightly thickened and exfoliated. The
+fissures occur in the web and are due to the skin losing its
+normal flexibility so that the tissues, as they expand in
+walking or in drying the parts with a heavy, rough towel,
+<span class="pagenum" id="Page_331">[Pg 331]</span>are not sufficiently extensible, and so they crack or fissure.
+These cracks may be merely superficial splits through the
+epidermic layers or they may become deep and ugly fissures
+which penetrate well into the corium. When they reach
+this latter stage, the parts are found to be exceedingly tender
+and the irritation to the tissues is severe. These fissures
+are prone to infective processes as their deep recesses
+present an excellent lodgment for invading bacteria.</p>
+
+<p>The fissured area is usually confined to the web, but
+may be found extending around under the toe on either side
+or upon the plantar surface of the foot. When these conditions
+are of long standing, the edges of the fissure will
+be found to be thickened and calloused; it is found necessary
+to remove this growth before normal granulations may
+be expected.</p>
+
+<p><b>Treatment.</b> In cases where only pruritis is present
+and no distinct lesion manifests itself, tr. benzoes compositas
+will be found an efficient agent in reducing the itching
+and in aiding the general irritation to subside. In superficial
+fissures, tr. benzoin compound may also be used in
+many cases with good results. The parts should first be
+thoroughly cleansed with alcohol, 60%, dried, any loosened
+or exfoliated epidermis to be removed before the benzoin is
+applied. More or less smarting is to be expected from the
+application of the tincture, but as this is very transient, no
+great amount of pain is suffered by the patient. The tincture
+is applied by means of a sterile, cotton wound applicator,
+and is painted well down into the fissure itself, and
+over considerable of the surrounding integument. This
+tincture is very sticky and should be allowed to dry thoroughly
+before the hosiery is replaced. As compound tincture
+of benzoin forms a thin film or coating upon thoroughly
+drying, no gauze or cotton need be placed over the painted
+areas. This application may be renewed daily, the coating
+from the previous application being removed by alcohol
+and the parts cleansed and dried before the second application
+is made.</p>
+
+<p><span class="pagenum" id="Page_332">[Pg 332]</span></p>
+
+<p>Mild vegetable astringents may also be employed in
+such cases. Principal among these are gallic and tannic
+acid. These drugs may be used in solution, ointment or
+dusting powder form and seem to be efficient in all.
+Dusting powders are usually preferred and the two
+most popular are bismuth subgallate (dermatol), a combination
+of bismuth and gallic acid, and tannoform, a
+powder containing 5 to 10% of tannic acid. These are
+applied after the parts have been made aseptic and thoroughly
+dried. Bismuth subnitrate may also be used with
+good results in this condition, as may thymol iodide (aristol).
+The latter has very little astringent action and, therefore,
+except for its antiseptic properties, cannot compare
+with the other powders mentioned. Pure ichthyol may also
+be used in the treatment of superficial fissures. The drug
+is dropped into the lesion and covered with gauze or cotton,
+as are the dusting powders. Another drug recommended in
+these cases is sodium bicarbonate. This agent is alkaline in
+its reaction and, coming in contact with the perspiration
+(acid) in these parts, serves to neutralize this excretion and
+so aids in returning the tissues to normal.</p>
+
+<p>There are many other preparations, any of which may
+be used in the treatment of fissured toe webs. Among these
+are ichthyol ointments, 5 to 10%; balsam of Peru, scarlet
+red, and a 5% ointment of ammoniated mercury. Reports
+of cases treated by the above varying drugs show good
+results.</p>
+
+<p>When the fissures are deep, and the discharge from
+their surfaces is considerable, slightly different measures
+must be adopted to hasten granulation. The edges of deep
+fissures are almost always found to be calloused and thickened
+and this condition, of course, must be eradicated before
+further treatment is administered. This is accomplished
+with a knife or shallow curette and the operation is
+usually painless to the patient and creates no hemorrhage.
+After the removal of this tissue, if the fissure be deep, silver
+nitrate, 5% solution, will be found efficient as an astringent
+<span class="pagenum" id="Page_333">[Pg 333]</span>to contract the parts and reduce exudation. After this
+application, a bland ointment is smeared over the area for
+the purpose of keeping the tissues soft, and this is covered
+by a sheet of gauze or cotton to hold it in place. Applications
+of the silver solution are made at frequent intervals
+until the desired result is obtained, when it may be discontinued
+and some dusting powder resorted to, to complete
+the healing process. Should proud flesh have developed in
+a lesion of this nature, through neglect, stronger solutions
+of silver nitrate or the fused stick must be resorted to for
+reduction of the superfluous granulations, followed by a wet
+dressing of liq. alum. acetate to aid in the reduction of the
+accompanying inflammatory symptoms. Lanolin and cocoanut
+oil have both been found efficient to massage into the
+parts in order to keep them soft and to prevent continued
+dryness and fissuring.</p>
+
+<p><b>Blebs.</b> Aside from the fissuring of the interdigital
+webs, super-acidity manifests itself upon the skin of the
+foot, and the whole body for that matter, in the formation
+of yellow or brownish blebs or vesicles. They are found to
+be a more or less circumscribed eruption and are met most
+frequently in the foot on the plantar surface in the hollow
+of the longitudinal arch. They range in size from a pinhead
+to a pea and, in most instances, are but slightly elevated
+above the surface of the surrounding epidermis.
+This is in all probability due to the involvement of the
+superficial parts of the true skin.</p>
+
+<p>These lesions are usually uniform with a tendency to
+coalesce, and cases have been noted where patches of these
+eruptions covered a considerable area, in one instance, from
+the under surface of the foot, over its inner side, to the
+internal malleolus. Vesicular developments of this nature
+seldom occur singly but are often found in several groups
+on different parts of the integument, each group consisting
+of two, three or four distinct blebs.</p>
+
+<p>Pruritis may or may not be present in connection with
+this dermatitis. When itching is present it is usually intense
+<span class="pagenum" id="Page_334">[Pg 334]</span>and the patient often breaks and tears the skin in an effort
+to relieve the irritation.</p>
+
+<p>The areas of normal tissue adjacent to the eruptions
+may be found involved in a slight inflammatory process,
+although this is not common. These inflammatory symptoms
+usually subside rapidly under treatment.</p>
+
+<p><b>Treatment.</b> It is usually found advisable, if possible,
+to allow these blebs to remain intact, making no effort to
+puncture them but simply applying a dressing which will
+promote and hasten their absorption. Cases have been
+noticed where these lesions have been opened and have developed
+into angry, deep ulcerations which showed a
+marked tendency toward indolent granulation accompanied
+by profuse discharge.</p>
+
+<p>However, when a bleb for any reason must be opened,
+it is best accomplished by use of a sharp pointed, sterile
+knife. The fluid contents are found to be a thin, syrupy,
+translucent, discolored serum, without any great odor, although
+resembling ichorous pus to some degree. There is
+a distinct loss of tissue as the ulcerations are often found to
+involve the upper parts of the derma. Upon evacuation of
+the fluid contents, the parts should be thoroughly sprayed
+with alcohol, 60%, and a moist, unguent or dusting powder
+dressing, as the operator desires, applied.</p>
+
+<p>The solutions which may be used as moist applications
+are liq. aluminum acetate, or boric acid (saturated solution).
+Powerful germicides, such as mercury bichloride, are not
+necessary unless an infective process be present, and when
+used needlessly, they simply prevent or break down new
+granulations.</p>
+
+<p>The dusting powders found useful in this connection
+are aristol (thymol iodide) and dermatol (bismuth subgallate).
+The parts should first be thoroughly dried before
+the powder is dusted on. If the discharge is found negative
+and the pruritis still persists, an ointment of ichthyol and
+sulphur, such as follows will prove efficient in reducing the
+itching and in stimulating healthy granulations:</p>
+
+<p><span class="pagenum" id="Page_335">[Pg 335]</span></p>
+
+
+<table class="autotable3">
+<tr>
+<td class="tdl">
+Ichthyol
+</td>
+<td class="tdr">
+1.
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Sulphur
+</td>
+<td class="tdr">
+1.
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Menthol
+</td>
+<td class="tdr">
+1.
+</td>
+</tr>
+<tr>
+<td class="tdl">
+Vaseline
+</td>
+<td class="tdr">
+32.
+</td>
+</tr>
+</table>
+
+
+<p>This unguent is best held in place by a cocoon dressing
+and should be renewed until granulation is complete. Other
+unguents which may be used in this connection are sulphur,
+10% (lanolin or vaseline base), balsam of Peru, 5%, and
+unguentine (a proprietary but useful combination of ichthyol,
+balsam of Peru and zinc oxide). These, however, do
+not tend to relieve the intense pruritis which usually accompanies
+these lesions as efficiently as the first mentioned
+combination.</p>
+
+
+<h3 id="URIC_ACID_AND_THE_NAILS">
+  URIC ACID AND THE NAILS
+</h3>
+
+<p>The toe nails also manifest conditions of super-acidity.
+They may be affected as to color or texture, and sometimes
+in advanced or neglected cases, as to size and shape.</p>
+
+<p><b>Discoloration.</b> The nails, due to functional derangements
+in the matrix, become loosened and discolored from
+the presence of an abnormal amount of uric acid. They
+may be whitish, yellowish or brown, and in some cases are
+found almost entirely black, as if bruised. The nails in
+these instances are usually entirely loosened, or at least in
+part, from the bed, and sometimes fall off, practically of
+their own accord.</p>
+
+<p><b>Treatment.</b> Nothing much can be done locally for
+these conditions, and the main concern of the podiatrist is
+to see that the edges of the loosened nail are not allowed to
+irritate the softer tissues adjacent. This is best accomplished
+by packing cotton or gauze under these edges so that
+the nail, if movable, will rub upon this packing and not upon
+the skin. It may be found advisable to first clean out (from
+under and around the nail) any excrementitious matter
+which is always present to a greater or lesser degree. However,
+too much “digging” about these parts should never
+<span class="pagenum" id="Page_336">[Pg 336]</span>be indulged in, as the operator is liable not only to cause a
+lesion, but to loosen the nail to such a degree that its removal
+is imperative. If possible, this is to be generally
+avoided, for it has been found advantageous to allow the
+older nail to remain in place as long as possible in order to
+protect the new-forming nail beneath. Alcohol, 60%,
+sprayed over the part after removing the disintegrated
+material, will serve as a cleansing agent and will insure
+asepsis to the parts.</p>
+
+<p><b>Texture Changes.</b> Under the influence of uric acid precipitation
+in the pedal extremities, the texture of the nail
+is often found changed to a marked degree. The nail becomes
+exceedingly hard, dry and brittle so that it powders,
+chips off and breaks away under any sort of pressure. The
+nails are often found ridged, and in some instances these
+longitudinal ridges have become decided and permanent
+cracks in the nail body.</p>
+
+<p><b>Treatment.</b> In clipping nails of this nature, care
+should be taken that too much does not chip off or break
+away from the pressure of the clipper blades. It will be
+found advisable to cut but a small portion of the nail at a
+time, and that very carefully. The waste material found
+around or under the nail body should be carefully removed
+and, if necessary, the nail itself should be thinned out by
+the use of a rotary file. The parts should be thoroughly
+cleansed, and the grooves and free edge should be packed
+with gauze or cotton to prevent the nail from moving during
+the movements of the toe and thereby developing trouble.</p>
+
+<p><b>Changes in Size and Shape.</b> The so-called “club” nail
+is found in many cases where the patient is a sufferer from
+a uric acid diathesis. This does not occur as frequently in
+cases of acute dermatitis as in cases of chronic rheumatism
+and gout. These are cases where there is functional derangement
+of the matrix which causes the nail’s longitudinal
+growth to be arrested, followed by an increased vertical
+development.</p>
+
+<p>The nail is generally found to be about one-half its normal
+<span class="pagenum" id="Page_337">[Pg 337]</span>length and may be from one-sixteenth to one inch or
+more in thickness. Cases have occurred where the nail in
+appearance and structure closely resembled a cow’s horn.</p>
+
+<p>Club nails of this variety do not, as a rule, cause a great
+amount of discomfort and then only when they develop to
+such thickness as to receive and transmit direct pressure
+from the shoe.</p>
+
+<p><b>Treatment.</b> Club nails are not curable and the treatment
+is merely cosmetic. It consists in grinding and filing
+the nail down to what would be its normal thickness, or as
+nearly that as possible. This, of course, is best accomplished
+by means of a rotary file. As much of the nail is
+clipped away as is possible, when the rotary file with a
+coarse-grained “barrel” bur is used. Considerable pressure
+should be brought to bear unless the patient complains
+of heat due to the friction. When the greater portion of the
+nail is thus removed a “finishing” bur is substituted and
+the roughened surfaces are smoothed off. The clippers
+should then again be used to give the nail a fairly normal
+shape and the parts under the nail are to be then cleansed
+out as much as is advisable.</p>
+
+<p>In using a rough cutting bur the operator must exercise
+great care that the skin covering the posterior or the
+lateral folds is not broken. If the handpiece of the file is
+grasped firmly in the palm of the hand and directed by the
+index finger while the thumb is rested on the toe and the
+bur is directed to it (the thumb), the operator will always
+have complete control of the instrument, and this danger
+is minimized. It will be found advisable, after cleaning
+under and around the nail, to spray the parts with some
+antiseptic solution or to paint the parts with tincture of
+iodine. This is done to insure complete asepsis. Should the
+skin be broken during the filing or cleaning, the parts should
+be first made thoroughly aseptic and a dressing to prevent
+contamination should be applied.</p>
+
+<p><b>Prognosis.</b> It must always be remembered that these
+lesions are merely local manifestations of a systemic derangement
+<span class="pagenum" id="Page_338">[Pg 338]</span>and although the painful or annoying characteristics
+may be alleviated or cured, the cause of the trouble
+must be reached, through internal channels.</p>
+
+<p>Diet is the principal means of removing this surcharged
+acid condition of the blood and, although some
+medicines or waters may be and are ordered by the physician
+as eliminants, proper care as to dietetics is essential to
+the patient’s well-being. Systemic treatment by the physician,
+combined with local applications by the podiatrist, are
+usually conducive to beneficent and lasting results. In cases
+of manifestations of a uric acid diathesis in the nails,
+nothing much can be done except through the channels just
+described; and in cases of club nails due to a like etiology,
+nothing can be done to cure them. Removal of the nail does
+not, as is sometimes supposed, effect a cure, and in many
+instances serves but to make the new nail even worse than
+its predecessor.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_339">[Pg 339]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_XXII">
+    <span class="chap">CHAPTER XXII</span>
+    <br>
+    VOCATIONAL FOOT DISORDERS
+  </h2>
+</div>
+
+
+<p>Among the numerous diseases of the foot, there is a
+class of lesions produced by strain and misuse, in consequence
+of the occupation of the individual. Many occupations
+cause those who are engaged in them to stand or walk
+for long periods of time on hard and unelastic ground, and
+others subject the foot or a part of it to such unusual work
+that the entire foot, or a part of it, ceases to functionate
+normally.</p>
+
+<p><b>Weakfoot.</b> The general term “weakfoot” is used to
+indicate all types of disability caused by improper functioning
+of the foot. It is particularly applied to that condition
+of the foot in which the muscles and ligaments on its
+inner side have become weakened by overuse or by improper
+use, and it is, as a vocational foot disorder, common among
+barbers, waiters, letter-carriers, policemen and servants. It
+manifests itself by pain in the foot, particularly in the heel
+and on the inner side, and sometimes by pain in the calves of
+the legs, in the knees and lower part of the spine.</p>
+
+<p>At rest, the foot has a normal appearance, but, under
+weightbearing, it assumes an attitude of deformity varying
+in degree with the extent of the overwork to which it has
+been subjected. The chief characteristics of weakfoot are:
+abduction of the forefoot, an inward rotation of the upper
+part of the heelbone and a flattening, or obliteration, of the
+longitudinal arch under weightbearing, only. When seen
+in its incipiency, an anatomically correct shoe, together with
+suitable exercises, can be made to arrest the progress and
+effect a cure of weakfoot; but when found in the advanced
+stages it takes from several months to several years of conscientious
+<span class="pagenum" id="Page_340">[Pg 340]</span>work on the part of the practitioner and the
+patient to get results. In such cases, massage, adhesive
+plaster strapping, corrective braces and shoes, exercises and
+sometimes immobilization in an overcorrected attitude by
+means of plaster of Paris dressings, have to be employed
+in order again to get a normally functionating foot.</p>
+
+<p><b>Flatfoot.</b> This is a condition in which the longitudinal
+arch is depressed and does not regain its normal position
+when relieved from pressure. The forefoot is abducted, the
+head of the astragalus rotates downward and inward, and
+the os calcis rotates inward from above and outward from
+below. It is the successor to the weakfoot and differs from
+it only in that it exhibits also at rest, the abnormal attitude
+that a weakfoot assumes under weightbearing only. In flat foot
+this attitude is static, in weakfoot it is only temporary.
+The person afflicted with it walks with a shuffling gait, due
+to the accommodative changes that have taken place in the
+muscles and ligaments of the foot.</p>
+
+<p><b>The Subjective Symptoms</b> are similar to those in weakfoot
+and quite often are not as pronounced as in weakfoot,
+due probably to the fact that in this condition a further
+stretching and strain of the ligaments is impossible as the
+limit has already been reached.</p>
+
+<p><b>The Treatment</b> is similar to weakfoot, but must be augmented
+by means to overcome the accommodative changes
+in the foot and leg. The same class of patients suffer from
+this condition as are sufferers from vocational weakfoot.</p>
+
+<p><b>Chauffeur’s Foot.</b> As the term indicates, this condition
+is found in people who professionally, or otherwise, drive
+an automobile for many hours each day. It is an affection,
+usually of the right foot and leg, due to the excessive use of
+those members while “feeding the car.”</p>
+
+<p>The constant pressure of the “ball” of the foot on the
+accelerator causes pain in that part of the foot, followed
+by a numbness of the entire foot. The foot feels as if it
+were dead and when moved, later on, feels as if a
+thousand needles were penetrating it. Cramps in the calf
+<span class="pagenum" id="Page_341">[Pg 341]</span>muscles are usually associated with the symptoms in the
+foot.</p>
+
+<p><b>Treatment.</b> Massage of the foot and leg together with
+flexion exercises of the foot and toes.</p>
+
+<p><b>Policeman’s Heel.</b> When a person is compelled to
+stand upon hard pavements for a long period of time, great
+strain is put upon the tissues over the os calcis or heel.
+The calcaneo bursa becomes inflamed and gives rise to
+pains in that region. This inflammation may affect the
+periosteum, causing periostitis and finally a spur may
+develop on the under surface of the heel bone, which will
+become a source of constant pain.</p>
+
+<p><b>The Treatment</b> consists of rest to the part, and of transferring
+the weight to a place other than the painful area,
+by means of a felt pad or a brace. If a spur has developed,
+surgical intervention will be necessary.</p>
+
+<p><b>Dancer’s Foot.</b> This is a foot lesion first described by
+Miss Bryde Campbell, of New York City, who termed it the
+“Modern Dancer’s Foot,” because she found it to occur
+almost invariably in women who were in the habit of
+dancing excessively in a modern high-heeled slipper. It
+is a painful enlargement of the tissues under the head of
+the first metatarsal bone and is found, as a rule, in the left
+foot only. The under and inner side around the head of
+the first metatarsal bone becomes painful to the touch, and
+under weightbearing. It is best described as a periarthritis
+although it is often complicated by a bursitis.</p>
+
+<p><b>Treatment.</b> Measures to relieve the painful part from
+weightbearing. (Felt pads, braces, etc.) Rest and means
+to reduce the existing inflammation.</p>
+
+<p><b>Golfer’s Foot.</b> The attitude assumed in playing golf,
+especially when driving the ball from the tee, often gives
+rise to a painful condition called “Golfer’s foot.” This
+pain is felt on the dorsum of the foot over the course of
+the extensor brevis digitorum muscle. The extreme extension
+of the foot, while striking at the ball, is the direct cause
+<span class="pagenum" id="Page_342">[Pg 342]</span>of the pain. Massage and rest have proven of benefit in
+Golfer’s Foot.</p>
+
+<blockquote class="sm">
+<p>(Full details of all orthopedic lesions have been but superficially
+treated in these pages by reason of the fact that “Podiatry
+Orthopedics,” a volume now in the course of preparation and the
+next of this series (Otto F. Schuster and Alvah H. Stafford,
+authors), will provide exhaustive material bearing upon all phases
+of foot orthopedics).</p>
+</blockquote>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_343">[Pg 343]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_XXIII">
+    <span class="chap">CHAPTER XXIII</span>
+    <br>
+    LOCOMOTION AS AN AID
+    IN DIAGNOSIS
+  </h2>
+</div>
+
+
+<p>One need not be a very experienced physician to know
+that there is a group of diseases, mostly of the nervous system,
+which at a certain point of their evolution, stamp the
+sufferer with a characteristic mode of locomotion. To
+observe such a modification of the normal walk is often sufficient
+to make a correct diagnosis.</p>
+
+<p>It is strange, however, how little attention this important
+subject has received from the medical profession. In
+fact, other than the work of the brothers Weber, who established
+the physiology and mechanism of human locomotion,
+of Neugebauer and of Gilles de la Tourette, who developed
+the ichnogram method of gait study, scarcely anything of
+importance has been done along these lines for the last quarter
+of a century. The study of the mode of locomotion in
+various diseases and ailments remains, therefore, a fertile
+field of research for the podiatrist.</p>
+
+<p><b>Elements of Locomotion.</b> The act of locomotion or the
+<i>power</i> of progression is not a simple one. Various co-related
+movements combine to form what we ordinarily term
+the <i>walk</i>. The three chief elements are: (1) <i>Posture</i>, (2)
+<i>Station</i>, and (3) <i>Gait</i>. These three factors may be influenced
+by local or general diseases, either separately or
+together.</p>
+
+<p><b>Posture.</b> Posture is the term applied to the position
+of the body in space and is not of much interest to the podiatrist
+except as corroborative of the two other elements of
+locomotion. It has, however, its value in diagnosis and the
+new practitioner of podiatry will do well to learn to observe
+<span class="pagenum" id="Page_344">[Pg 344]</span>the position of the body at various angles and in various diseases.
+One should learn early, for instance, that <i>immobility</i>
+is not always due to paralysis. It may be due to <i>pain</i>,
+as in rheumatism or to a disinclination to move as in scurvy,
+rickets or any condition causing dyspnea. The <i>restlessness</i>
+in fevers and in large hemorrhages, as well as the <i>throwing
+about</i> in renal, gallstone or intestinal colics, is known to all.
+Equally characteristic are the <i>agitation</i> and irregular movements
+in chorea and hysteria; the <i>gun-hammer posture</i> in
+cerebrospinal meningitis, and the <i>opisthotonos</i> in tetanus
+and strychnine poisoning.</p>
+
+<p><b>Station.</b> Station is the <i>power</i> of standing more or less
+firmly on one’s feet. It includes <i>attitude</i> which is the <i>manner</i>
+of standing, i.e., the relation of the rest of the body to
+the erect position. The carriage of the head and shoulders
+should be noted; the shape of the entire body whether bending
+<i>forward</i>, as in “stooped shoulders” (faulty attitude
+habit) and in paralysis agitans, or bending <i>backward</i>, as in
+ascites and abdominal tumors, should be closely studied and
+differentiated from the actual lordosis which is seen in
+spinal diseases, in advanced pregnancy, in pseudo-hypertrophic
+paralysis and in cretinism. The strictest attention
+should be paid to the attitude of the lower limbs, their
+individual shapes and their relation to each other when the
+erect position is assumed. The degree of firmness with
+which the individual stands should always be taken into
+consideration before a final diagnosis is made. <i>Swaying</i> is
+the term applied to any departure from the ideally rigid
+erect attitude and perpendicular station. The normal
+individual, with eyes open and heels close together, sways
+about one inch forward and three-quarters of an inch from
+side to side. In functional and static ataxias, the swaying
+may become so extreme as to produce absolute incapacity
+to stand.</p>
+
+<p><b>Gait.</b> This term means the specific <i>manner</i> of walking.
+It is a narrower term than locomotion which is the <i>power</i>
+of walking. It is, however, the chief factor in the act of
+<span class="pagenum" id="Page_345">[Pg 345]</span>progression and in the majority of cases it is characteristic
+enough to stamp itself indelibly on the normal as well as
+on the diseased individual. While in character reading, gait
+expression may not be as popular as face expression, it is
+often more reliable and in certain diseases it is simply
+invaluable as an aid in diagnosis.</p>
+
+
+<h3 id="METHODS_OF_DIAGNOSIS">
+  METHODS OF DIAGNOSIS
+</h3>
+
+
+
+<p><b>A.—The Observation Method.</b> This is the usual method
+of ascertaining the gait of an individual. It is practised
+by the average physician and podiatrist and consists in
+observing the patient while he or she walks up and down
+the room, taking notice of the peculiarities of gait which
+may develop. The patient may be allowed to roam freely
+about the room or should be directed to follow a carpet seam
+or a crack in the floor at right angles to a previous line of
+vision. This may be varied by opening or closing the eyes,
+stretching out the arms, with legs wide apart, or keeping
+them close together. Brisk walking should alternate with
+a slower gait and the effect of stopping abruptly and turning
+sharply at command should be closely observed.</p>
+
+<p>It is best to have the patient uncovered from the hips
+down. In women, the nightgown or chemise can be pulled
+tightly between the thighs and fastened anteriorly with a
+safety pin.</p>
+
+<p><b>Caution.</b> Due allowance should be made for nervousness
+and a careful watch must be maintained against a
+serious fall.</p>
+
+<figure class="figcenter illowe24" id="i_p346_fig01">
+  <img class="w100" src="images/i_p346_fig01.jpg" alt="">
+  <figcaption>
+    Fig. 1<br>
+
+    ICHNOGRAM OF A
+    NORMAL GAIT
+  </figcaption>
+</figure>
+
+<p><b>B.—The Ichnogram Method</b> consists in studying the
+impressions left by <i>both</i> soles (previously colored) when
+walking on paper for a distance of about twenty-five feet.
+Ichnograms (from the Greek—<i>ichnos</i>—trace, and <i>gramma</i>—to
+write) as a method of gait diagnosis are more exact
+than the method of observation and should supplement it.
+Besides, they inform us, at the same time, of the state of
+the plantar arch as each <i>pelmatogram</i> (the impression of a
+<span class="pagenum" id="Page_346">[Pg 346]</span>single foot) shows more or less clearly
+a posterior oval which changes but
+little, and an anterior oval as well as
+toe marks which undergo characteristic
+contour changes, depending on
+the state of the ligaments, of the tarsal
+and metatarsal bones and phalanges,
+and the relation of these structures
+<span class="pagenum" id="Page_347">[Pg 347]</span>to the musculature and innervation of the foot.</p>
+
+<p>Comparatively little has been accomplished along this
+line of endeavor, although it offers a vast and fruitful field
+for podiatric research. In fact this branch of podiatry
+deserves a special treatise, and it will be discussed in fuller
+detail in our forthcoming book on Podiatry Orthopedics.</p>
+
+<div class="col2acontainer"><div class="col2"><figure class="figleft illowe15" id="i_p346_fig02">
+  <img class="w100" src="images/i_p346_fig02.jpg" alt="">
+  <figcaption>
+    Fig. 2<br>
+
+    A. PELMATOGRAM OF A NORMAL
+    FEMALE FOOT<br>
+
+    B. MODIFIED PELMATOGRAM
+    SHOWING WEIGHT BEARING
+    POINTS
+  </figcaption>
+</figure></div>
+
+<div class="col2"><figure class="figleft illowe15" id="i_p346_fig03">
+  <img class="w100" src="images/i_p346_fig03.jpg" alt="">
+  <figcaption>
+    Fig. 3<br>
+
+    PELMATOGRAM OF A MALE,
+    SHOWING FLAT FOOT
+  </figcaption>
+</figure></div></div>
+
+<p class="clear"><b>Classification of Gaits.</b> Strictly speaking there are only
+three types of gait: (1) the <i>paretic</i>, (2) the <i>ataxic</i> and (3)
+the <i>choreic</i>. In some diseases there may be a combination
+of the three, while in others one type of gait predominates
+during the early stage and another during the later developments.
+At times, one comes across a gait that combines
+characteristics of the three types and hence is difficult of
+classification.</p>
+
+<p><b>I.—Paretic Gait.</b> <i>Paresis</i> means a lessening of the normal
+motility of a muscle, while the term <i>paralysis</i> denotes
+entire absence of motor power. We may have, therefore,
+two or three distinct paretic gaits according to whether the
+muscle is slightly or severely weakened or entirely paralyzed:</p>
+
+<blockquote>
+<p>
+  A.—The mild paretic gait.<br>
+  B.—The moderate or flaccid paretic gait.<br>
+  C.—The severe or spastic paretic gait.
+</p>
+</blockquote>
+
+<p><b>A.—The Mild Paretic Gait</b> is caused by muscular weakness
+due to a large number of etiologic factors. It results
+in slowing of locomotion, the steps being shortened on
+account of an exaggerated flexion at the knee joint. The
+following are examples of mild paretic gaits:</p>
+
+<p>(1) <i>The Pompous Gait.</i> The upper part of the body
+leans backward, the back is hollowed, the abdomen is protuberant,
+the feet are widely separated and appear to move
+with deliberation and dignity, giving the impression of
+conscious importance—hence the name. This gait may be
+seen in obesity, pregnancy, ascites, large abdominal tumors,
+cretinism and rickets.</p>
+
+<p>(2) <i>The Hobbling Gait.</i> The pelvis tilts towards the
+<span class="pagenum" id="Page_348">[Pg 348]</span>sound side, while the trunk leans over to the affected side,
+causing more or less pronounced <i>limping</i>. This gait is
+seen in people afflicted with corns, rheumatism, gout, sciatica,
+plantar neuralgia, Morton’s neuralgia, metatarsalgia,
+hip or knee joint disease or injury (recent or old), sacro-iliac
+disease, sprains, inflammatory diseases of the lower
+extremity, chimatlon, short leg, paralysis of one leg,
+abdominal aneurism, and subacute and chronic appendicitis.</p>
+
+<p>(3) <i>Intermittent Limping</i> (disbasia angiosclerotica or
+intermittent claudication) may be classified here and is
+a curious limping gait which develops in arteriosclerosis
+of the lower extremities. There are pain and fatigue on
+walking, which disappear after a short rest, to reappear
+again soon after walking is resumed. The pulse is weak
+or absent below the knee.</p>
+
+<p>(4) <i>The Waddling or Goose Gait.</i> The pelvis and head
+of femur are jerked forward at each step, knee advanced
+and extended only after foot is flat upon the ground. There
+is more lordosis and swinging of the body from side to
+side at each step, than in the pompous gait. It resembles
+the gait of a goose. The patient cannot stand on tiptoe.
+It is seen in: congenital dislocation of both hip joints and
+in pseudo-hypertrophic muscular paralysis, a hereditary
+disease seen mostly in boys under ten years of age, and
+characterized by inability to get up from the floor.</p>
+
+<p>(5) <i>The Wobbly Gait.</i> Resembles the above and is due
+to atrophy or paralysis of the three glutei muscles and prevents
+the patient from climbing. This inability to climb is
+also seen in those exhibiting the waddling gait.</p>
+
+<p>(6) <i>The Tottering Gait.</i> Seen in those who have taken
+large doses of bromides for long periods; also in hydrocephalus,
+in Korsakoff’s disease (psychosis polyneuritica)
+and in idiopathic muscular atrophy.</p>
+
+<p>(7) <i>The Shuffling Gait</i> is the gait seen in normal old age
+or senility and is associated with slowly progressive loss of
+strength and mentality. It is also seen in general paresis
+and is the “normal” gait of the long-term prison inmate.
+<span class="pagenum" id="Page_349">[Pg 349]</span>The patient gives the impression of being too lazy to lift
+his feet and instead pushes them along with his legs.</p>
+
+<p>(8) <i>The “Charlie Chaplin” Gait</i> has been erroneously
+described as an ataxic gait. It is rather a combination of
+the “funny part” of several gaits in which the waddling,
+shuffling, tottering paretic gaits predominate and to which
+some elements of the spastic paretic, as well as the ataxic
+gaits, have been added. The inspiration must have come
+originally to the celebrated movie star from some waddling
+cripple whom he proceeded to imitate and later burlesqued.</p>
+
+<p><b>B.—The Moderate or Flaccid Paretic Gait.</b> In this
+form of the paretic gait there is commonly a paresis of a
+certain group of muscles, usually the extensors of the foot
+or the peronei, causing “toe drop” and apparent lengthening
+of the affected extremity. It corresponds to the “wrist
+drop” of the upper extremity. To compensate for the
+lengthening of the limb, overflexion at the hip or knee, or at
+both joints, takes place. The limb is flaccid or flabby.</p>
+
+<p>The foot is lifted high up with each step in order to
+raise it clear off the ground and avoid tripping. As the
+foot is brought down, heel first, this gait may sometimes
+be confused with tabes and is therefore sometimes referred
+to as the pseudo-tabetic gait. It is, however, easily differentiated
+from the true tabetic gait by its characteristic
+“high action” or “high stepping” quality which made
+Charcot compare it to the gait of a horse and hence called
+it:</p>
+
+<p>(1) <i>The Steppage Gait</i>, mostly seen in the chronic intoxications
+producing neuritis. It resembles the gait of a
+man walking through thick grass or brushwood and stepping
+over constantly recurring but non-existent obstacles. The
+typical steppage gait is seen in arsenical neuritis with
+ankle drop, also in alcoholic neuritis, polyneuritis potatorum
+(ataxia of drunkards) and in lead neuritis (lead
+palsy, plumbism, saturnism), in which first the peroneal
+muscles are affected, later the extensor communis digitorum
+and finally the extensor proprius hallucis. Phosphorus,
+<span class="pagenum" id="Page_350">[Pg 350]</span>copper and grain (ergotism) poisoning may give rise to
+a neuritis in the lower extremities and produce the characteristic
+steppage gait. Tuberculosis, malaria, diabetes and
+diphtheria (motor form) may sometimes produce this gait.
+It may also develop as a sequel of sunstroke (thermic fever,
+insolation) and in fact following any disease which will
+cause peripheral neuritis of the anterior tibial nerve.</p>
+
+<p>(2) <i>The Prancing Gait</i> is an exaggeration of the preceding
+gait. It is seen in epidemic anterior poliomyelitis
+(infantile paralysis) when the disease affects the anterior
+horn cells of the lumbar cord, causing atrophy of the extensor
+muscles of the foot, resulting in “foot drop.” It is also
+seen in acute ascending paralysis (Landry’s disease), which
+is probably a form of poliomyelitis, and in progressive
+hereditary muscular atrophy of the leg (Charcot-Marie-Tooth
+type) where the muscles of the leg, not the
+foot, are primarily affected, i.e., first the peronei become
+atrophied, later the extensors of the toes and finally the calcaneal
+muscles. Finally the prancing may be seen in connection
+with certain tumors of the cord, unilateral hip disease,
+dislocation or injury and in multiple neuritis and beriberi
+(epidemic multiple neuritis).</p>
+
+<p><b>C.—The Spastic or Severe Paretic Gait.</b> The spastic gait
+is due to the hypertonicity of the weakened muscles, the
+resulting stiffness causing a slowing of locomotion and
+diminished excursion of the affected limb. The hypertonicity
+is produced either by direct stimulation of the motor
+cells in the anterior horn of the spinal cord, as in traumatic
+myelitis, or by impulses coming down from the cerebral
+cortex. The limb is spastic or rigid, due to the tonic spasm.
+When the tonic spasm is of long standing, it is termed a
+<i>contracture</i>. The lower extremity moves as a whole, the
+toes clinging to the ground, scraping it and very often
+“catching.” Contrary to the moderate paretic gait, this
+group presents difficulty in flexion which is partly overcome
+by the elevation of the pelvis on the side of the swinging
+leg.</p>
+
+<p><span class="pagenum" id="Page_351">[Pg 351]</span></p>
+
+<p>(1) <i>The Mowing or Hemiplegic Gait.</i> This is the prototype
+of all spastic gaits and is encountered in its simplest
+form in all hemiplegias, i.e., in paralysis of one side of the
+body, which may be caused by cerebral hemorrhage,
+embolism, thrombosis, syphilis, brain tumor, multiple
+sclerosis of a cerebral hemisphere, meningeal hemorrhage
+or suppuration, Raynaud’s disease, general paresis of the
+insane; sometimes it may be due to hysteria (functional
+hemiplegia) or to uremia (transient hemiplegia). No matter
+what the cause of the hemiplegia, there is always the
+typical mowing gait. This mowing movement is due to the
+fact that the spastic limb swings lateralward, describing an
+arc of a circle (outward), and strikes the ground in a flail-like
+manner. Technically speaking, circumduction takes
+place by tilting of the pelvis and the swinging of the foot
+outward and around to the front. The patient afflicted with
+hemiplegia makes the same movement with his limb as does
+the reaper with the hand in which he holds the scythe.
+<i>Exception</i>: the only paralytic gait in which there is no mowing
+movement occurs in hysterical (functional) paraplegia,
+which is very rare. In this condition the leg is dragged
+forward instead of outward.</p>
+
+<p><i>Important shoe sign in paraplegia.</i> The sole of the
+shoe is worn down on the inner side.</p>
+
+<p>(2) <i>The Small-step Gait</i> (la marche à petits pas). This
+gait is seen in cerebral softening following an apoplectic
+stroke, especially in pseudo-bulbar paralysis; the steps are
+very short and the feet are lifted from the ground with
+difficulty, the patient seeming to count his steps.</p>
+
+<p>(3) <i>The Cross-legged Gait.</i> This gait is due to a
+spasm of the adductors of the thigh causing the knees to
+rub against each other, resulting in cross-legged progression,
+the lower limbs having a tendency to cross during
+locomotion. It is seen in both Little’s congenital and Erb’s
+syphilitic form of lateral spinal sclerosis. In the syphilitic
+form, a dragging and shuffling gait is often associated with
+the cross-legged type.</p>
+
+<p><span class="pagenum" id="Page_352">[Pg 352]</span></p>
+
+<p>(4) <i>The Ill-defined Spastic Gaits.</i> Ill-defined spastic
+gaits are seen in tetany (paroxysmal tonic spasm) from any
+cause, and in amyotrophic lateral sclerosis, which is the
+spastic form of progressive muscular atrophy (Charcot’s
+disease). This involution disease, due probably to developmental
+defects of the lateral pyramidal tracts, has the combined
+symptoms of spastic spinal paralysis, anterior poliomyelitis
+and bulbar palsy, hence the difficulty in classifying
+it. Myelitis (inflammation of the spinal cord) may be due to
+trauma, alcoholism, syphilis, vertebral caries (compression
+myelitis), tumors, aneurism, hemorrhages into the cord, etc.,
+and will exhibit various gaits according to the stage and
+severity of the disease. It may begin with a mild paretic
+gait passing through several stages of the spastic gait or
+to complete paraplegia (paralysis of both lower extremities).
+In complete paraplegia there is of course no gait,
+as the patient cannot walk, there being a loss of the power
+of locomotion but not of progression (a patient so afflicted
+may still move from place to place on his hands).</p>
+
+<p>(5) <i>The Dragging Gait.</i> In hemiplegia one foot only
+is dragged. Dragging of both feet is seen in multiple neuritis,
+hereditary peroneal atrophy, spasmodic spinal paralysis
+and spinal and syphilitic spinal paralyses.</p>
+
+<p>(6) <i>The Dromedary Gait</i>, so called on account of its
+resemblance to the gait of a camel, is seen in children suffering
+with progressive torsion spasm (Flatau-Sterling disease).</p>
+
+<p>Finally, spastic paretic gaits are often observed in
+pellagra (maidism, Italian leprosy, Alpine scurvy) and in
+lathyrism (lupinosis), where the slow toxic spinal sclerosis
+finally leads to spastic paraplegia and loss of the power
+of locomotion; also in caisson disease (divers’ paralysis).</p>
+
+<p><b>II.—The Ataxic Gait.</b> The ataxic gait may be either:</p>
+
+<blockquote>
+<p>
+  A—The Static ataxic gait, or<br>
+  B—The Functional ataxic gait
+</p>
+</blockquote>
+
+<p>and these are termed either (1) spinal or (2) cerebellar,
+according to the location of the lesion.</p>
+
+<p><span class="pagenum" id="Page_353">[Pg 353]</span></p>
+
+<p><b>A.—The Static Spinal Ataxic Gait</b> is the most easily
+recognized gait, and once seen, is never forgotten. There
+is an exaggeration of all the movements of locomotion. The
+hips are overflexed and rotated laterally, the foot is raised
+suddenly and too high, the toes are lifted and the whole limb
+is thrown suddenly forward with unnecessary vehemence
+and is then brought down heel first or flat-footed, with a
+stamping sound. The feet are kept wide apart and while in
+the air they move in an undecided manner, as if the patient
+was doubtful where to put them. The eyes of the afflicted
+person are glued to the ground or fixed to the limbs so as to
+supplement the lack of muscular and articular sensation by
+the sense of sight.</p>
+
+<p>In the cerebellar type of this gait the movement excursion
+is not as extensive as in the spinal type. A sudden
+turning movement or an abrupt sitting posture is difficult
+or impossible to assume in this type of locomotion.</p>
+
+<p>In order to test static ataxia, the patient is made to
+stand heels and toes together, whereupon marked swaying
+takes place. The swaying is increased when the eyes are
+closed and the patient looks like a “chicken on a clothes
+line.” If there is more than one inch forward swaying and
+more than three-quarters of an inch lateral swaying, the
+patient is considered ataxic.</p>
+
+<p>In the disease known as tabes dorsalis, or locomotor
+ataxia of syphilis, the swaying may be so pronounced as to
+produce absolute incapability to stand or to walk.</p>
+
+<p><b>B.—The Cerebellar (functional) Ataxic Gaits.</b> These
+gaits are produced by a disturbance of the equilibrium
+accompanied by vertigo resulting in a very irregular swaying
+from side to side, resembling the gait of an intoxicated
+person.</p>
+
+<p>The patient makes short steps, keeps his feet wide
+apart, staggers, rolls, sways to and fro and reaches a set
+point by zigzagging toward it. The swaying is relieved when
+support is given under the armpits.</p>
+
+<p>(1) <i>The Titubating Gait</i> is a form of functional cerebellar
+<span class="pagenum" id="Page_354">[Pg 354]</span>ataxic gait seen in the following affections: Friedreich’s
+(disease) ataxia; hereditary cerebellar ataxia;
+dementia paralytica; ataxic paraplegia; labyrinthine disease
+and to some extent in vertigo; syringomyelia; and in
+some cases of general paresis, and various chronic intoxications
+like lead or arsenic or alcohol poisoning affecting the
+cerebrospinal system.</p>
+
+<p>(2) <i>The Reeling or Staggering Gait</i> is seen in acute
+alcoholic intoxication and Mésnière’s disease (disease of the
+middle cerebellar lobe).</p>
+
+<p><b>III.—The Choreic Gait.</b> The choreic gait, sometimes
+called <i>tremor</i> gait, spasmodic or hysterical gait, is very
+variable in quality depending on the cause of the tremor.
+It consists of a series of quivering or trembling movements
+of varying intensity, but nearly all due to clonic spasm
+and disappearing during sleep or passive motion. This
+distinguishes it from the spastic or paraplegic gait in which
+the spasm is tonic in quality, lasting from one minute to
+one month. The clonic spasm, on the other hand, consists in
+rapidly alternating contractions and relaxations of the
+muscle.</p>
+
+<p>(1) <i>The Stumbling Gait</i> is seen in chorea (St. Vitus’
+dance) and Huntington’s (hereditary) chorea, in Friedreich’s
+paramyoclonus multiplex (which is not to be confounded
+with Friedreich’s ataxia), in Unverricht’s progressive
+myoclonus, and in multiple sclerosis of the spinal cord.
+The gait resembles that of a schoolboy, who clownishly
+stumbles or trips over his heel to attract attention. Technically
+it consists of spasmodic adduction, extension and outward
+rotation of the legs which soon renders locomotion
+impossible. When these abrupt twitchings and jerking
+movements, which are involuntary and purposeless, affect
+only one-half of the body, we speak of the condition as hemichorea.
+The patient appears restless, unsettled and fidgety.</p>
+
+<p>(2) <i>The Festination Gait</i> is typical of the disease
+known as paralysis agitans (Parkinson’s disease, shaking
+palsy) and is an advanced choreic gait in which there may
+<span class="pagenum" id="Page_355">[Pg 355]</span>be observed the curious phenomena of propulsion and retropulsion,
+i.e., the impossibility of stopping, once the patient
+is pushed either forward or backward. In some instances,
+when pulled suddenly backward, the patient will take a few
+backward steps with increasing rapidity, also the body
+remains in the characteristic posture of paralysis agitans;
+namely, in the forward-leaning attitude. In festination
+“the body tries to overtake its centre of gravity” (Trousseau).</p>
+
+<p>(3) <i>The Saltatory Gait</i> (“The jumpers”), is a very
+rare condition occurring the instant the weight of the body
+is put upon the feet. It consists in strong and rapid contractions
+of the muscles of the thigh and leg causing the
+patient to jump up violently. It is probably a hysterical
+spasm.</p>
+
+<p>(4) <i>The Myotonia Gait</i> occurs in Thomsen’s disease
+and consists of tonic, <i>painless</i> spasms whenever a certain
+group of muscles begin to functionate. The steps are first
+checked and delayed; but this gradually wears off. This
+curious condition returns again when the same group of
+muscles are called into action. Owing to the tonic spasms,
+this gait might have been properly classified as a spastic paretic
+gait, were it not for the fleeting and irregular
+character of the spasticity.</p>
+
+<p>(5) <i>The Hysteria Gait</i>, known also as astasia-abasia,
+is notable by the ease with which it may simulate any and
+all of the gaits described above, the spastic as well as the
+flaccid types of paralyses,—even the cross-legged gait, ending
+in complete inability to stand or walk. It differs from
+all of them, however, in the ability of the patient to perform
+all the nervous functions of the limb when lying in bed. The
+hysterical gait may also end in:</p>
+
+<p><i>Catalepsy</i> which is a state of muscular rigidity enabling
+a limb to maintain a posture in opposition to gravity for
+one hour or more (waxy flexibility). This curious phenomenon
+of retaining the leg or any other part of the body in
+a fixed attitude (given to it by the operator) is sometimes
+<span class="pagenum" id="Page_356">[Pg 356]</span>seen in catatonia, general paresis, brain tumors and,
+(rarely) in meningitis.</p>
+
+<blockquote class="sm">
+<p>(The above chapter was especially prepared for “Practical
+Podiatry” by Paul Luttinger, M.D., Professor of Bacteriology in
+The First Institute of Podiatry. It is the first compilation of its
+kind ever published and should prove a valuable aid to both practitioners
+of medicine and of podiatry—<i>Editor</i>).</p>
+</blockquote>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_357">[Pg 357]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_XXIV">
+    <span class="chap">CHAPTER XXIV</span>
+    <br>
+    MISCELLANEOUS FOOT LESIONS
+  </h2>
+</div>
+
+
+<h3>TRENCH FOOT</h3>
+
+<p>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.”</p>
+
+<p>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.</p>
+
+<p>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
+<i>The Medical Record</i>; “Anonymous,” in the same publication;
+H. Oswald Smith, in <i>The Lennox</i>, a journal devoted to
+dentistry, and several articles in the <i>Journal of the American
+Medical Association</i>.</p>
+
+<p>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
+<span class="pagenum" id="Page_358">[Pg 358]</span>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.</p>
+
+<p><b>Etiology.</b> 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.</p>
+
+<p>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.</p>
+
+<p>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.”</p>
+
+<p>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.</p>
+
+<p>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 <i>trench fever</i>. Their unfinished
+report (they are still investigating) shows as follows:
+<span class="pagenum" id="Page_359">[Pg 359]</span>(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&#x2060;<a id="FNanchor_7_7" href="#Footnote_7_7" class="fnanchor">[7]</a>&#x2060;.</p>
+
+<p><b>Symptomatology.</b> 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.</p>
+
+<p>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_360">[Pg 360]</span>times extends to a condition of anesthesia. The mildest
+form is characterized simply by pain and paresthesia.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><b>Prognosis.</b> 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.</p>
+
+<p>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.</p>
+
+<p><b>Treatment.</b> 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,
+<span class="pagenum" id="Page_361">[Pg 361]</span>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.</p>
+
+<p>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.</p>
+
+<p>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,
+<span class="pagenum" id="Page_362">[Pg 362]</span>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.</p>
+
+<p>The treatment of the lesion itself, depends upon the
+severity and the extent of the condition.</p>
+
+<p>1. <b>Simple Edematous Form.</b> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>When the disease proves obstinate and is accompanied
+by persistent pain, some relief is afforded by bathing the
+<span class="pagenum" id="Page_363">[Pg 363]</span>feet at the time of the daily dressing in warm water, using
+the same liquid soap as at first.</p>
+
+<p>2. <b>Vesicular Form.</b> 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.</p>
+
+<p>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.</p>
+
+<p>3. <b>The Formation of Crusts.</b> 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.</p>
+
+<p>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.</p>
+
+<p>Not infrequently the crusts will re-form, in which event
+it is well to treat them with pomade of Reclus, made as
+<span class="pagenum" id="Page_364">[Pg 364]</span>follows: vaseline, 200; boric acid, 3; iodoform, 1; antipyrine,
+5; salol, 3; carbolic acid (crystals), 1; bichloride of
+mercury, 0.1.</p>
+
+<p>4. <b>Extensive Invasion.</b> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_365">[Pg 365]</span>an amputation becomes necessary, it should be made at a
+healthy point beyond the infected area.</p>
+
+<p>5. <b>Reparation Stage.</b> 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°.</p>
+
+<p>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.</p>
+
+<p>6. <b>General Treatment.</b> 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.</p>
+
+<p>7. <b>Complications.</b> 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).</p>
+
+<p>Gaseous gangrene is infrequent with the treatment here
+<span class="pagenum" id="Page_366">[Pg 366]</span>indicated. If present, it can be treated in the usual way.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p><span class="pagenum" id="Page_367">[Pg 367]</span></p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_368">[Pg 368]</span>layers of the true skin is notable; a rich red velvet color
+persists for several days.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+
+<h3 id="GROUND_ITCH_OR_UNCINARIAL_DERMATITIS">
+  GROUND ITCH OR UNCINARIAL DERMATITIS
+</h3>
+
+<p>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.</p>
+
+<p>“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
+<span class="pagenum" id="Page_369">[Pg 369]</span>become raw, oozing surfaces accompanied by considerable
+local swelling. Pustulation and ulceration may result if
+these surfaces become infected with pus producing microorganisms.”</p>
+
+<p><b>Treatment.</b> 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.</p>
+
+<p>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.</p>
+
+
+<h3 id="GAS_INFECTION_AND_GAS_GANGRENE">
+  GAS INFECTION AND GAS GANGRENE
+</h3>
+
+<p>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.</p>
+
+<p><b>Etiology.</b> 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.</p>
+
+<p>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
+<span class="pagenum" id="Page_370">[Pg 370]</span>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.</p>
+
+<p><b>Symptoms.</b> 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.</p>
+
+<p>The course of the disease varies somewhat, being at
+first, a <i>local</i> 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.</p>
+
+<p>A more serious and fatal form, is the <i>diffuse</i> 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.</p>
+
+<p>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.</p>
+
+<p><b>Treatment.</b> The paramount importance of the earliest
+<span class="pagenum" id="Page_371">[Pg 371]</span>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.</p>
+
+<p>Taylor points out clearly what is to be done:</p>
+
+<p>1. Destruction of the bacillus.</p>
+
+<p>2. Removal of the tissues especially favoring its
+growth, which are the necrotic muscles.</p>
+
+<p>3. Measures to prevent the destruction of the muscles
+as a result of mechanical pressure.</p>
+
+<p>For the destruction of the bacilli, Taylor recommends a
+one per cent. solution of chlorhydrate of quinine. Others
+have found Dakin’s fluid effective.</p>
+
+<p>All foreign bodies (clothing, etc.) in the wound, must
+be removed as they will keep up the anærobic infection; <i>all</i>
+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.</p>
+
+<p>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.</p>
+
+<p>If gas gangrene occurs or has already set in, the same
+<span class="pagenum" id="Page_372">[Pg 372]</span>free incision should be made, unless this has already been
+done.</p>
+
+<p>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.</p>
+
+<p><b>Antitoxin Treatment.</b> 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.</p>
+
+<blockquote class="sm">
+<p>(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).</p>
+</blockquote>
+
+<p><span class="pagenum" id="Page_373">[Pg 373]</span></p>
+
+
+<h3 id="SYPHILIS">
+  SYPHILIS
+</h3>
+
+<p>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:</p>
+
+<p><b>Derivation.</b> From the Greek <i>sus</i> and <i>philos</i>, “a companion
+of swine.”</p>
+
+<p><b>Synonyms.</b> Syphilis cutanea, lues, syphilis of the
+skin.</p>
+
+<p><b>Definition.</b> 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.”</p>
+
+<p><b>Etiology.</b> 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.</p>
+
+<p><b>Pathology.</b> Syphilitic deposits are new growths and
+consist of round cell infiltration, especially about the vessels,
+generally endothelial proliferation, and in the tubercular
+<span class="pagenum" id="Page_374">[Pg 374]</span>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.</p>
+
+<p>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.</p>
+
+<p><b>Diagnosis.</b> 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.</p>
+
+<p><b>Distribution.</b> 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.</p>
+
+<p><b>Color.</b> 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.</p>
+
+<p><b>Form.</b> 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.</p>
+
+<p>Early ulcers are superficial and the scars are insignificant.
+<span class="pagenum" id="Page_375">[Pg 375]</span>Later ulcers are deeper, and the scars, often pigmented,
+are sometimes diagnostic.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<figure class="figcenter illowe24" id="i_p375">
+  <img class="w100" src="images/i_p375.jpg" alt="">
+  <figcaption>
+    PLANTAR SYPHILID
+  </figcaption>
+</figure>
+
+<p><b>Plantar Syphilid.</b> The plantar surface of the foot is a
+common site for dry syphilids. The palm of the hand, and
+<span class="pagenum" id="Page_376">[Pg 376]</span>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.</p>
+
+<p>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.</p>
+
+<p>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:</p>
+
+<p><span class="pagenum" id="Page_377">[Pg 377]</span></p>
+
+
+<table class="autotable3">
+<tr class="xsm">
+<td class="tdc"  colspan="2">
+PAPULOSQUAMOUS
+SYPHILODERM
+</td>
+<td rowspan="8"></td>
+<td class="tdc"  colspan="2">
+ECZEMA
+</td>
+
+</tr>
+<tr>
+<td class="tdr">
+1.
+</td>
+<td class="tdl">
+History of syphilis.
+</td>
+<td class="tdr">
+1.
+</td>
+<td class="tdl">
+History of previous outbreaks.
+</td>
+</tr>
+<tr>
+<td class="tdr">
+2.
+</td>
+<td class="tdl">
+Concomitant signs present.
+</td>
+<td class="tdr">
+2.
+</td>
+<td class="tdl">
+No associated signs.
+</td>
+</tr>
+<tr>
+<td class="tdr">
+3.
+
+</td>
+<td class="tdl">
+Favorite seats, palms and
+soles.
+</td>
+<td class="tdr">
+3.
+
+</td>
+<td class="tdl">
+Favorite seats, flexor surfaces.
+
+</td>
+</tr>
+<tr>
+<td class="tdr">
+4.
+</td>
+<td class="tdl">
+Itching usually absent.
+</td>
+<td class="tdr">
+4.
+</td>
+<td class="tdl">
+Itching present.
+</td>
+</tr>
+<tr>
+<td class="tdr">
+5.
+
+</td>
+<td class="tdl">
+Edge of lesion surrounded
+by detached scales.
+</td>
+<td class="tdr">
+5.
+
+</td>
+<td class="tdl">
+Scales completely detached.
+
+</td>
+</tr>
+<tr>
+<td class="tdr">
+6.
+</td>
+<td class="tdl">
+Scales scanty and dirty-grayish.
+</td>
+<td class="tdr">
+6.
+</td>
+<td class="tdl">
+Scales abundant, and granular.
+</td>
+</tr>
+<tr>
+<td class="tdr">
+7.
+
+</td>
+<td class="tdl">
+Infiltrated, dull red papules
+beneath the scales.
+</td>
+<td class="tdr">
+7.
+
+</td>
+<td class="tdl">
+Flat, reddish patches beneath
+the scales.
+</td>
+</tr>
+</table>
+
+
+<p>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.</p>
+
+<p><b>Blood Tests.</b> 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
+<span class="pagenum" id="Page_378">[Pg 378]</span>should be able to make a diagnosis without the aid of the
+blood tests in cases of syphilis in which there are skin
+lesions.</p>
+
+<p>The luetin test, a vaccine test, is of most value in the
+late stage of the disease.</p>
+
+<p><b>Course and Duration.</b> 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.</p>
+
+<p><b>Treatment.</b> 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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>Recently many practitioners of medicine have been
+using a complex compound of arsenic, viz., arsphenamine,
+<span class="pagenum" id="Page_379">[Pg 379]</span>(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.</p>
+
+<p>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.</p>
+
+<blockquote class="sm">
+<p>(The above is largely compiled from the lectures of Dr.
+Andrew H. Montgomery, Prof. of Dermatology at The First Institute
+of Podiatry).</p>
+</blockquote>
+
+
+<h3 id="FOCAL_INFECTION">
+  FOCAL INFECTION
+</h3>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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.</p>
+
+<p>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
+<span class="pagenum" id="Page_380">[Pg 380]</span>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.</p>
+
+<p><b>Mode of Infection.</b> 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.</p>
+
+<p><b>Relationship Between the Foot and Focal Infection.</b>
+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.</p>
+
+<p>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.</p>
+
+<p><b>Gonorrheal Heel</b> 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
+<span class="pagenum" id="Page_381">[Pg 381]</span>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.”</p>
+
+<p><b>Painful Feet in Women.</b> 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.</p>
+
+<p><b>Treatment.</b> 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.</p>
+
+<p>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
+<span class="pagenum" id="Page_382">[Pg 382]</span>all cases of foot pains, in which, by exclusion, a diagnosis
+has been reached that focal infection may be the cause of
+the same.</p>
+
+
+<h3 id="MORTONS_TOE_AND_METATARSALGIA_1">
+  MORTON’S TOE AND METATARSALGIA
+</h3>
+
+<p>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.</p>
+
+<p><b>Morton’s Toe or Morton’s Neuralgia.</b> 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.</p>
+
+<p><b>Treatment.</b> 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
+<span class="pagenum" id="Page_383">[Pg 383]</span>stable substance should be substituted, with an elevation at
+the point at which the pressure is desired.</p>
+
+<p>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.</p>
+
+<p><b>Metatarsalgia.</b> 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.</p>
+
+<p><b>Treatment.</b> 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.</p>
+
+<p>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
+<span class="pagenum" id="Page_384">[Pg 384]</span>level. Adhesive plaster and rubber bands may also be used
+for this purpose.</p>
+
+<p>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.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_385">[Pg 385]</span></p>
+
+
+  <h2 class="nobreak" id="CHAPTER_XXV">
+    <span class="chap">CHAPTER XXV</span>
+    <br>
+    X-RAYS IN PODIATRY
+  </h2>
+</div>
+
+
+<p>Roentgenology is the science that deals with the use
+of the Roentgen, or X-rays, in all their applications. The
+subject is divided into three parts, each distinct from the
+other, and with special required study for each part. The
+first branch of roentgenology is known as <i>roentgenotherapy</i>
+or <i>actinotherapy</i>, and comprehends the treatment of disease
+by the use of the X-rays or by other radiant energy.</p>
+
+<p>Roentgenotherapy, to be intelligently applied by the
+practitioner, requires a thorough knowledge of pathology
+and is strictly within the province of the licensed doctor of
+medicine. The second branch variously styled <i>fluoroscopy</i>,
+<i>skiascopy</i>, <i>radioscopy</i> or <i>roentgenoscopy</i>, is utilized for
+examining the various parts of the body by projecting the
+X-rays through the body and fixating the shadows cast on
+the fluoroscope. This branch of the science of light is of
+great assistance in diagnosis and is used extensively in
+surgery for the location of foreign bodies in the tissues.
+The third division of roentgenology is called <i>radiography</i>,
+<i>skiagraphy</i> or <i>roentgenography</i>, and consists of the making
+of X-ray photographs by passing the ray through the body
+in front of a photographic plate. This branch is of great
+importance to the podiatrist because of the value it possesses
+in the diagnosis of foot lesions, involving the bony structures;
+it often clears up a doubt as to the true state of a
+lesion when other means have failed. The soft tissues
+through which the ray passes readily appear in light
+shadow, while the bones, because they are solid, cast a
+darker shadow on the plate.</p>
+
+<p>Experiments with electricity and with the modifications
+<span class="pagenum" id="Page_386">[Pg 386]</span>of the various currents of electricity, have been responsible
+for all of the new discoveries and inventions along these
+lines, and the same may be said of the X-rays.</p>
+
+<p>The two divisions of electric current are the direct and
+the alternating, named after the direction in which they
+flow. The direct current moves in one direction and may
+be likened to the flow of water from a faucet, while the
+alternating current does not maintain a steady pressure
+nor does it flow in the same direction continuously. The
+alternating current, which is commonly used for lighting
+purposes, reverses its direction of flow and pressure 120
+times per second. It is therefore called 60 cycle current,
+in that it makes 60 complete cycles per second. The alternating
+current may be likened to the tide, which rises and
+falls every twelve hours. Instead of passing from ebb to
+flood and back again each twelve hours, the alternating current,
+used for illuminating purposes, does so in one-sixtieth
+of a second.</p>
+
+<p>The alternating current, is of most value to the sciences,
+because its voltage or pressure may be easily changed.
+Thus it can be raised or lowered by passing it through
+special apparatus. One particular form of alternating current
+has a voltage of from 30,000 to 120,000 and can be used
+for the production of Roentgen rays, if it be transformed
+into a so-called pulsative or unidirectional high tension current.
+This transformation is easily brought about by
+modern Roentgen ray apparatus.</p>
+
+<p>The discovery of the X-rays was preceded by an
+improvement in the knowledge of alternating currents.
+Many scientists were experimenting and looking for new
+rays and currents, and after the invention of the air pump
+and the production of glass globes, from which the air was
+removed by means of the pump, Geissler invented the process
+of sealing platinum into glass and produced the Geissler
+air pump, which is used to the present day. This made
+it possible to seal electric conductors into vacuum tubes.</p>
+
+<p>Following this, Faraday and Maxwell developed the
+<span class="pagenum" id="Page_387">[Pg 387]</span>electro-magnetic theory of light and laid the foundation for
+a theory of the Roentgen ray, which, although later considerably
+changed, has proven one of the most useful adjuvants
+to the science of physics. The period between 1840
+and the discovery of the X-rays was an active one in electric
+experimenting. Many men were interested in this work, and
+their observations and discoveries were important in the
+final discovery of the rays. In fact, Roentgen’s discovery
+was fully expected, inasmuch as several investigators,
+including Sir William Crookes and Roentgen himself, were
+convinced that rays existed of which they knew nothing.
+The earlier of the two workers, Crookes, had probably produced
+X-rays, but overlooked them and it fell to Roentgen
+to become aware of the conditions under which they were
+produced. He called them X-rays or unknown rays, but
+after a time, they were named after him, and are known in
+science as Roentgen rays. Roentgen wrote and published
+three papers on the subject and these have become classics
+on this topic. All of the facts announced by him at that time
+continue to be accepted, because, notwithstanding all the
+work done along these lines, they have never been disproven.</p>
+
+<p>Experiments have been continuous, and gradually the
+types of generators and tubes have changed, always
+improving. Where at first only simple work could be accomplished,
+the most wonderful things in this art are now being
+done, with probably many more wonderful things still to
+come. The dangers to which the earlier workers were subjected
+have been gradually eliminated, and today with
+proper care, the danger from the X-rays has been reduced
+to a minor factor. This danger came about from lack of
+knowledge of what occurred in the tube when the ray was
+being generated. There are three rays produced, one of
+which causes destruction of the human tissues, when
+exposed for a prolonged period of time. By preventing the
+passage of this ray, by the use of lead and lead glass, as
+protective mediums, the danger has been practically controlled.</p>
+
+<p><span class="pagenum" id="Page_388">[Pg 388]</span></p>
+
+
+<h3 id="X-RAY_APPARATUS">
+  X-RAY APPARATUS
+</h3>
+
+<p>The apparatus used in the generation of the X-rays
+consists of a generator, a vacuum tube and an appliance for
+holding the tube in a fixed position, called the tube stand.</p>
+
+<p><b>The Generator.</b> The generators used in X-ray work
+are of three types, the motor generator, the interrupterless
+type and the coil generator with a chemical interrupter.</p>
+
+<p>The function of the Roentgen ray apparatus is to produce
+high potential electric discharges in one and the same
+direction, or what is known as a unidirectional current.
+Dependent upon the kind of current used to start with, distinction
+can be made between the types of apparatus previously
+mentioned. These types are operated by either
+direct or alternating current.</p>
+
+<p>Direct current apparatus requires an interrupting
+device for the purpose of producing the necessary change
+of flux of magnetic lines in the inductive part of the apparatus.
+Interrupting devices, which are used in connection
+with such apparatus, are of three kinds: <i>first</i>, the hammer
+interrupter; <i>second</i>, the mercury interrupter; <i>third</i>, the
+electrolytic interrupter. The function of any one of these
+interrupters is to break up the continuous flow of direct
+current into small fragments. Each one of these fragments
+then produces one impulse of high potentiality, which is
+then directed through the tube.</p>
+
+<p>The alternating current, as its name implies, is already
+interrupted, but the impulses are alternately changing direction,
+passing first in one direction and then in the opposite
+direction. Hence, if the alternating current is used as a
+primary source of electric energy, then the secondary or
+high potential impulses will also be changing their direction
+alternately. Two methods are used in employing the alternating
+current as a primary source of energy. The first
+consists of the suppression of one phase (that which would
+pass in the negative direction) by means of the so-called
+rectifier cell. The second consists of producing high potential
+<span class="pagenum"><a id="Page_389"></a><a id="Page_390"></a>[Pg 390]</span>impulses which flow in alternate directions, and to then
+redirect these impulses so that all of those passing through
+the tube are in the one and the same direction.</p>
+
+<figure class="figcenter illowe15" id="i_p389">
+  <img class="w100" src="images/i_p389.jpg" alt="">
+  <figcaption>
+    INTERRUPTERLESS TYPE GENERATOR
+  </figcaption>
+</figure>
+
+<p>Accordingly, X-ray apparatus can be divided into the
+three classes previously mentioned. The coil, consisting of
+an induction coil activated by direct current, which is broken
+into small sections by the interrupter; or the induction coil
+which is energized by the alternating current of which one
+phase is suppressed through a liquid rectifier cell, and in
+which the proper interruptions are again produced by some
+interrupting device. The most extensively used type of
+apparatus is known as the “interrupterless machine.” This
+machine operates on either the direct or the alternating current,
+but, if the direct current is used as a primary source,
+it is transformed into an alternating current by means of
+a rotary converter or motor generator set. The alternating
+current, therefore, either produced or already available,
+passes into the primary coil of a transformer which changes
+it into alternating impulses of high potentiality. In order
+to transform them into impulses, all of which shall pass in
+the same direction, a so-called rectifying system is
+employed. This consists of either a disk or of cross-sticks,
+which are so arranged that they produce contact with both
+terminals of the transformer in such a way that current
+of the same polarity, the unidirectional current, is always
+delivered to the tube. The name “interrupterless machine”
+merely implies that the devices used for interrupting the
+primary current have been eliminated.</p>
+
+<p>There is one other type of apparatus which is built on
+the principle of an electrically oscillating system. Here
+again a start is made with the alternating current, obtained
+either from the line or by changing the direct current by
+means of an interrupter. The current is transformed
+through a so-called step-up transformer into one of high
+potentiality which is then still alternating. This current
+oscillates over a spark gap. Parallel to this spark gap a
+resonator is connected in which impulses are produced that
+<span class="pagenum" id="Page_391">[Pg 391]</span>correspond to the discharges over the gap and which, if
+applied to a specially built, so-called high frequency Roentgen
+ray tube, will produce X-rays. Since the principle of
+electric oscillations of a high frequency is used in this type
+of apparatus, it is generally called the high frequency
+Roentgen ray apparatus.</p>
+
+<figure class="figcenter illowe18" id="i_p391">
+  <img class="w100" src="images/i_p391.jpg" alt="">
+  <figcaption>
+    TUNGSTEN TARGET TUBE
+  </figcaption>
+</figure>
+
+<p><b>Roentgen Ray Tubes.</b> The various types of apparatus
+previously described require special forms of Roentgen
+ray tubes. For the coils by virtue of their relatively small
+capacity, platinum target tubes are generally employed.
+The capacity of the interrupterless type being considerably
+higher, the use of a material of greater resistance as a target
+is necessitated. For this purpose tungsten is generally
+employed. For the high frequency, or Tesla coils, a tube
+which embodies a rectifying or valve action device is necessary.</p>
+
+<p>The mechanism of the production of Roentgen rays can
+be described in the following way: the cathode, or negative
+terminal of the tube, consists of a hollow spherical surface
+of aluminum. When this electrode is attached to a negative
+potential, a stream of negative ions or cathode rays
+<span class="pagenum" id="Page_392">[Pg 392]</span>is projected perpendicular to the surface of the electrode.
+By reason of its curvature, the electrode is therefore focused
+to produce a converging beam of cathode rays, the area of
+which is smallest where, in the centre of the tube, the tungsten
+block or anticathode is placed.</p>
+
+<p>According to whether the area selected for the location
+of the anticathode is small or large, the possibility to distinguish
+between fine, medium or broad focused tubes arises.
+The discharge from the negative electrode takes place,
+dependent upon conditions which give to the discharge
+either a high or a low velocity. If the velocity is high, the
+change from kinetic energy to Roentgen ray energy will be
+greater than if the velocity of the cathode ray stream is
+decreased. In the latter case, the radiations will have less
+penetrating power. The velocity of the discharge must
+therefore depend upon the magnitude of the charge on the
+negative electrode, and also upon the number of gas particles
+present in the tube at that time. If there is a large
+quantity of gas present, there will be a reduction in the
+speed of the ray, due to collision and impact with the gas.
+The penetration of the Roentgen rays depends therefore
+directly upon the potential produced by the apparatus and
+inversely on the gas pressure (or directly on the vacuum)
+of the tube.</p>
+
+<p>For the purpose of controlling the state of vacuum in
+the tube, a regulating system has been improvised which,
+when an electric current is passed through it, liberates a
+certain amount of gas which passes into the tube proper.
+This is a convenient device for reducing the vacuum of the
+tube. Up to the present time, no one has succeeded in
+inventing an efficient method or device for removing gas
+from the tube, or a means which would help to increase the
+vacuum. It is for that reason that operators should guard
+against reducing the tube unduly. It is a simple matter to
+reduce the vacuum but difficult to increase it. When a tube
+becomes low (when the gas content is high), resting the tube
+<span class="pagenum"><a id="Page_393"></a><a id="Page_394"></a>[Pg 394]</span>by allowing it to remain in its bracket for a period of time,
+will usually suffice to increase the vacuum.</p>
+
+<p>The proper care of the tube is essential for good radiograms.
+It should be kept free from dust, and before being
+used the degree of vacuum should be determined by the
+testing apparatus on the generator. If the tube is dusty or
+dirty, the passage of the rays through the glass will be
+hampered, as these particles tend to deflect the rays from
+their straight course. If the vacuum of the tube is too high,
+it will affect the quality of the plate, and if it is too low there
+will be no penetration and therefore a blank plate.</p>
+
+<figure class="figcenter illowe15" id="i_p393">
+  <img class="w100" src="images/i_p393.jpg" alt="">
+  <figcaption>
+    TUBE STAND
+  </figcaption>
+</figure>
+
+<p><b>The Tube Stand.</b> The tubes used in Roentgenology are
+delicate structures and great care must be exercised so as
+to prevent breakage. To guard against such damage it is necessary
+to securely hold the tube in a proper device while it
+is being used. The tube stand should be so arranged that it is
+possible to raise or lower the tube, with its connections,
+without being compelled to touch the tube itself, to swing it
+from side to side, to tilt it forward or backward, or in or
+out. This is best accomplished by the modern tube stand
+which is so arranged that after having set the tube in its
+proper place, it is no longer necessary to touch the apparatus
+in order to secure all of the above named motions. A
+careful study of the accompanying photograph will make
+this clear.</p>
+
+<p><b>The Roentgen or X-rays.</b> The rays generated in the
+apparatus heretofore described, and named after their discoverer,
+are of a peculiar character, and although they have
+proven a boon to mankind, serious trouble and even death
+has come to those who in their ignorance used the X-rays
+promiscuously. It has been discovered that there are three
+distinct rays generated when the high potential current is
+passed through the vacuum tube and they have been named
+after the first three letters of the Greek alphabet, namely:
+the alpha, the beta and the gamma rays. The <i>alpha</i> ray
+is the ray that is seen in the tube and is of no consequence.
+The <i>beta</i> and <i>gamma</i> rays are invisible and it is these rays
+<span class="pagenum" id="Page_395">[Pg 395]</span>that penetrate the tissues of the body. To the gamma ray
+is attributed the harmful effects of Roentgen’s discovery.
+Although the X-ray is used as a therapeutic measure it
+should only be applied by those who have a thorough
+knowledge of its properties. Prolonged exposure will cause
+severe burns, and in some cases continued contact with the
+ray has caused cancer. Their action in this respect is due
+to the actinic quality of the gamma rays. The symptoms
+of a burn do not manifest themselves until a minimum of
+a week or ten days after exposure and, when they do appear,
+they are usually severe. Sloughing of the tissues takes
+place, and the wounds produced do not heal readily and, in
+consequence, ugly disfiguring scars remain.</p>
+
+<p><b>Radiography.</b> This branch of Roentgenology is of most
+interest to the podiatrist. By means of photographic plates,
+properly exposed and well developed, it is often possible to
+make diagnoses where other means have failed. It is essential
+for one who would be correct in diagnosing X-ray plates,
+to have a thorough knowledge of the structure of the bones
+of the foot and to understand the meaning of the various
+shadows cast upon the plate.</p>
+
+<p>When the X-rays penetrate the foot they pass through
+the tissues, and when they strike a tissue of great density
+they cannot penetrate it as readily as the rays passing
+through a tissue of less density. The result is that as the
+rays pass through the foot they cast a series of shadows
+on the sensitized photographic plate beneath, the density
+of which depends upon the tissues through which the rays
+have passed. So, in reality, the plate when finished is not
+a photograph, as most laymen imagine, but a shadowgraph
+or, as it is variously termed, a radiogram or skiagram.</p>
+
+<p>For the purposes of producing radiographs that are
+clear and easily interpreted, it is necessary to have good
+materials and to follow the technic of developing and fixing
+the plate in every detail. The photographic plates used in
+general photography do not, as a rule, give satisfactory
+results. Plates, with specially prepared emulsions that are
+<span class="pagenum" id="Page_396">[Pg 396]</span>adapted for radiography, are preferred. These plates are
+sensitized with a gelatinous substance containing bromide
+of silver. When this substance is exposed to the action of
+the rays it undergoes chemical decomposition, the degree
+of which varies with the amount of exposure. It is upon
+this decomposition of the salt that the art of photography
+depends and so, too, the science of radiography. The plate
+is then developed.</p>
+
+<p>Developing of a photographic plate consists of making
+visible the metallic silver which is produced by the decomposition
+of the silver bromide. This is accomplished by
+the use of a mixture of chemicals called the developer. The
+plate is put into a tray about two inches deep and large
+enough to allow for its easy removal, and the developing
+solution is poured over the emulsion. Gradually the exposed
+portions of the negative will appear and developing must
+continue until every such exposed part has been brought
+out in its fullest detail. The unexposed portions are then
+dissolved by placing the plate in a solution of sodium hyposulphite,
+sometimes called the <i>fixer</i> or the fixing bath. As
+its name implies, this solution permanently fixes the exposed
+silver, and if the plate were not treated in this manner the
+entire mass would become blackened upon exposure to light.</p>
+
+<p>The preparation of radiographic plates is carried on in
+a room that is protected from light with the exception of a
+dull, red glow from a “ruby lamp” which has no effect upon
+the plate. The plate is placed into an envelope made of
+black paper, and this in turn is placed, flap down, into a
+second envelope of red paper. This insures protection from
+light rays when the plate is brought out of the dark room.
+After exposure, the negative must be taken back to the
+dark room before it is removed from the envelope. After
+it has been developed and fixed it may be brought into the
+light with safety.</p>
+
+<p>The length of time required in making exposures
+varies with the different types of apparatus. When the
+flow of rays is great, it will require a proportionately shorter
+<span class="pagenum" id="Page_397">[Pg 397]</span>exposure. So, too, the length of exposure with a certain
+type of generator varies with the part being exposed. The
+bones of the fingers would require less time than those of
+the leg, while the bones of the head would require more time
+than either of the above for the production of a clear radiograph.
+It is essential in all branches of radiography to
+remember that the part to be skiagraphed be parallel to
+and in close proximity to the plate. This will prevent elongations
+and foreshortenings of the shadows cast.</p>
+
+<figure class="figcenter illowe18" id="i_p398">
+  <img class="w100" src="images/i_p398.jpg" alt="">
+  <figcaption>
+    SPUR ON THE UNDER SURFACE OF THE HEEL
+  </figcaption>
+</figure>
+
+
+<h3 id="DIAGNOSIS_OF_RADIOGRAPHS">
+  DIAGNOSIS OF RADIOGRAPHS
+</h3>
+
+<p>There are several lesions of the foot commonly arising
+in the practice of the podiatrist, which are easily recognized
+by radiographic examination but which otherwise are difficult
+of diagnosis. Some of these cases are shown in the accompanying
+pictures, which were selected from a large collection
+at The First Institute of Podiatry of New York City.
+They are characteristic of the lesions they depict, and it is
+needless to emphasize their value as an aid to diagnosis. If
+a condition involves the bony structure of the foot, clinical
+symptoms are never so certain that an absolutely positive
+diagnosis can be made, but the X-ray plate readily reveals
+such disturbances so that there is no doubt left in the minds
+of the practitioner as to the exact nature of the trouble.
+Periostitis, exostosis, fractures, arthritis, bone abscesses,
+bone ulcers, etc., are thus easily distinguished.</p>
+
+<p><b>Periostitis.</b> Periostitis is an inflammation of the periosteum,
+the outer covering of the bone. There are two types,
+the acute and the chronic, both of which are not really
+diseases themselves, but are indications of the reaction of
+the periosteum to some irritant. In acute periostitis the
+X-ray plate shows a slight destruction of the outer portion
+of the bone, and a slight thickening of the periosteum, and
+if suppuration is present, the lesion is a mild osteomyelitis
+rather than a periostitis.</p>
+
+<p>Chronic periostitis causes an increase in the osteogenetic
+<span class="pagenum"><a id="Page_398"></a><a id="Page_399"></a>[Pg 399]</span>cells of the periosteum and is common in a great many
+lesions. Trauma, blows or contusions cause a chronic
+thickening of the bone covering with additional bone formation,
+as do syphilis and superficial abscesses in the soft
+tissues, in the immediate vicinity of long bones. Thus
+chronic ulcer of the leg over the shaft of the tibia will
+produce this condition. The picture shows that the even
+line of the bone surface is lost, and there is a rough, uneven
+edge, with or without an increase in the bone cells. The
+entire shaft of the bone is often thicker than normal, especially
+in the metatarsals, and it is quite common to find one
+of these bones greatly increased in size. The fourth metatarsal
+is the one most usually affected.</p>
+
+<p><b>Exostosis.</b> This lesion is common in the foot, and is a
+source of great pain and annoyance. It is usually the result
+of a chronic bursitis which has affected the periosteum over
+a localized area. Due to the destructive changes brought
+about by the inflammatory processes, the periosteum is
+absorbed and the bone cells beneath protrude in the form
+of a spur which shows on the plate. The most common site
+of exostosis of the foot is on the inferior surface of the
+os calcis, under the calcaneo bursa. The part is somewhat
+swollen and is extremely painful when pressure is brought
+to bear directly over the growth. The heads of the metatarsal
+bones on their lateral surfaces are occasionally
+affected, especially the outer side of the head of the first
+metatarsal. Lateral pressure gives rise to pain in this type
+of exostosis. The treatment for all exostoses is purely
+surgical.</p>
+
+<p><b>Fractures.</b> There are several kinds of fracture, and
+they are classified variously, but for the purposes of the
+podiatrist, the following types, with the description of each,
+will prove sufficient:</p>
+
+<p><b>Incomplete Fractures</b>, among which are the greenstick
+and the fissured fractures, are those in which there is not
+a complete separation of the fragments. The greenstick is
+really a bending rather than a breaking of the bone, and is
+<span class="pagenum" id="Page_400">[Pg 400]</span>found mostly in children under fifteen and then only rarely
+affects the bones of the leg. Fissured fractures are splits
+or cracks in the bone which do not separate it into two parts
+and occur occasionally in the fibula or in the metatarsals.
+They are easily seen in the radiograph by the dark shadow
+they produce in the region that would ordinarily appear
+light. This shadow extends over the entire length of the
+break.</p>
+
+<p><b>Complete Fractures</b> are the most common type found
+in the lower extremity and are divided according to the line
+and the seat of the breach of continuity. Thus we have
+transverse, longitudinal, oblique and spiral fractures. The
+radiograph will reveal the nature of the break, and a dark
+shadow will be cast between the fragments of bone. The
+most common of these found in the leg are the oblique and
+the spiral fractures.</p>
+
+<p><b>Comminuted Fractures</b> are those in which there is extensive
+splintering of the bone adjoining the fracture or one
+of the fragments. This class of fracture does not occur in
+the foot.</p>
+
+<p><b>Impacted Fractures</b> are those in which the fragments
+are driven into each other, forming a wedge, thus preventing
+abnormal motion, so common in other types. This occurs
+mostly in the neck of the femur.</p>
+
+<p><b>Crushing or Compression Fractures</b> are those in which
+the bones are crushed. The spongy portion and the cortical
+layer are both involved and in some cases the bones may be
+pulpified. The tarsal bones are subject to this type of
+fractures as the result of falls from heights, upon the soles
+of the feet. (See accompanying picture of fracture of the
+os calcis.)</p>
+
+<p><b>A simple fracture</b> is one in which a wound of the skin
+is absent, or if present, there is no connection between it
+and the broken bone.</p>
+
+<p>If the bone is broken in two or more places or if two or
+more non-adjacent bones are simultaneously broken, the
+condition is called a <b>multiple fracture</b>.</p>
+
+<p><span class="pagenum" id="Page_401">[Pg 401]</span></p>
+
+<figure class="figcenter illowe18" id="i_p401">
+  <img class="w100" src="images/i_p401.jpg" alt="">
+  <figcaption>
+    FRACTURE OF THE OS CALCIS
+  </figcaption>
+</figure>
+
+<p><span class="pagenum" id="Page_402">[Pg 402]</span></p>
+
+<p><b>A compound fracture</b> is one in which the fragments of
+bone pierce the soft tissues and protrude beyond the skin.</p>
+
+<p>It is essential in examining a patient who has suffered
+from a recent fracture, to obtain a history of the case as
+well as a description of the accident. An examination of
+the part should be made, and the various symptoms such
+as deformity, abnormal mobility and crepitus should be
+noted. The X-ray picture is then taken and if a fracture is
+found, the case should be put in the hands of a competent
+surgeon for immediate and proper treatment.</p>
+
+<p><b>Sesamoid Bones.</b> The sesamoid bones which are found
+in the flexor tendons under the head of the first metatarsal
+bones, are subjected to injury in those who follow vocations
+in which the ball of the foot is put to great strains. Among
+such may be mentioned dancers and acrobats. The normal
+position of these bones is directly beneath the head of the
+first metatarsal bone, and when this part is put to a great
+strain, the bones may become fractured, or they may become
+displaced. The outer sesamoid is usually forced outward
+and the X-ray picture shows it in the first interosseous
+space. The inner sesamoid is not affected, but may also be
+forced outward, and is then found under the outer side of
+the first metatarsal, in the normal position of the outer sesamoid
+bone.</p>
+
+<p>Fracture of these bones is not unusual and is a result
+of a severe injury. The line of division is shown by a dark
+shadow, much the same as in other fractures. One or both
+of the bones may be involved. It is essential to remember
+that if the bone is broken, the opposite sides will fit into
+each other perfectly, whereas, in cases of a freakish nature,
+in which there are four sesamoid bones, this will not be
+the case.</p>
+
+<p><b>Arthritis.</b> Arthritis, or inflammation of the joints, may
+involve any one or all of the structures which make up
+joints, viz., bone, cartilage, ligaments, synovial membrane
+and fibro-cartilage. The acute forms of inflammation are
+not detected by the radiogram, but the chronic type leaves
+<span class="pagenum"><a id="Page_403"></a><a id="Page_404"></a>[Pg 404]</span>its characteristic marks which, when present, are easily
+seen. The synovial covering of the ends of the bones is
+destroyed, and shows a rough, uneven surface. In cases of
+long standing, there is complete bony ankylosis, and the
+shadows of the joint line are completely obliterated. This
+is particularly true in the tarsal joints, in which the joint
+lines between the bones can hardly be seen. There is no
+motion in such joints, and in milder cases, in which no union
+has occurred, the sensation of crepitus is conveyed to the
+hand if the joints are moved passively. Tubercular arthritis
+shows a rarification of the bone with a thickening of
+the periosteum.</p>
+
+<p><b>Arteriosclerosis</b>, or hardening of the arteries, is often
+detected by means of the X-ray picture. Light shadows
+cast in the normal dark shade produced by the soft tissues,
+which appear over the course of the arteries, are indications
+of this condition.</p>
+
+<p>This disease of the arteries causes a change in the
+vessels whereby there are calcareous salts deposited in the
+middle coat. These salts, containing the metal calcium, are
+not readily penetrated by the ray, and thus a difference
+between the artery and other soft tissues is established.</p>
+
+<p>There are many other conditions in which the X-rays
+are a valuable aid in making diagnosis, but these are of no
+interest to the podiatrist, being within the exclusive
+province of the physician and surgeon. The reader is
+referred to books which deal with the subject of Roentgenology
+exclusively, for further information upon the subject.</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_405">[Pg 405]</span></p>
+
+<figure class="figcenter illowe24" id="i_p403">
+  <img class="w100" src="images/i_p403.jpg" alt="">
+  <figcaption>
+    HALLUX VALGUS
+  </figcaption>
+</figure>
+
+
+  <h2 class="nobreak" id="CHAPTER_XXVI">
+    <span class="chap">CHAPTER XXVI</span>
+    <br>
+    THE PODIATRIST’S OFFICE
+  </h2>
+</div>
+
+
+<p>The equipment of an office of a professional man or
+woman, whether it be the surgeon, the dentist, the podiatrist
+or any other of the practitioners of the allied branches
+of medicine, cannot be set to an absolute standard. There
+are several factors that govern variations, one from the
+other, among which are considerations of finance and the
+amount of available space. Regardless of these differences,
+however, certain fundamental principles must be observed
+in equipping such an office, and these depend upon two cardinal
+requirements: (1) cleanliness, and (2) the comfort of
+the patient. Such an office must be fitted out with the laws of
+asepsis and antisepsis ever in mind, otherwise it will prove
+unsafe for the treatment of patients whose feet require
+surgical attention. Again, the patient must feel at ease
+while being treated, or revisits will be scarce.</p>
+
+<p>There are other and secondary standards which should
+be considered among which is the appeal to the eye. First
+impressions often are lasting ones, and an office which
+makes a favorable impression will help attract patients.
+One often hears the thoughtless layman express himself,
+“Go to Dr. Blank for treatment, he has a beautiful office.”
+So it often occurs that a professional person is judged by
+the equipment in his office, and the effects of such an impression
+should be considered.</p>
+
+<p><b>The Waiting Room.</b> The waiting or reception room
+should be furnished with chairs upholstered in leather or
+made of solid wood. In waiting rooms in which many
+patients must wait at the same time, and space is valuable,
+smaller chairs with cane seats are very useful. The table
+<span class="pagenum" id="Page_406">[Pg 406]</span>should be of polished wood, covered with a plate glass top.
+The wood work of the room itself should be white, and the
+walls should be painted in preference to being papered.
+Buff is a pleasing color to the eye, and readily matches all
+kinds of furniture. The floor should be of hard wood, and
+may be covered by linoleum or rugs. Carpets should not
+be tolerated, as they are dirty; and even though frequently
+swept, they become the repositories of dust and of germs.</p>
+
+<p><b>The Operating Room.</b> The operating room must be
+scrupulously clean. As a white background best shows dirt
+spots, that should prevail in furniture and in decorations.
+A door, either of glass and wood or entirely of wood, should
+separate the reception room and the operating room; if
+hangings must be used, they should be of some washable,
+white material, that can be readily changed. The floor
+should be of tile, marble or stone; if these materials are not
+available, hard wood floors, well polished, are permissible.
+No covering of any kind should be used for the floor of this
+room. The ceilings and walls should be painted white, and
+the wood work should be enameled the same color. Tile or
+marble walls are preferable to plaster or wood. No curtains
+should be used on windows or doors, and if necessary the
+glass can be frosted to secure privacy. A wash basin, with
+running hot and cold water, should be in the operating room,
+and the valves should be controlled by foot levers in preference
+to hand faucets.</p>
+
+<p>To summarize, everything in the operating room should
+be of such a character as to make it possible to wash it
+daily with soap and water. Nooks and corners that tend to
+collect dust and dirt must be thoroughly cleaned, bearing in
+mind that disease-producing bacteria will not grow, unless
+a breeding place be provided for them. Wall pictures and
+their frames should be selected with a view to having them
+equally sanitary.</p>
+
+<p><b>The Equipment.</b> The equipment of a modern office is
+divided into three classes: (1) the furniture, which, when
+bought, is permanent; (2) the instruments; and (3) the
+<span class="pagenum" id="Page_407">[Pg 407]</span>supplies, which are replenished from time to time as they
+are exhausted.</p>
+
+<p>Furniture should consist of the following in the order
+of their importance:</p>
+
+<blockquote>
+<p>
+  Sterilizer<br>
+  Operating Chair and Stool<br>
+  Cabinet<br>
+  Glass-Top Table<br>
+  Drill<br>
+  High Frequency Machine<br>
+  Air Compressor<br>
+  Galvanic Machine<br>
+  Wall Cabinet and Extra Accessories.
+</p>
+</blockquote>
+
+<p>The authors are not interested in the wares of any
+manufacturer, and any equipment that is efficient and well
+made will answer the purposes of the podiatrist. There
+are many styles of chairs, cabinets, electric machines, etc.,
+on the market and the selection of such furniture and equipment
+rests with the finances and the taste of the individual.</p>
+
+<p>Chairs should be roomy and have a suitable rest for the
+patient’s back and head. The foot rest should be adjustable
+and so arranged that the patient’s foot is made comfortable,
+regardless of the position in which it is held.
+This part of the chair is very important, as upon it often
+depends the result of the podiatrist’s work. If the foot
+and leg are held so that the patient is uncomfortable or so
+that muscular cramps are the result, both patient and operator
+are at a disadvantage which it is difficult to overcome.</p>
+
+<p>There are two types of foot-rests on the market which
+have proven efficient. One gives support along the entire
+length of the leg and allows the foot to hang free at the end,
+and the other gives support at the foot proper and is so
+arranged that it gives this support no matter in what position
+the foot be held. The chair itself should be so constructed
+that no matter how the weight of the patient’s
+body may be distributed, the chair will remain firm, with
+<span class="pagenum" id="Page_408">[Pg 408]</span>no danger of spilling its occupant. It is on this account that
+a chair with a heavy metal base or with heavy spreading
+legs is best. When the chair is placed in a horizontal position
+so that the patient is prone, it should be as firm as
+with the patient in a sitting posture. The stool should
+match the chair and should be adjustable.</p>
+
+<p>The cabinet is the most important part of the podiatrist’s
+equipment from an aseptic standpoint, for therein
+are kept the instruments, dressings, drugs, etc. There are
+many styles and shapes from which to select, but only those
+that afford proper protection from dust and dirt should be
+considered. Drawers should be provided for bandages and
+dressings, and one drawer should be divided into compartments
+for the various sized shields. This adds to the neatness
+as well as to the efficiency of the cabinet. Special
+movable racks which fit into shallow drawers should be provided
+for the instruments, so that, if necessary, they may
+be collectively removed, thus avoiding the need for handling
+each instrument separately. Instrument compartments of
+this type should be so made that the blades of the various
+instruments are suspended in the air; moreover such racks
+and drawers are easily cleaned. Drugs should be kept in
+special compartments provided with glass doors, or, if the
+cabinet has no such provision, the bottles should fit in
+metallic clamps arranged in the rear of the top of the
+cabinet. Glass tops on the cabinets are best for they are
+easily cleaned, but white enameled metal tops are quite as
+good. The towels should be kept in a compartment of the
+sterilizer, otherwise in a special compartment in the cabinet,
+one having a glass door being preferred.</p>
+
+<p>Sterilizers may be heated by gas or electricity and
+when boiling water is not available, even formaldehyde gas
+is better than nothing for sterilizing purposes. The sterilizer,
+a necessity and not an ornament, should be cleaned
+and polished and the water should be changed daily.
+Unfortunately in the past, practitioners of podiatry did
+not use the sterilizer with regularity, and one could
+<span class="pagenum" id="Page_409">[Pg 409]</span>enter many of these offices and not even find such a contrivance.
+This state of affairs, however, is becoming a memory
+because the practitioner, as well as the public, has learned
+the importance of asepsis and antisepsis. The podiatrist
+who fails to observe the needs of this dispensation is unworthy
+of the title he bears.</p>
+
+<p>The sterilizer should be kept on a white enameled table
+with a detachable metal top, so that boiling water or hot
+instruments will cause no damage to it, as might occur on a
+glass-topped table. This table should have a glass shelf
+below, on which may be kept additional remedial agents
+for which there is no room in the cabinet.</p>
+
+<p>The surgical drill or rotary file is a valuable asset to
+the podiatrist in treating the nails, and should be a part
+of the equipment. There are several makes of rotary files,
+all with the same fundamental structure. The motors and
+cables are of one type, and are held either by a wall bracket
+or suspended upon a metal hook, resting on a metal pedestal.
+When the instrument is kept in only one operating room,
+the former type is sufficient, but when the drill is moved
+from one room to another, the latter style is necessary.</p>
+
+<p>Other accessories in the office, such as an air compressor,
+high frequency coil, galvanic machine, wall cabinet,
+etc., should be selected with care as to quality, and with
+judgment as to their harmonizing with the other equipment.
+If space allows, all of these accessories are desirable because
+useful, but when quarters are contracted, care must
+be taken in arranging the paraphernalia that the effect is
+not such as to give the patient the impression that he is
+in a podiatry supply shop.</p>
+
+<p>“Cleanliness is next to Godliness,” should be the
+slogan of every practitioner of medicine in any and in all
+of its collateral branches and the manner in which he conducts
+his office should be evidence that such is the belief
+and the practice of every podiatrist.</p>
+
+<p><span class="pagenum"><a id="Page_410"></a><a id="Page_411"></a>[Pg 411]</span></p>
+
+
+<div class="footnotes">
+<p id="FOOTNOTES">
+  FOOTNOTES:
+</p>
+
+<div class="footnote"><p><a id="Footnote_1_1" href="#FNanchor_1_1" class="label">[1]</a> The District of Columbia has now a similar law, passed since the above was
+written. Ernest Stanaback, former President of the N. A. C., and Harry P. Kenison, the
+present President of the N. A. C., were potent factors in procuring most of the legislation
+in the above states.</p></div>
+
+<div class="footnote"><p><a id="Footnote_2_2" href="#FNanchor_2_2" class="label">[2]</a> Podiatrists are advised to refrain from using cocaine on account of its dangers.</p></div>
+
+<div class="footnote"><p><a id="Footnote_3_3" href="#FNanchor_3_3" class="label">[3]</a> Hypodermic and hypodermatic are synonymous terms although medical lexicographers,
+as a rule, give preference to the latter.</p></div>
+
+<div class="footnote"><p><a id="Footnote_4_4" href="#FNanchor_4_4" class="label">[4]</a> <i>Apothesine</i> (Parke Davis &amp; Co.) is a new synthetic preparation of definite chemical
+composition. It is ¹⁄₈ as toxic as cocaine, is very soluble in water and alcohol, and may be
+sterilized by boiling for five or ten minutes. It is used in a one per cent. solution and
+came into favor during the war, by reason of the scarcity of cocaine and novocaine.
+Apothesine is not a habit-forming drug and is therefore easily obtainable. At The First
+Institute of Podiatry this preparation and novocaine are almost exclusively used for producing
+local anesthesias.</p></div>
+
+<div class="footnote"><p><a id="Footnote_5_5" href="#FNanchor_5_5" class="label">[5]</a> Apothesine, lately introduced, is proving efficacious and reliable (see page 148).</p></div>
+
+<div class="footnote"><p><a id="Footnote_6_6" href="#FNanchor_6_6" class="label">[6]</a> These experiments were carried on at The First Institute of Podiatry under the
+direction of Monroe Redell and W. H. A. Fletcher, clinicians, and on the suggestion of
+Dr. F. Oefele.</p></div>
+
+<div class="footnote"><p><a id="Footnote_7_7" href="#FNanchor_7_7" class="label">[7]</a> (Capt. V. N. Sorapure, R. A. M. C., who has lectured to the students of The First
+Institute of Podiatry, has contributed to the literature on this subject; see Journal of the
+A. M. A., July 6, 1918).</p></div>
+</div>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+  <h2 class="nobreak" id="GLOSSARY">
+    GLOSSARY
+  </h2>
+</div>
+
+
+<p class="center bolden" id="A">
+  A
+</p>
+
+<p><b>a-, an.</b> A prefix conveying a negative
+meaning—without, not, away from.</p>
+
+<p><b>aa.</b> A sign used in prescription writing
+to indicate equal parts of each ingredient
+so designated.</p>
+
+<p><b>ab.</b> A prefix signifying from, away
+from, off.</p>
+
+<p><b>abdominal.</b> Relating to the abdomen or
+belly.</p>
+
+<p><b>abduction.</b> Rotation of the foot outward.</p>
+
+<p><b>abnormal.</b> Not normal, contrary to the
+rule or type; irregular.</p>
+
+<p><b>aboriginal.</b> Primitive, existing from the
+beginning.</p>
+
+<p><b>abrasion.</b> A circumscribed removal of
+the epidermis of skin or mucous membrane.</p>
+
+<p><b>abscess.</b> A circumscribed cavity in the
+tissues containing pus.</p>
+
+<p><b>absorption.</b> The taking into the tissues,
+through the medium of the lymphatics
+or blood vessels, of any material in
+suitable form.</p>
+
+<p><b>acetanilid.</b> An analgesic made from aniline
+by treating it with acetyl chloride.</p>
+
+<p><b>acetic.</b> Relating to vinegar; acid.</p>
+
+<p><b>acid.</b> A chemical compound containing
+replacible hydrogen, having a sour
+taste, and neutralizing a base to form
+a salt and water.</p>
+
+<p><b>acidum.</b> Acid.</p>
+
+<blockquote>
+<p><b>a.</b> Aceticum, acetic acid; useful as a
+counter-irritant.</p>
+
+<p><b>a.</b> aceticum glaciale, glacial acetic
+acid; employed externally as a
+caustic.</p>
+
+<p><b>a.</b> boricum, boric acid; dusting powder,
+antiseptic.</p>
+
+<p><b>a.</b> carbolicum, carbolic acid, phenol;
+antiseptic.</p>
+
+<p><b>a.</b> chromicum, chromic acid; caustic.</p>
+
+<p><b>a.</b> dichloraceticum, dichloracetic acid;
+caustic.</p>
+
+<p><b>a.</b> hydrochloricum, hydrochloric acid;
+escharotic.</p>
+
+<p><b>a.</b> iodicum, a white crystalline powder;
+antiseptic and deodorant.</p>
+
+<p><b>a.</b> monochloraceticum, a white deliquescent
+powder; caustic.</p>
+
+<p><b>a.</b> nitricum, nitric acid; caustic.</p>
+
+<p><b>a.</b> nitricum fumans, fuming nitric
+acid; caustic.</p>
+
+<p><b>a.</b> nitrohydrochloricum; a fusing corrosive
+liquid; caustic.</p>
+
+<p><b>a.</b> salicylicum, salicylic acid; disintegrant.</p>
+
+<p><b>a.</b> sulphocarbolicum, sozolic acid;
+antiseptic and disinfectant.</p>
+
+<p><b>a.</b> sulphuricum, sulphuric acid, oil of
+vitriol; caustic.</p>
+
+<p><b>a.</b> tannicicum, tannic acid, astringent.</p>
+
+<p><b>a.</b> trichloraceticum, trichloracetic acid;
+caustic.</p>
+</blockquote>
+
+<p><b>acquired.</b> Noting a disease which is not
+congenital but has taken possession of
+one at some period after birth.</p>
+
+<p><b>actinic.</b> Relating to chemically active
+rays.</p>
+
+<p><b>actinotherapy.</b> The treatment of disease
+by radiant energy.</p>
+
+<p><b>acute.</b> Of short and sharp duration, not
+chronic; said of a disease.</p>
+
+<p><b>adduction.</b> Rotation of the foot inward.</p>
+
+<p><b>adhesive.</b> Sticky; causing adhesion.</p>
+
+<p><b>adipose.</b> Fatty; relating to fat.</p>
+
+<p><b>adjacent.</b> Next to; along side of.</p>
+
+<p><b>adjuvants.</b> Agents added to a prescription
+to assist or increase the action of
+the main ingredient.</p>
+
+<p><b>adolescents.</b> Youths, those between the
+ages of puberty and the attainment of
+full growth.</p>
+
+<p><b>adrenalin.</b> A principle obtained from the
+suprarenal glands having marked
+astringent and hemostatic powers.</p>
+
+<p><b>agar.</b> A gelatinous substance prepared
+from seaweed, and used as a base for
+culture media.</p>
+
+<p><b>agent.</b> Anything which produces an
+effect upon the organism.</p>
+
+<p><b>agnail.</b> Hangnail, whitlow.</p>
+
+<p><b>albumin.</b> A protein contained in the
+tissues of plants and animals.</p>
+
+<p><b>albuminous.</b> Containing or consisting of
+albumin.</p>
+
+<p><b>albuminuria.</b> The presence of albumin
+in the urine as voided.</p>
+
+<p><b>alcohol.</b> One of a series of organic compounds,
+especially one whose formula
+is C<sub>2</sub>H<sub>5</sub>OH, and called ethyl alcohol.</p>
+
+<p><b>algia.</b> A suffix indicating pain. (Exam.
+metatarsalgia—pain in the metatarsals).</p>
+
+<p><b>alignment.</b> Alinement; the act of bringing
+into line.</p>
+
+<p><b>alkaline.</b> Relating to an alkali; having
+the reaction of an alkali.</p>
+
+<p><b>alkaloid.</b> A basic substance found in
+plants, usually constituting the active
+principle of the crude drug.</p>
+
+<p><b>alum.</b> A double sulphate of aluminum;
+burnt a. alumen exsiccatum.</p>
+
+<p><b>aluminum chloride.</b> A substance used as
+an astringent in hyperidrosis and bromidrosis.</p>
+
+<p><b>alypin.</b> A crystalline powder used as a
+local anesthetic.</p>
+
+<p><b>ammoniated mercury.</b> See unguentum,
+hydrarg, amm.</p>
+
+<p><b>ampere.</b> The unit of strength of an
+electric current.</p>
+
+<p><b>amyotrophic lateral sclerosis.</b> A form of
+progressive muscular atrophy with increased
+reflexes due to hardening of
+the lateral columns of the spinal cord.</p>
+
+<p><b>anærobe.</b> A microorganism which
+thrives best or only when deprived of
+oxygen.</p>
+
+<p><b>analgesic.</b> An agent which causes analgesia
+or freedom from pain.</p>
+
+<p><b>anastomose.</b> To open one into the other
+directly or by connecting channels;
+said of blood vessels and nerves.</p>
+
+<p><b>anatomy.</b> The science devoted to the
+study of the structure of organized
+bodies, more especially the human
+body.</p>
+
+<p><span class="pagenum" id="Page_412">[Pg 412]</span></p>
+
+<p><b>anemia.</b> A condition in which the blood
+is reduced in amount, or is deficient in
+red blood cells or in hemoglobin.</p>
+
+<p><b>anesthesia.</b> Loss of sensation, especially
+of tactile sensibility.</p>
+
+<p><b>anesthetic.</b> 1. Insensible to touch or to
+pain or to other stimuli. 2. A drug
+which produces local or general anesthesia.</p>
+
+<p><b>anesthetize.</b> To induce anesthesia; to
+render anesthetic.</p>
+
+<p><b>aneurism.</b> A blood-containing tumor
+connecting directly with the lumen of
+an artery.</p>
+
+<p><b>angioma.</b> A swelling or tumor due to
+dilatation of a blood vessel.</p>
+
+<p><b>ankylosis.</b> Stiffening or fixation of a
+joint.</p>
+
+<p><b>anterior.</b> In front of, or, in the front
+part of.</p>
+
+<p><b>anterior poliomyelitis.</b> Inflammation of
+the anterior horns of the spine; infantile
+spinal paralysis.</p>
+
+<p><b>antheloticum or remedium heloticum.</b>
+Remedy for helomata.</p>
+
+<p><b>anti.</b> A prefix signifying against, opposing.
+(Exam. antifebrile—against
+fever).</p>
+
+<p><b>anticathode.</b> The platinum or other
+plate in a Crookes tube on which the
+cathode rays impinge, giving origin to
+the X-rays.</p>
+
+<p><b>antiphlogistic.</b> An agent which subdues
+or allays inflammation.</p>
+
+<p><b>antisepsis.</b> The destruction of germs
+causing disease, fermentation or putrefaction.</p>
+
+<p><b>antiseptic.</b> 1. Destructive to the germs
+of disease, fermentation or putrefaction.
+2. A substance which prevents
+the action of the germs of fermentation,
+decomposition, or disease.</p>
+
+<p><b>aperture.</b> An opening, orifice.</p>
+
+<p><b>apex.</b> The summit or tip.</p>
+
+<p><b>apodal.</b> Without feet.</p>
+
+<p><b>apodia.</b> Congenital absence of feet.</p>
+
+<p><b>apoplectic.</b> Relating to, predisposed to
+or suffering from apoplexy.</p>
+
+<p><b>apoplexy.</b> A sudden loss of consciousness
+followed by paralysis, due to cerebral
+hemorrhage or blocking of an
+artery of the brain.</p>
+
+<p><b>apothesine.</b> A synthetic product used to
+produce local anesthesia, which came
+into popular favor at a time when the
+usually employed local anesthetics were
+unobtainable because of war conditions.</p>
+
+<p><b>apparatus.</b> A collection of instruments
+adapted for a special purpose.</p>
+
+<p><b>appendage.</b> Any part, subordinate in
+size, attached to a main structure.</p>
+
+<p><b>appendicitis.</b> Inflammation of the vermiform
+appendix.</p>
+
+<p><b>applicator.</b> A slender rod of wood or
+metal by means of which with cotton,
+local applications may be made to a
+part.</p>
+
+<p><b>apus.</b> A monster without feet.</p>
+
+<p><b>aqua.</b> Water.</p>
+
+<p><b>aqua cinnamomi.</b> Cinnamon water.</p>
+
+<p><b>aqua fortis.</b> Nitric acid; see acidum
+nitricum.</p>
+
+<p><b>aqueous.</b> Watery.</p>
+
+<p><b>arch.</b> In anatomy, any vaulted or arch-like
+structure.</p>
+
+<p><b>argentum.</b> The metal, silver.</p>
+
+<p><b>aristol.</b> Trade name of thymol iodide,
+a local antiseptic.</p>
+
+<p><b>armamentarium.</b> In podiatry, all the
+means (drugs, instruments, etc.) at
+the disposal of the podiatrist to fit him
+for the practice of his profession.</p>
+
+<p><b>arsenic.</b> A steel-gray metal, one of the
+elements; arsenic trioxide, white arsenic.</p>
+
+<p><b>arteria.</b> Artery: a blood vessel conveying
+blood away from the heart.</p>
+
+<p><b>arteries of the foot</b>:</p>
+
+<blockquote>
+<p><b>a.</b> communicans; communicating
+branch of dorsalis pedis (to plantar
+surface to join plantar arch).</p>
+
+<p><b>a.</b> digitales dorsales; digital branches
+of dorsalis pedis (dorsal surface of
+the toes).</p>
+
+<p><b>a.</b> dorsalis pedis; dorsalis pedis artery
+(dorsum of foot).</p>
+
+<p><b>a.</b> metatarsae dorsales; metatarsal
+branch of dorsalis pedis (dorsum of
+foot to metatarsus).</p>
+
+<p><b>a.</b> plantaris lateralis; external plantar
+artery (plantar surface, joining
+communicating branch of dorsalis
+pedis, completing the plantar arch).</p>
+
+<p><b>a.</b> plantaris medialis; internal plantar
+artery (plantar surface of foot).</p>
+
+<p><b>a.</b> tarsae lateralis; tarsal branch of
+dorsalis pedis (dorsum of foot to
+the tarsus).</p>
+</blockquote>
+
+<p><b>arteriosclerosis.</b> Hardening of the arteries.</p>
+
+<p><b>areolar.</b> A tissue made up of loose connective
+tissue, with many interspaces
+and found under the skin.</p>
+
+<p><b>arsenical.</b> Relating to or containing any
+of the salts of arsenic.</p>
+
+<p><b>arthritis.</b> Inflammation of the joints.</p>
+
+<p><b>articulation.</b> A joining or connecting
+together loosely so as to allow of
+motion between the parts.</p>
+
+<p><b>articular.</b> Relating to a joint.</p>
+
+<p><b>ascites.</b> An accumulation of serous fluid
+in the peritoneal cavity.</p>
+
+<p><b>asepsis.</b> A condition in which living
+bacteria are absent.</p>
+
+<p><b>astasia-abasia.</b> Inability through muscular
+incoordination, to walk or stand,
+although the muscles functionate normally
+when the patient is lying down.</p>
+
+<p><b>astragalus.</b> The ankle bone.</p>
+
+<p><b>astringent.</b> An agent which causes contraction
+of the tissues or arrest of the
+secretions.</p>
+
+<p><b>ataxia.</b> A loss of the power of muscular
+coordination.</p>
+
+<p><b>ataxic.</b> Relating to ataxia.</p>
+
+<p><b>atony.</b> Lack of tone or tension.</p>
+
+<p><b>atrophy.</b> A wasting of the tissues of a
+part or of the entire body.</p>
+
+<p><b>atypical.</b> Not typical.</p>
+
+<p><b>auto.</b> A prefix denoting self. (Exam.
+autogenesis—self-production).</p>
+
+<p><b>auto-serotherapic.</b> Relating to the treatment
+of certain conditions by the injection
+of the patient’s own blood serum.</p>
+
+<p><b>axilla.</b> The armpit (pl. axillae).</p>
+
+<p><b>axis.</b> A straight line passing through a
+spherical body between its two poles
+and about which the body may revolve.</p>
+
+
+<p class="center bolden" id="B">
+  B
+</p>
+
+<p><b>bacillus.</b> A bacterium; more especially,
+a rod-shaped or elongated variety.</p>
+
+<p><b>bacillus aërogenes capsulatus.</b> The
+specific organism causing gas infection
+and gas gangrene. <b>b. of Welch</b>, the
+same; <b>b. perfringens</b>, the same.</p>
+
+<p><span class="pagenum" id="Page_413">[Pg 413]</span></p>
+
+<p><b>bacteria.</b> Unicellular vegetable microorganisms,
+usually those which produce
+disease.</p>
+
+<p><b>bactericidal.</b> Causing the death of bacteria.</p>
+
+<p><b>bacterium fetidum.</b> A microorganism
+producing a stench. <b>b. prodigiosus.</b>
+A microorganism found on food, but
+not pathogenic.</p>
+
+<p><b>bandage.</b> A piece of cloth or other
+material applied to any part of the
+body, to make compression, prevent
+motion and to retain surgical dressings.</p>
+
+<p><b>base.</b> The lower part or bottom. In
+pharmacy, the chief ingredient of a
+compound. In chemistry, a compound
+which neutralizes an acid to form a
+salt.</p>
+
+<p><b>belladonna.</b> Deadly nightshade. A perennial
+herb, the leaves and roots of
+which are used in medicine.</p>
+
+<p><b>beneficent.</b> The disposition to do good;
+of help to.</p>
+
+<p><b>benign.</b> Mild in character, said of an
+illness; not malignant.</p>
+
+<p><b>benzine.</b> A purified distillate of American
+petroleum.</p>
+
+<p><b>beriberi.</b> Endemic neuritis; a specific
+polyneuritis occurring in eastern and
+southern Asia. It prevails especially
+in armies, prisons, ships, etc., wherever
+large numbers of men are kept
+together.</p>
+
+<p><b>bi.</b> A prefix denoting two, twice, or
+double. (Exam. bicuspid—having two
+prongs).</p>
+
+<p><b>bichloride of mercury.</b> A chemical compound,
+HgCl<sub>2</sub>, called corrosive sublimate
+and mercuric chloride. It is
+used as an antiseptic.</p>
+
+<p><b>bifid.</b> Split or cleft bilateral. Having
+two sides, biped. Two-footed.</p>
+
+<p><b>bismuth subgallate.</b> A yellowish dusting
+powder; trade name, dermatol.</p>
+
+<p><b>bismuth subnitrate.</b> A white dusting
+powder with astringent properties.</p>
+
+<p><b>bistoury.</b> A long, narrow-bladed knife,
+straight or curved on the edge, sharp
+or blunt pointed; employed for opening
+abscesses, slitting up sinuses, etc.</p>
+
+<p><b>bleb.</b> A circumscribed area of separation
+of the epidermis due to the
+presence of a clear non-purulent fluid.</p>
+
+<p><b>blister.</b> A bleb.</p>
+
+<p><b>blood.</b> Sanguis, cruor; the red fluid circulating
+in the arteries, capillaries and
+veins. <b>b. plasma</b>, the fluid portion of
+the blood as it is contained in the
+vessels. <b>b. serum</b>, the fluid which is
+squeezed out by shrinkage of a blood clot.</p>
+
+<p><b>bones.</b> The hard substances that make
+up the framework of the body.</p>
+
+<p><b>bones of the foot</b>:</p>
+
+<blockquote>
+<p><b>astragalus.</b> Ankle bone.</p>
+
+<p><b>cuboid.</b> In front of the os calcis.</p>
+
+<p><b>internal, middle and external cuneiforms.</b>
+In front of the scaphoid.</p>
+
+<p><b>metatarsals.</b> Five; in front of the
+tarsal bones.</p>
+
+<p><b>os calcis.</b> Heel bone.</p>
+
+<p><b>phalanges.</b> Fourteen; in front of the
+metatarsals, two in the great toe and
+three in each of the four lesser toes.</p>
+
+<p><b>scaphoid.</b> In front of the astragalus.</p>
+</blockquote>
+
+<p><b>boric acid.</b> A powder, soluble in water
+used as an antiseptic dusting powder.</p>
+
+<p><b>bromidrosis.</b> Foul-smelling perspiration.</p>
+
+<p><b>buckskin.</b> A leather made from the skin
+of the buck.</p>
+
+<p><b>buffing.</b> Polishing by means of some soft
+material, attached to a rapidly revolving
+motor.</p>
+
+<p><b>bulb.</b> Any globular or fusiform structure.</p>
+
+<p><b>bulbar palsy.</b> Paralysis of the tongue
+and larynx.</p>
+
+<p><b>bulla.</b> A bleb.</p>
+
+<p><b>bullous.</b> Relating to or of the nature
+of bullae.</p>
+
+<p><b>bunion.</b> An inflammatory swelling of
+the bursa over the metatarsophalangeal
+joint of the great toe.</p>
+
+<p><b>bur.</b> A small disc or bulb, made to revolve
+rapidly and used by podiatrists in
+connection with their employment of
+the rotary drill, or file.</p>
+
+<p><b>Burow’s solution.</b> A solution of alum
+and lead acetate.</p>
+
+<p><b>bursa</b> (plural, bursae). A closed sac
+or pouch containing synovial fluid,
+found over joints and where tendons
+play over bones.</p>
+
+<p><b>bursitis.</b> Inflammation of a bursa.</p>
+
+
+<p class="center bolden" id="C">
+  C
+</p>
+
+<p><b>caisson disease.</b> The bends, divers’
+paralysis, tunnel disease; a symptom-complex,
+occurring in tunnel workers
+and others working in places under
+high air pressure when they return
+too suddenly to the normal atmosphere.</p>
+
+<p><b>calamine.</b> Zinc carbonate; a pink powder
+used as an astringent.</p>
+
+<p><b>calcaneoastragaloid.</b> Relating to the
+os calcis and the astragalus.</p>
+
+<p><b>calcareous.</b> Chalky.</p>
+
+<p><b>calcified.</b> Hardened by the deposition of
+lime salts in a part.</p>
+
+<p><b>calcium.</b> A metallic element having a
+yellow color.</p>
+
+<p><b>calibre.</b> The diameter of a canal or
+vessel.</p>
+
+<p><b>callositas.</b> Callous, tyloma, a circumscribed
+thickening of the epidermic
+layers of the skin.</p>
+
+<p><b>callous.</b> Callositas.</p>
+
+<p><b>callus.</b> Callosity. The bone-like substance
+thrown out between and around
+the ends of a fractured bone.</p>
+
+<p><b>calomel.</b> Hydrargyrum chloride mite.</p>
+
+<p><b>calor.</b> Heat.</p>
+
+<p><b>camphorated soap liniment.</b> Soap liniment,
+camphorated tincture of soap.</p>
+
+<p><b>capillary.</b> One of the microscopic blood
+vessels forming the capillary system,
+intermediate between the arteries and
+the veins.</p>
+
+<p><b>capsicum.</b> The dried fruit of Cayenne,
+African or red pepper.</p>
+
+<p><b>capsule.</b> A membranous structure enveloping
+an organ or any other part.</p>
+
+<p><b>carbolic acid.</b> Phenol.</p>
+
+<p><b>carbon.</b> An element, occurring in the
+form of the diamond, graphite and coal.</p>
+
+<p><b>carbon dioxide pencil.</b> A mass of solidified
+carbon dioxide used for the
+destruction of verruca, etc.</p>
+
+<p><b>carborundum.</b> A very hard substance
+(carbide of silicon) used to sharpen instruments.</p>
+
+<p><b>caries.</b> Molecular decay of a bone.</p>
+
+<p><b>carpal.</b> Relating to the wrist.</p>
+
+<p><b>carpus.</b> The wrist.</p>
+
+<p><b>cartilage.</b> A connective tissue substance.</p>
+
+<p><span class="pagenum" id="Page_414">[Pg 414]</span></p>
+
+<p><b>cashmere.</b> A woolen fabric made from
+goat hair.</p>
+
+<p><b>cast.</b> An object formed by the solidification
+of a liquid poured into a mold.</p>
+
+<p><b>castor oil.</b> Oleum ricini; a fixed oil from
+the seeds of Ricinus communis.</p>
+
+<p><b>catalepsy.</b> A morbid state in which
+there is rigidity of the limbs.</p>
+
+<p><b>cataplasma.</b> A poultice, a soft magma
+or mush, prepared by wetting or
+heating various powders or other
+absorbent substances.</p>
+
+<p><b>catatonia.</b> Stupor.</p>
+
+<p><b>cathode.</b> The negative pole of an electric
+current.</p>
+
+<p><b>caustic.</b> Corrosive.</p>
+
+<p><b>cautery.</b> An agent used for scarring or
+burning the skin or tissues by means
+of heat or of caustic chemicals.</p>
+
+<p><b>c.c.</b> Abbreviation for cubic centimeter.</p>
+
+<p><b>cell.</b> A minute structure, the living
+active basis of all plant and animal
+organization, composed of a mass of
+protoplasm and containing a nucleus.</p>
+
+<p><b>cellulitis.</b> Inflammation of the cellular
+or connective tissue.</p>
+
+<p><b>centigrade scale.</b> A thermometer scale,
+in which there are 100 degrees between
+the freezing point and the boiling point
+of water.</p>
+
+<p><b>centimeter.</b> The hundredth part of a
+meter or .3937 (²⁄₅) of an inch.</p>
+
+<p><b>cerate</b> (Lat. ceratum). An unctuous
+solid preparation, containing sufficient
+wax to prevent it from liquefying
+when applied to the skin.</p>
+
+<p><b>cerebellar.</b> Relating to the cerebellum
+or hind-brain.</p>
+
+<p><b>cerebral.</b> Referring to the brain.</p>
+
+<p><b>cerebral cortex.</b> The external layer of
+gray matter covering the hemispheres
+of the brain.</p>
+
+<p><b>cerebral hemisphere.</b> The large mass of
+brain substance on either side of the
+great longitudinal fissure.</p>
+
+<p><b>cerebrospinal.</b> Relating to the brain and
+the spinal cord.</p>
+
+<p><b>cerebrospinal meningitis.</b> An acute infectious
+inflammation of the brain and
+spinal cord caused by the meningococcus.</p>
+
+<p><b>chamois.</b> The skin of the goat family,
+prepared for purposes of utility.</p>
+
+<p><b>chancre.</b> The initial sore of syphilis.</p>
+
+<p><b>characteristics.</b> The traits which mark
+a substance or condition, and differentiate
+it from others.</p>
+
+<p><b>Charcot’s disease.</b> Amyotrophic lateral
+sclerosis.</p>
+
+<p><b>chauffeur’s foot.</b> A painful condition of
+the anterior part of the foot.</p>
+
+<p><b>chilblain.</b> An inflammation of the skin
+due to exposure to cold and dampness.</p>
+
+<p><b>chimatlon.</b> Chilblains, an inflammation
+of the skin due to exposure to cold
+and dampness.</p>
+
+<p><b>chiropodical.</b> Relating to chiropody
+(podiatry).</p>
+
+<p><b>chiropodist.</b> One who treats the minor
+lesions of the foot. Originally probably,
+chirurg-podist, a surgeon of the
+foot.</p>
+
+<p><b>chiropody.</b> The study of the minor
+lesions of the foot. Podiatry.</p>
+
+<p><b>chisel.</b> The podiatrist’s instrument; helotomon.</p>
+
+<p><b>chlorine.</b> An element in nature; an irritating,
+greenish, gaseous element used
+for disinfectant and bleaching purposes.</p>
+
+<p><b>cholesterin.</b> A monatomic alcohol.</p>
+
+<p><b>chorea.</b> A disorder of childhood characterized
+by spasmodic, involuntary
+movements of the limbs and facial
+muscles; St. Vitus’ dance.</p>
+
+<p><b>chromidrosis.</b> A disease of the sweat
+glands in which the perspiration is
+colored.</p>
+
+<p><b>chromium.</b> A very hard steel-gray
+element.</p>
+
+<p><b>chronic.</b> Of long duration; noting a
+disease of slow progress and long continuance.</p>
+
+<p><b>cicatricial.</b> Referring to scars or scar
+tissue.</p>
+
+<p><b>cicatrix.</b> A scar.</p>
+
+<p><b>circinate.</b> Circular, ring-shaped.</p>
+
+<p><b>circum.</b> A prefix denoting a circular
+movement. (Exam. circumcision—to
+cut around).</p>
+
+<p><b>circumduction.</b> Movement of a part in
+a circular direction.</p>
+
+<p><b>circumscribed.</b> A definitely limited area.</p>
+
+<p><b>claudication.</b> Limping.</p>
+
+<p><b>claw-foot.</b> Muscular atrophy with caval
+contraction of the foot.</p>
+
+<p><b>clavus.</b> Heloma, corn.</p>
+
+<p><b>clinic.</b> An institution in which medical
+attention is given to patients who live
+elsewhere and do not require hospital
+care.</p>
+
+<p><b>clonic.</b> Marked by alternate contraction
+and relaxation of muscle.</p>
+
+<p><b>clot.</b> Coagulated blood.</p>
+
+<p><b>club-foot.</b> Talipes.</p>
+
+<p><b>coagulation.</b> Clotting, the process of
+changing from a liquid state to that
+of a soft, jelly-like solid.</p>
+
+<p><b>coalesce.</b> To grow together, to become
+one.</p>
+
+<p><b>coaptation.</b> The joining together of two
+surfaces, as in sewing up a wound or
+setting a fracture.</p>
+
+<p><b>cocaine.</b> An alkaloid derived from coca
+and used for producing local anesthesia.</p>
+
+<p><b>cocoon dressing.</b> A dressing made of
+absorbent cotton covered with collodion.</p>
+
+<p><b>cohesion.</b> The power of attraction between
+the molecules of any substance,
+keeping the mass from falling apart.</p>
+
+<p><b>collateral.</b> Secondary or subordinate.</p>
+
+<p><b>collodial.</b> Glue-like. A substance which
+remains permanently suspended in a
+liquid, but does not dissolve.</p>
+
+<p><b>collodion</b> (Collodium). A solution of
+guncotton in ether and alcohol.</p>
+
+<p><b>coma.</b> A state of profound unconsciousness
+from which one cannot be roused.</p>
+
+<p><b>comatose.</b> A state of coma.</p>
+
+<p><b>comminuted.</b> Broken into a number of
+fragments, as in a multiple fractured
+bone.</p>
+
+<p><b>compound.</b> Not simple but made up of
+two or more parts. In chemistry, a
+substance formed by the chemical
+union of two or more elements.</p>
+
+<p><b>compress.</b> A pad of gauze or other
+material placed over a part to make
+compression.</p>
+
+<p><b>concave.</b> A surface which is evenly
+curved inward.</p>
+
+<p><b>concentrated.</b> Referring to a solution
+which has been made strong by evaporation
+or other means.</p>
+
+<p><b>concentric.</b> Having a common centre.</p>
+
+<p><b>concomitant.</b> Accompanying; occurring
+at the same time.</p>
+
+<p><b>concrete.</b> Hardened; solidified into a
+mass.</p>
+
+<p><span class="pagenum" id="Page_415">[Pg 415]</span></p>
+
+<p><b>condyle.</b> A rounded articular surface at
+the extremity of a long bone.</p>
+
+<p><b>configuration.</b> External form.</p>
+
+<p><b>congelation.</b> Freezing.</p>
+
+<p><b>congenital.</b> Existing at birth.</p>
+
+<p><b>congestion.</b> The presence of an abnormal
+amount of blood in the vessels of
+a part.</p>
+
+<p><b>connective.</b> Binding, joining.</p>
+
+<blockquote>
+<p><b>c. tissue.</b> The general supporting or
+uniting tissue of the body.</p>
+</blockquote>
+
+<p><b>constitutional.</b> Relating to the system
+as a whole; not local.</p>
+
+<p><b>contact.</b> The touching or apposition of
+two bodies.</p>
+
+<p><b>contagion.</b> Transmission of an infectious
+disease.</p>
+
+<p><b>contamination.</b> Pollution, soiling with
+infectious matter.</p>
+
+<p><b>continuity.</b> Without a break; absence of
+interruption.</p>
+
+<p><b>contour.</b> The outline of a part, the
+surface configuration.</p>
+
+<p><b>contra.</b> A prefix signifying against or
+opposite. (Exam. contra-lateral—relating
+to the other side).</p>
+
+<p><b>contra-indicated.</b> Not indicated, as in the
+purposed use of a remedy or in the
+consideration of a surgical procedure.</p>
+
+<p><b>contract.</b> To shorten.</p>
+
+<p><b>contracture.</b> A permanent muscular contraction,
+due to tonic spasm or to loss
+of muscular equilibrium, the antagonists
+being paralyzed.</p>
+
+<p><b>contused.</b> Bruised.</p>
+
+<p><b>convex.</b> A surface which is evenly
+curved outward.</p>
+
+<p><b>coordination.</b> The harmonious working
+together of several muscles or groups
+of muscles.</p>
+
+<p><b>core.</b> The central mass of necrotic tissue
+in a boil.</p>
+
+<p><b>corium.</b> Cutis vera, true skin; the
+deeper or connective tissue layers of
+the skin.</p>
+
+<p><b>corn.</b> Heloma, an overgrowth of the
+epidermic layers of the skin, containing
+a radix, or nucleus.</p>
+
+<p><b>cornification.</b> Conversion into a horny
+substance.</p>
+
+<p><b>corpuscle.</b> A primary atom.</p>
+
+<p><b>corrode.</b> To wear away gradually.</p>
+
+<p><b>corrosive sublimate.</b> Bichloride of mercury.</p>
+
+<p><b>cortex.</b> The outer portion of an organ.</p>
+
+<p><b>cosmetic.</b> Relating to the care of a person
+with a view to improving the
+appearance.</p>
+
+<p><b>cotton.</b> The white fluffy fibrous covering
+of the seeds of the plant, genus gossypium,
+used in surgical dressings.</p>
+
+<p><b>counterextension.</b> The resistance, or
+back-pull, made to extension on a
+limb.</p>
+
+<p><b>counter-irritant.</b> An agent which causes
+counter-irritation.</p>
+
+<p><b>counter-irritation.</b> Inflammation or irritation
+of the skin excited for the purpose
+of relieving an inflammation of
+the deeper structures.</p>
+
+<p><b>coup de fouet.</b> Rupture of the plantaris
+muscle; lawn tennis leg.</p>
+
+<p><b>c. p.</b> Abbreviation for chemically pure.</p>
+
+<p><b>cramp.</b> A painful tonic muscular contraction;
+spasm.</p>
+
+<p><b>creosote.</b> A substance obtained from
+beechwood tar.</p>
+
+<p><b>crepitus.</b> The sensation (a crackling)
+felt when the hands are placed over
+the seat of a fracture, and the broken
+ends of the bones are moved against
+each other.</p>
+
+<p><b>cretinism.</b> A disease occurring in the
+first three years of life, and resulting
+in the arrest of bodily growth and
+of mental development.</p>
+
+<p><b>crinoline.</b> A stiff material with a coarser
+mesh, and heavier than gauze or
+cheesecloth.</p>
+
+<p><b>criss-cross.</b> Referring to plaster applied
+to a part, each strip when applied being
+at an angle to the strip previously applied.</p>
+
+<p><b>Crookes tube.</b> See Chapter, “X-rays in
+Podiatry.”</p>
+
+<p><b>croupous.</b> Marked by a fibrinous exudation.</p>
+
+<p><b>crural.</b> Relating to the leg or thigh.</p>
+
+<p><b>crystalline.</b> Clear, transparent.</p>
+
+<p><b>cuboid.</b> A bone of the tarsus.</p>
+
+<p><b>cuneiform.</b> Three bones of the tarsus.</p>
+
+<p><b>curettage.</b> Scraping the interior of a
+cavity for the removal of the abnormal
+tissues, with the curette.</p>
+
+<p><b>cutaneous.</b> Relating to the skin.</p>
+
+<p><b>cuticle.</b> Epidermis or outer horny layer
+of the skin.</p>
+
+<p><b>cutis.</b> The skin.</p>
+
+<p><b>cylinder.</b> A geometric figure formed by
+the revolution of a rectangle around
+one of its sides.</p>
+
+<p><b>cylindrical.</b> Relating to or the shape of
+a cylinder.</p>
+
+<p><b>cyst.</b> An abnormal sac containing gas,
+fluid or a semi-solid material.</p>
+
+<p><b>cytoplasm.</b> Protoplasm, the substance
+of the cell, exclusive of the nucleus.
+It is composed of spongioplasm and
+hyaloplasm.</p>
+
+
+<p class="center bolden" id="D">
+  D
+</p>
+
+<p><b>D.</b> Abbreviation in prescription writing
+for da, give, detur, let there be given.</p>
+
+<p><b>dactyl.</b> A finger or toe.</p>
+
+<p><b>Dakin Solution.</b> A solution compounded
+by Dr. Dakin for the treatment of
+wounds by means of chlorine gas in
+solution, applied directly to the parts
+affected or injured.</p>
+
+<p><b>dancer’s foot.</b> A painful condition of the
+great toe joint.</p>
+
+<p><b>decay.</b> Slow destruction of an organic
+substance.</p>
+
+<p><b>débris.</b> Fragments; broken rubbish.</p>
+
+<p><b>deformity.</b> A deviation from the normal
+shape or size, resulting in disfigurement.</p>
+
+<p><b>degeneration.</b> Deterioration; sinking from
+a higher to a lower level of a type.</p>
+
+<p><b>dehydrating.</b> Losing water; being deprived
+of water.</p>
+
+<p><b>deliquesce.</b> To become damp or liquid
+by absorbing water from the atmosphere.</p>
+
+<p><b>delirium.</b> A condition of extreme mental
+excitement, marked by confused
+ideas.</p>
+
+<p><b>demarcation.</b> A setting of limits, determining
+a boundary. <b>Line of d.</b>, a
+zone of inflammatory reaction separating
+a gangrenous area from healthy
+tissue.</p>
+
+<p><b>dementia paralytica.</b> General paresis, or
+paralysis, of the insane.</p>
+
+<p><b>denuded.</b> Deprived of a covering; bared.</p>
+
+<p><span class="pagenum" id="Page_416">[Pg 416]</span></p>
+
+<p><b>deodorant.</b> An agent which destroys
+odors, especially disagreeable odors.</p>
+
+<p><b>depressed.</b> Flattened from above downward.
+as in fractures of that type.</p>
+
+<p><b>derma.</b> The connective tissue layer of
+the skin; the true skin.</p>
+
+<p><b>dermatalgia.</b> Skin pain.</p>
+
+<p><b>dermatitis.</b> Inflammation of the skin.</p>
+
+<p><b>dermatitis calorica.</b> Inflammation of the
+skin resulting from the action of cold
+or heat.</p>
+
+<p><b>dermatol.</b> Trade name of bismuth subgallate.</p>
+
+<p><b>dermatorrhea.</b> Excessive skin secretion.</p>
+
+<p><b>dermosynovitis.</b> Perforating ulcer of the
+foot.</p>
+
+<p><b>desiccant.</b> A skin-drying agent.</p>
+
+<p><b>desiccation.</b> Drying.</p>
+
+<p><b>desquamation.</b> The shedding of the
+cuticle in scales or shreds.</p>
+
+<p><b>developer.</b> A solution of chemicals used
+to develop photographic and X-ray
+plates.</p>
+
+<p><b>devitalized.</b> Deprived of vitality or
+energy.</p>
+
+<p><b>dexter.</b> Right, in contradistinction to
+sinister, left.</p>
+
+<p><b>diabetes.</b> A disease in which sugar is
+excreted in the urine, and is also
+present in the blood. There are two
+types, insipidus and mellitus. The
+latter is the diabetes in which sugar
+is excreted. In the former, large
+quantities of pale urine are excreted.</p>
+
+<p><b>diachylon.</b> Lead plaster.</p>
+
+<p><b>diagnosis.</b> The determination of the
+nature of a disease.</p>
+
+<p><b>diapedesis.</b> The passage of the blood cells
+through the unruptured walls of
+the blood vessels.</p>
+
+<p><b>diathesis.</b> A constitutional state predisposing
+to any disease or group of
+diseases.</p>
+
+<p><b>digit.</b> A finger or toe.</p>
+
+<p><b>diet.</b> Food and drink in general. A prescribed
+course of eating and drinking.</p>
+
+<p><b>dietetics.</b> The therapeutics of food and
+drink in relation to health and disease.</p>
+
+<p><b>diffuse.</b> Spread about; not confined.</p>
+
+<p><b>dioxygen.</b> Trade name for hydrogen
+peroxide.</p>
+
+<p><b>diphtheria.</b> A specific infectious disease
+caused by the Klebs-Loeffler bacillus.</p>
+
+<p><b>direct cautery.</b> Actual fire or heat
+applied to a part to destroy it.</p>
+
+<p><b>disbasia angiosclerotica.</b> A disease characterized
+by intermittent limping.</p>
+
+<p><b>disease.</b> Illness, sickness; an interruption
+of the function of any part of the
+body.</p>
+
+<p><b>disintegration.</b> Separation of the component
+parts of a substance.</p>
+
+<p><b>dislocation.</b> A disturbance of the relation
+of the bones entering into a joint.</p>
+
+<p><b>dissection.</b> The act of cutting apart or
+separating the tissues of the body in
+the study of anatomy. In an operation,
+to separate the structures along
+natural lines. In podiatry, to remove
+a growth in its entirety and as a
+whole.</p>
+
+<p><b>disseminatum.</b> Widely scattered, referring
+to heloma d., which is so scattered.</p>
+
+<p><b>distal.</b> Farthest from the centre or
+median line. Opposed to proximal.</p>
+
+<p><b>distension.</b> The act of stretching.</p>
+
+<p><b>dorsal.</b> Referring to the upper or posterior
+surface, or the back of any part.</p>
+
+<p><b>douche.</b> A current of water or other
+fluid, directed against the surface or
+projected in a cavity.</p>
+
+<p><b>drain.</b> To draw off the fluid from a
+cavity.</p>
+
+<p><b>dressings.</b> The materials applied to a
+wound for the purpose of excluding
+the air, stimulating repair, etc.</p>
+
+<p><b>drop-foot.</b> Paralysis of the dorsal flexor
+muscles of the foot.</p>
+
+<p><b>dropsy.</b> An excessive accumulation of
+clear watery fluid in any of the tissues
+or cavities of the body. (Latin—hydrops).</p>
+
+<p><b>duck shield.</b> A dressing for heloma
+molle, devised by Alfred Ahrens.</p>
+
+<p><b>duct.</b> A tubular structure giving exit to
+the secretion of a gland, or conducting
+any fluid.</p>
+
+<p><b>ductility.</b> The quality possessed by some
+metals to spread and elongate without
+breaking.</p>
+
+<p><b>dys.</b> A prefix meaning bad or difficult.
+(Exam. dysphasia—an impairment in
+the sense of touch).</p>
+
+<p><b>dyspnea.</b> Shortness of breath, difficult
+respiration.</p>
+
+
+<p class="center bolden" id="E">
+  E
+</p>
+
+<p><b>ebullition.</b> Boiling.</p>
+
+<p><b>ecchymosis.</b> A purplish patch of the
+skin caused by extravasation of blood.</p>
+
+<p><b>ectrodactylia.</b> A congenital malformation
+in which one or more fingers or
+toes are absent.</p>
+
+<p><b>eczema.</b> Salt rheum, tetter; an inflammation
+of the skin, characterized by
+weeping and itching.</p>
+
+<p><b>edema.</b> An abnormal amount of clear
+watery fluid in the lymph spaces of
+the tissues.</p>
+
+<p><b>edematous.</b> Dropsical, marked by edema.</p>
+
+<p><b>effusion.</b> Escape of fluid from the blood vessels
+or lymphatics into the tissues
+or a cavity.</p>
+
+<p><b>electrode.</b> One of the two poles of an
+electric battery or of the ends of the
+conductors connected therewith.</p>
+
+<p><b>electrolysis.</b> Decomposition of the tissues
+by means of electricity.</p>
+
+<p><b>eleidin.</b> A deeply staining substance
+forming the granules of the stratum
+granulosum of the epidermis.</p>
+
+<p><b>element.</b> A simple substance which has
+not been subdivided.</p>
+
+<p><b>elephantiasis.</b> Barbados leg. Hypertrophy
+of the skin and subcutaneous tissues.</p>
+
+<p><b>eliminants.</b> Agents promoting the removal
+of waste.</p>
+
+<p><b>emaciation.</b> Extreme loss of flesh.</p>
+
+<p><b>embolism.</b> Obstruction of a vessel due
+to a clot or foreign matter, which has
+been transported to it, usually from a
+thrombus.</p>
+
+<p><b>emollient.</b> Soothing to the skin.</p>
+
+<p><b>emphysema.</b> The presence of air in the
+spaces of the connective tissues of a
+part.</p>
+
+<p><b>empiric.</b> Founded on experience; the
+treatment of disease based on experience;
+opposed to rational.</p>
+
+<p><b>encapsulated.</b> Inclosed in a sheath or
+capsule.</p>
+
+<p><b>encysted.</b> Encapsuled; surrounded by a
+closed membrane.</p>
+
+<p><b>endarteritis.</b> Inflammation of the inner
+coat of an artery.</p>
+
+<p><span class="pagenum" id="Page_417">[Pg 417]</span></p>
+
+<p><b>endemic.</b> Noting a disease common to a
+region.</p>
+
+<p><b>endo.</b> A prefix signifying within. (Exam.
+endotoscope—a form of ear speculum).</p>
+
+<p><b>endosmosis.</b> Osmosis in a direction
+towards the interior of a cavity.</p>
+
+<p><b>endothelium.</b> A layer of flat cells lining
+serous cavities, blood vessels, etc., and
+cavities not exposed to the air.</p>
+
+<p><b>enervation.</b> Failure of nerve force.</p>
+
+<p><b>engorgement.</b> Distension with fluid or
+other material; congested.</p>
+
+<p><b>enucleate.</b> To remove in its entirety.</p>
+
+<p><b>epidemic.</b> Noting a disease which attacks,
+nearly simultaneously, a large
+number of people in a community.</p>
+
+<p><b>epidermis.</b> The epithelial layer of the
+skin; the scarf skin or outer skin.</p>
+
+<p><b>epithelioid.</b> Resembling epithelium.</p>
+
+<p><b>epithelioma.</b> A cancerous growth originating
+from squamous epithelium.</p>
+
+<p><b>epithelium.</b> The purely cellular, non-vascular
+layer covering all cavities and
+surfaces exposed to the air, such as the
+epidermis, mucous membrane, etc.</p>
+
+<p><b>eponychium.</b> The skin adherent to the
+nail at its root; the nail skin.</p>
+
+<p><b>eradicated.</b> Removed.</p>
+
+<p><b>ergot.</b> Spurred rye, rye smut; a drug
+made from rye.</p>
+
+<p><b>erosion.</b> A wearing away.</p>
+
+<p><b>erysipelas.</b> An acute spreading inflammation
+of the skin and subcutaneous
+tissues.</p>
+
+<p><b>erythema.</b> A redness of the skin; rose-rash.</p>
+
+<p><b>erythematous.</b> Relating to or marked by
+redness.</p>
+
+<p><b>eschar.</b> A slough following a burn or
+cauterization of the skin.</p>
+
+<p><b>escharotic.</b> Caustic, corrosive; an agent
+producing an eschar.</p>
+
+<p><b>Esmarch’s bandage.</b> A rubber bandage
+wound tightly about a limb in order
+to exsanguinate the member preparatory
+to offering a bloodless field for
+operation.</p>
+
+<p><b>essence of geranium.</b> A solution of the
+volatile oil of geranium.</p>
+
+<p><b>essence of thyme.</b> A solution of the
+volatile oil of thyme.</p>
+
+<p><b>ether.</b> An organic oxide, more especially
+ethyl ether (C<sub>2</sub>H<sub>5</sub>)<sub>2</sub>O.</p>
+
+<p><b>ethics.</b> The principles of correct professional
+conduct as they relate to the
+public, to the practitioner, and to
+his fellow-practitioners.</p>
+
+<p><b>ethyl bromide.</b> A colorless liquid employed
+as a local anesthetic.</p>
+
+<p><b>ethyl chloride.</b> A colorless liquid employed
+as a local anesthetic, by spraying.</p>
+
+<p><b>ethylate of soda.</b> A reddish yellow
+powder, employed in aqueous solution
+in the treatment of lupus and other
+skin diseases.</p>
+
+<p><b>etiology.</b> The causes of disease.</p>
+
+<p><b>eucalyptol oil.</b> Oleum eucalypti; an oil
+distilled from the leaves of the Eucalyptus
+globulus.</p>
+
+<p><b>evaporate.</b> To change from liquid to
+vapor form.</p>
+
+<p><b>evaporation.</b> A change from liquid to
+vapor form.</p>
+
+<p><b>eversion.</b> A turning outward.</p>
+
+<p><b>ex.</b> A prefix denoting out of, from, away
+from. (Exam. excision—to cut out).</p>
+
+<p><b>excavator.</b> A spoon-shaped instrument
+used to scrape out pathologic tissue.</p>
+
+<p><b>excision.</b> The operative removal of a
+limb, organ or other part.</p>
+
+<p><b>excrementitious.</b> Relating to any cast-out
+waste material.</p>
+
+<p><b>excrescence.</b> Any outgrowth from the
+surface, especially a pathologic growth.</p>
+
+<p><b>excretion.</b> The process whereby the
+waste material is thrown out of the
+body.</p>
+
+<p><b>excretory.</b> Relating to excretion.</p>
+
+<p><b>exfoliate.</b> To strip off in layers or sheets,
+noting especially a form of desquamation.</p>
+
+<p><b>exostosis.</b> A bony tumor springing from
+the surface of a bone.</p>
+
+<p><b>expansion.</b> Spreading out; an increase in
+size.</p>
+
+<p><b>exsanguinate.</b> To make bloodless.</p>
+
+<p><b>exsiccant.</b> A dusting or drying powder.</p>
+
+<p><b>extension.</b> The act of extending a limb;
+the position of a limb that is extended.</p>
+
+<p><b>extr. cannabis indica.</b> A soft solid (Indian
+hemp) of blackish-green color.</p>
+
+<p><b>extravasated.</b> Exuded from, or passed
+out of a vessel into the tissues.</p>
+
+<p><b>exuberant.</b> Copious, plentiful, as exuberant
+granulations.</p>
+
+<p><b>exudate.</b> To exude; a fluid, or formed
+elements of the blood, which enters the
+tissues or any cavity.</p>
+
+
+<p class="center bolden" id="F">
+  F
+</p>
+
+<p><b>F.</b> Abbreviation for Fahrenheit temperature.</p>
+
+<p><b>fabella.</b> One of two small fibro-cartilages
+or sesamoid bones in the tendons of
+the gastrocnemius muscle.</p>
+
+<p><b>fabric.</b> The structure of anything.</p>
+
+<p><b>fabrics.</b> Materials constructed for manufacturing
+purposes.</p>
+
+<p><b>facet.</b> A small smooth area on a bone
+or other firm structure.</p>
+
+<p><b>Fahrenheit scale.</b> The degree markings
+on the F. thermometer in which the
+freezing point is 32° and the point of
+boiling water is 212°.</p>
+
+<p><b>faradic.</b> Relating to induced electricity.</p>
+
+<p><b>fasciculi.</b> Small bands or bundles of
+fibres, usually of muscle or nerve tissue.</p>
+
+<p><b>fascia.</b> A sheet of fibrous tissue enveloping
+the body beneath the skin and also
+enclosing the muscles.</p>
+
+<p><b>fatty degeneration.</b> A retrogressive
+change associated with the appearance
+of fat in the cells and formed within
+them. <b>f. infiltration.</b> A deposit of fat
+in abnormal quantity between and in
+the cells, and not formed within them.</p>
+
+<p><b>felon.</b> Paronychia, inflammation around
+the nail. Whitlow.</p>
+
+<p><b>felt.</b> Matted wool, unwoven. Used for
+podiatry dressings.</p>
+
+<p><b>femur.</b> The thigh bone.</p>
+
+<p><b>fermentation.</b> A chemical change induced
+in an organic compound by the
+action of a ferment.</p>
+
+<p><b>ferrum.</b> The metal iron; the basic ingredient
+of tincture of the subsulphate
+of iron.</p>
+
+<p><b>festination.</b> The peculiar acceleration of
+gait noted in paralysis agitans and
+some other nervous affections.</p>
+
+<p><b>fetid.</b> Foul-smelling; having a rank
+odor.</p>
+
+<p><b>fibre.</b> A filamentous element; an
+elongated cell or cell process.</p>
+
+<p><b>fibrillae.</b> Minute fibres.</p>
+
+<p><span class="pagenum" id="Page_418">[Pg 418]</span></p>
+
+<p><b>fibrin.</b> An elastic filamentous substance
+derived from the blood after coagulation.</p>
+
+<p><b>fibroblast.</b> A cell produced by the connective
+tissue in the formation of
+fibrous tissue.</p>
+
+<p><b>fibula.</b> The external and smaller of the
+two bones of the leg.</p>
+
+<p><b>filament.</b> A fibril, a fine fibre, or thread-like
+structure.</p>
+
+<p><b>fish skin.</b> A preparation used as a covering
+to wounds, etc.; a substitute for
+oil-silk.</p>
+
+<p><b>fissure.</b> A furrow, cleft or slit.</p>
+
+<p><b>fistula.</b> A sinus leading from an abscess
+cavity to the surface.</p>
+
+<p><b>flaccid.</b> Relaxed; flabby; without bone.</p>
+
+<p><b>flail-like.</b> Resembling an instrument
+used for thrashing or beating.</p>
+
+<p><b>flat foot.</b> Pes planus; a foot in which
+the arch is sunken.</p>
+
+<p><b>flax-seed.</b> Linseed. Used in making
+poultices.</p>
+
+<p><b>flexion.</b> Bending; bending of a joint so
+as to approximate the parts they connect.</p>
+
+<p><b>fluctuation.</b> A wave-like motion felt on
+palpating a cavity containing fluid.</p>
+
+<p><b>fluffy.</b> Feathery.</p>
+
+<p><b>fluoroscope.</b> An apparatus for rendering
+visible the effects of the X-rays.</p>
+
+<p><b>fluoroscopy.</b> Examination of the inner
+parts of the body by means of the
+fluoroscope.</p>
+
+<p><b>flux.</b> Flow of electricity or other substance.</p>
+
+<p><b>focal infection.</b> An infectious process
+which starts at a point remote from
+the part where the symptoms manifest
+themselves.</p>
+
+<p><b>follicle.</b> A simple tubular gland.</p>
+
+<p><b>fomentation.</b> The application of warmth
+and moisture in the treatment of disease;
+poulticing.</p>
+
+<p><b>foot.</b> Pes; the lower, pedal, extremity of
+the leg.</p>
+
+<p><b>forceps.</b> An instrument for seizing anything
+and for making compression or
+traction.</p>
+
+<p><b>formaldehyde.</b> An antiseptic gas with a
+pungent odor. The water solution,
+formalin, is used in podiatry.</p>
+
+<p><b>fracture.</b> A break, especially of a bone.</p>
+
+<p><b>friction.</b> Rubbing.</p>
+
+<p><b>Friedreich’s ataxia.</b> Hereditary spinal
+ataxia.</p>
+
+<p><b>frost bite.</b> Inflammation of the skin and
+deeper tissues due to exposure to severe
+cold. Chimatlon severe.</p>
+
+<p><b>fulguration.</b> Lightning stroke. Treatment
+of tumors by means of the sparks
+of the high frequency current.</p>
+
+<p><b>function.</b> The special action or physiologic
+property of a part.</p>
+
+<p><b>fusiform.</b> Spindle-shaped; tapering at
+both ends.</p>
+
+<p><b>fusion.</b> Liquefaction by heat; melting.</p>
+
+
+<p class="center bolden" id="G">
+  G
+</p>
+
+<p><b>G.</b> Abbreviation for gram.</p>
+
+<p><b>gait.</b> Specific manner of walking; manner
+of stepping.</p>
+
+<p><b>gallic acid.</b> A yellowish-white substance
+used as an astringent.</p>
+
+<p><b>gallstone.</b> A concretion, chiefly of
+cholesterin, formed in the gall bladder
+or bile-duct.</p>
+
+<p><b>galvanic.</b> Constant current electricity
+produced by chemical action.</p>
+
+<p><b>gangrene.</b> Death of the soft tissues, en
+masse.</p>
+
+<p><b>gas gangrene.</b> Gangrene caused by the
+bacillus of Welch; gaseous gangrene.</p>
+
+<p><b>gastric.</b> Relating to the stomach.</p>
+
+<p><b>gastrocnemius.</b> One of the calf muscles.</p>
+
+<p><b>gastro-intestinal.</b> Referring to the
+stomach and the intestines.</p>
+
+<p><b>gauze.</b> A thin loose-meshed cloth employed
+for dressings, bandages, etc.</p>
+
+<p><b>genitalia.</b> The genitals.</p>
+
+<p><b>genu.</b> The knee.</p>
+
+<p><b>germ.</b> A rudiment. A microbe.</p>
+
+<p><b>germicide.</b> An agent which destroys
+germs or microorganisms.</p>
+
+<p><b>ginglymus.</b> A hinge joint.</p>
+
+<p><b>glands.</b> Secreting organs or excreting
+organs, such as the sebaceous or sweat
+glands.</p>
+
+<p><b>gliomatous.</b> Relating to a tumor formed
+of the nerves of the brain and spinal
+cord.</p>
+
+<p><b>glucose.</b> Grape sugar.</p>
+
+<p><b>gluteal.</b> Relating to the buttocks.</p>
+
+<p><b>glycerin.</b> Glycerinum; a sweet, oily fluid
+obtained by the saponification of fats
+and fixed oils.</p>
+
+<p><b>golfer’s foot.</b> A painful condition of the
+dorsum of the foot.</p>
+
+<p><b>gomenol.</b> A germicidal, ethereal oil obtained
+from a plant.</p>
+
+<p><b>gonococcus.</b> The specific organism causing
+gonorrhea.</p>
+
+<p><b>gonorrheal heel.</b> A focal infection of the
+heel caused by an original urethral
+infection with the gonococcus.</p>
+
+<p><b>Goulard’s extract.</b> A solution of lead
+subacetate.</p>
+
+<p><b>gout.</b> A disease of metabolism characterized
+by recurrent attacks of arthritis,
+particularly in the metatarsophalangeal
+joint of the great toe, though any joint
+may be attacked, by deposits of sodium
+biuret in and around the affected
+joints, and by inflammation of fibrous
+structures elsewhere (Stedman).</p>
+
+<p><b>grain.</b> A unit of weight, ¹⁄₆₀ dram.</p>
+
+<p><b>gram</b>, <b>gramme</b>. A unit of weight equal
+to 15.4 grains.</p>
+
+<p><b>granulation.</b> The formation of minute,
+rounded, fleshy projections on the surface
+of a wound in the process of healing.</p>
+
+<p><b>gross.</b> Large, coarse, macroscopic in contradistinction
+to microscopic.</p>
+
+<p><b>growth.</b> The increase in size of a living
+being or any of its parts.</p>
+
+<p><b>gt.</b> (plural gtt.). Abbreviation of drop
+or drops.</p>
+
+<p><b>gumma.</b> An infectious granuloma, the
+characteristic lesion of late or tertiary
+syphilis.</p>
+
+<p><b>guncotton.</b> Pyroxylin.</p>
+
+<p><b>gutta percha.</b> The dried milky juice of
+a Malay tree.</p>
+
+<p><b>gypsum.</b> Calcium sulphate. <b>Dried g.</b>
+Calcii sulphas exsiccatus, plaster of
+Paris.</p>
+
+
+<p class="center bolden" id="H">
+  H
+</p>
+
+<p><b>hair follicle.</b> A cylindrical pit dipping
+down through the corium and containing
+the root of the hair.</p>
+
+<p><b>hallux.</b> The great toe; the first digit of
+the foot.</p>
+
+<p><b>hallux dolorosus.</b> Painful toe.</p>
+
+<p><b>hallux flexus.</b> Hammer toe.</p>
+
+<p><span class="pagenum" id="Page_419">[Pg 419]</span></p>
+
+<p><b>hallux rigidus.</b> Stiff toe.</p>
+
+<p><b>hallux valgus.</b> A deformity in which the
+great toe is bent outwards.</p>
+
+<p><b>hallux varus.</b> Deviation of the great toe
+to the inner side of the foot away from
+its neighbor.</p>
+
+<p><b>hammer toe.</b> A condition of permanent
+flexion of the mid-phalangeal joint of
+one or more of the toes; hallux flexus.</p>
+
+<p><b>heloma (plural, helomata).</b> Corn; clavus;
+an overgrowth of the epidermis, with
+a central core or nucleus.</p>
+
+<p><b>heloma durum.</b> Hard corn.</p>
+
+<p><b>heloma miliare.</b> Seed corn.</p>
+
+<p><b>heloma molle.</b> Soft corn.</p>
+
+<p><b>heloma neurofibrosum.</b> Corn containing
+nerve fibres.</p>
+
+<p><b>heloma vasculare.</b> Vascular corn.</p>
+
+<p><b>helosis.</b> The condition of having heloma.</p>
+
+<p><b>helotomeia.</b> The surgery of helomata.</p>
+
+<p><b>helotomon.</b> The knife for cutting helomata.</p>
+
+<p><b>hematidrosis.</b> The excretion of sweat
+stained with blood.</p>
+
+<p><b>hematocele.</b> A blood cyst; hematocist.</p>
+
+<p><b>hemi.</b> A prefix signifying one-half.
+(Exam. hemiplegia—half paralysis).</p>
+
+<p><b>hemichorea.</b> Chorea involving the
+muscles of one side, only.</p>
+
+<p><b>hemiplegia.</b> Paralysis of one side of the
+body.</p>
+
+<p><b>hemoglobin.</b> The coloring matter of the
+blood.</p>
+
+<p><b>hemorrhage.</b> Bleeding; a flow of blood.</p>
+
+<p><b>hemorrhoids.</b> Piles; a varicose condition
+of the external hemorrhoidal veins
+causing painful swellings at the anus.</p>
+
+<p><b>hemostatic.</b> Arresting hemorrhage;
+styptic.</p>
+
+<p><b>hereditary.</b> Transmitted from parent to
+offspring.</p>
+
+<p><b>hermetically.</b> In an air-tight manner;
+noting a vessel closed or sealed in such
+a way that air can neither enter it nor
+issue from it.</p>
+
+<p><b>hidrosis.</b> Sweating, especially heavy
+sweating; hyperidrosis; sudoresis.</p>
+
+<p><b>high frequency.</b> An electric current with
+a high voltage, and a rapid change in
+direction from one pole to the other.</p>
+
+<p><b>hirsute.</b> Hairy; pertaining to hair.</p>
+
+<p><b>histology.</b> The branch of anatomy which
+deals with the cells and the minute
+structure of the tissues; microscopic
+anatomy.</p>
+
+<p><b>homogeneous.</b> Of uniform structure or
+composition throughout.</p>
+
+<p><b>homo heloticus.</b> The person having helomata.</p>
+
+<p><b>hone.</b> A flat stone or a piece of leather
+used to sharpen knives.</p>
+
+<p><b>hookworm.</b> A worm of the genus ankylostoma
+or uncinaria.</p>
+
+<p><b>hornification.</b> Conversion into horn;
+cornification.</p>
+
+<p><b>Huntington’s chorea.</b> Hereditary chorea.</p>
+
+<p><b>hydrocephalus.</b> A condition, usually congenital,
+marked by an extensive effusion
+of serum into the cerebral ventricles.</p>
+
+<p><b>hydrochloric acid.</b> See acidum.</p>
+
+<p><b>hydrogen.</b> An odorless, colorless, tasteless
+gaseous element, the lightest substance
+known.</p>
+
+<p><b>hydro-therapeutics.</b> The treatment of
+disease by the use of water, in a
+scientific way; hydrotherapy.</p>
+
+<p><b>hygiene.</b> The science of health.</p>
+
+<p><b>hyper.</b> A prefix denoting excessive.
+(Exam. hyperidrosis—excessive sweating).</p>
+
+<p><b>hyperemia.</b> The presence of an increased
+amount of blood in a part; congestion.</p>
+
+<p><b>hyperesthesia.</b> Excessive sensibility to
+touch, to pain or to other sensory
+stimuli.</p>
+
+<p><b>hyperidrosis.</b> Hyperhidrosis; excessive
+sweating.</p>
+
+<p><b>hyperporosis.</b> Excessive formation of
+callus after fracture of a bone.</p>
+
+<p><b>hypertonicity.</b> A greater degree of tension.</p>
+
+<p><b>hypertrophy.</b> Overgrowth; general increase
+in a part, not due to tumor
+formation.</p>
+
+<p><b>hypodermatic.</b> Hypodermic; under the
+skin.</p>
+
+<p><b>hysteria.</b> A chronic neurosis or psycho-neurosis,
+characterized by disorders of
+the will, and partial cessation or exaltation
+of the individual functions of
+the brain.</p>
+
+
+<p class="center bolden" id="I">
+  I
+</p>
+
+<p><b>iasis.</b> See osis.</p>
+
+<p><b>ichnogram.</b> An imprint of the soles of
+the feet, showing a series of steps.</p>
+
+<p><b>ichorous.</b> Relating to a thin watery discharge
+from an ulcer.</p>
+
+<p><b>ichthyol.</b> Ichthyolum; a brownish oil,
+used in medicine and in podiatry because
+of the sulphur (from fossil fish)
+which it contains.</p>
+
+<p><b>ichthyosis.</b> A congenital rough skin due
+to hypertrophy of the horny layer of
+the epidermis with diminished sweat
+and sebaceous secretion; fish-skin disease.</p>
+
+<p><b>idiopathic.</b> Noting a primary disease,
+one originating without apparent extrinsic
+cause.</p>
+
+<p><b>idiosyncrasy.</b> An individual mental or
+physical characteristic or peculiarity.</p>
+
+<p><b>immersion.</b> The placing of a body under
+water or other liquid.</p>
+
+<p><b>immobility.</b> Incapability of moving; the
+fixed position of a part.</p>
+
+<p><b>immune.</b> Free from the possibility of
+infection.</p>
+
+<p><b>impacted.</b> Pressed closely together so as
+to be immovable as in <b>impacted</b> fracture.</p>
+
+<p><b>impermeable.</b> Impervious.</p>
+
+<p><b>impervious.</b> Impassable, impenetrable,
+to fluids.</p>
+
+<p><b>impingement.</b> Used in podiatry to denote
+the pinching of tissues between
+two adjacent or opposite bones or
+muscles.</p>
+
+<p><b>incipient.</b> Just beginning.</p>
+
+<p><b>incision.</b> A cut; a division of the soft
+parts made with a knife.</p>
+
+<p><b>incompatible.</b> Not capable of being
+mixed without undergoing radical
+changes.</p>
+
+<p><b>incoordination.</b> Lack of harmonious
+action, as of muscles.</p>
+
+<p><b>indentation.</b> The act of notching or
+pitting.</p>
+
+<p><b>indolent.</b> Inactive; sluggish; painless, or
+nearly so.</p>
+
+<p><b>induction.</b> Production or causation.</p>
+
+<p><b>induction coil.</b> An apparatus for the induction
+of a secondary electric current.</p>
+
+<p><b>induration.</b> Hardening.</p>
+
+<p><b>inert.</b> Slow in action, sluggish.</p>
+
+<p><span class="pagenum" id="Page_420">[Pg 420]</span></p>
+
+<p><b>infant.</b> A child during the first two
+years of life; a babe.</p>
+
+<p><b>infection.</b> Invasion by living pathogenic
+bacteria of a part of the body where
+conditions are favorable to their growth
+and whence they act injuriously upon
+the tissues.</p>
+
+<p><b>infiltration.</b> The act of passing into or
+interpenetrating a cell or tissue; said
+of gases and fluids.</p>
+
+<p><b>inflammation.</b> The reaction of the tissues
+against injury or bacterial invasion,
+characterized by heat, redness,
+pain, swelling and impaired function.</p>
+
+<p><b>inflation.</b> Distension of a part by a gas
+or a liquid.</p>
+
+<p><b>inflection.</b> An inward bending.</p>
+
+<p><b>influenza.</b> The grip; an acute infectious
+disease caused by Pfeiffer’s bacillus.</p>
+
+<p><b>in-footed.</b> Pigeon-toed; standing or
+walking with toes turned in.</p>
+
+<p><b>ingrown toe nail.</b> Onychocryptosis.</p>
+
+<p><b>inhibition.</b> The diminution or arrest of
+function in an organ.</p>
+
+<p><b>injection.</b> The introduction of a substance
+in fluid form into the tissues or
+cavities of the body.</p>
+
+<p><b>innervation.</b> Distribution of the nerves
+in a part.</p>
+
+<p><b>innocuous.</b> Harmless.</p>
+
+<p><b>inoculate.</b> To introduce the virus of a
+disease into the tissues or blood vessels.</p>
+
+<p><b>in situ.</b> In position.</p>
+
+<p><b>instep.</b> The arch, or highest part of the
+dorsum of the foot.</p>
+
+<p><b>instrument.</b> A tool or implement.</p>
+
+<p><b>integument.</b> The enveloping membrane
+of the body; the skin.</p>
+
+<p><b>inter.</b> A prefix denoting between or
+among. (Exam. interdigital—between
+the fingers or toes).</p>
+
+<p><b>intercellular.</b> Between or among cells.</p>
+
+<p><b>interosseous.</b> Between bones.</p>
+
+<p><b>interphalangeal.</b> Between the phalanges.</p>
+
+<p><b>intertrigo.</b> Dermatitis occurring between
+two folds of the skin.</p>
+
+<p><b>intestinal.</b> Relating to the intestine or
+belly.</p>
+
+<p><b>intima.</b> The inner coat of a blood vessel.</p>
+
+<p><b>intoe.</b> Hallux valgus.</p>
+
+<p><b>intoxication.</b> Acute alcoholism; drunkenness.</p>
+
+<p><b>inunction.</b> The administration of a drug
+in ointment form by rubbing it into the
+skin.</p>
+
+<p><b>inversion.</b> Bending inward.</p>
+
+<p><b>involuntary.</b> Independent of the will;
+not volitional.</p>
+
+<p><b>involution.</b> The return of an enlarged
+organ to normal size.</p>
+
+<p><b>iodine.</b> A non-metallic element occurring
+in lustrous steel-gray crystals, soluble
+in water and alcohol and used externally
+as a counter-irritant and antiseptic.</p>
+
+<p><b>iodoform.</b> Iodoformum; a yellow crystalline
+powder having a strong, disagreeable
+odor; employed as an antiseptic
+dusting powder to wounds and syphilitic
+sores.</p>
+
+<p><b>ions.</b> A group of atoms carrying an
+electric charge.</p>
+
+<p><b>irritation.</b> Extreme reaction of the tissues
+to an insult or injury; incipient
+inflammation.</p>
+
+<p><b>ischemia.</b> Local anemia due to mechanical
+obstruction of the blood supply.</p>
+
+<p><b>ischidrosis.</b> Suppression of the perspiration.</p>
+
+<p><b>ist.</b> An affix denoting an agent. (Exam.
+podiatrist).</p>
+
+<p><b>itis.</b> A suffix grown to mean inflammation
+of. (Exam. osteitis—inflammation
+of bone).</p>
+
+
+<p class="center bolden" id="J">
+  J
+</p>
+
+<p><b>jaborandi.</b> See pilocarpin.</p>
+
+<p><b>joint-capsule.</b> Capsular ligament of a
+joint.</p>
+
+<p><b>joint-muscle.</b> A muscle which causes
+motion at a joint.</p>
+
+
+<p class="center bolden" id="K">
+  K
+</p>
+
+<p><b>kakidrosis.</b> Bromidrosis.</p>
+
+<p><b>keloids.</b> Lesions of a skin disease
+marked by patches of a whitish color
+surrounded by a purplish border.</p>
+
+<p><b>keratin.</b> A scleroprotein present in hair,
+in nails, in horn, etc.</p>
+
+<p><b>keratogenesis.</b> The production of horny
+cells or tissue.</p>
+
+<p><b>keratohyalin.</b> Eleidin.</p>
+
+<p><b>keratoma.</b> A horny tumor.</p>
+
+<p><b>keratosis.</b> Circumscribed overgrowth of
+horny tissue.</p>
+
+<p><b>kilogram.</b> One thousand grams weight.</p>
+
+<p><b>kinesiatrics.</b> The therapeutic employment
+of movements; movement-cure.</p>
+
+<p><b>kinetic.</b> Relation to motion or muscular
+movements.</p>
+
+<p><b>Kneipp method.</b> The treatment of disease
+by water; hydrotherapy.</p>
+
+<p><b>knock-knee.</b> Genu valgum.</p>
+
+<p><b>kolionychia.</b> Spoon-nail; a malformation
+of the nails in which the outer surface
+is concave.</p>
+
+<p><b>Korsakoff’s disease.</b> Polyneuritic psychosis.</p>
+
+<p><b>kyllosis.</b> Club-foot.</p>
+
+
+<p class="center bolden" id="L">
+  L
+</p>
+
+<p><b>labyrinthine.</b> Perplexing, intricate, involved.</p>
+
+<p><b>laceration.</b> A tear or torn wound.</p>
+
+<p><b>laity.</b> Non-professional persons.</p>
+
+<p><b>lamb’s wool.</b> A material used in shielding.</p>
+
+<p><b>lamelia.</b> In osteology, a thin sheet or
+scale of bone.</p>
+
+<p><b>lancet.</b> A surgical knife with a short,
+sharp pointed, two-edged blade.</p>
+
+<p><b>lancinating.</b> Noting a sharp cutting or
+tearing pain.</p>
+
+<p><b>Landry’s disease.</b> Acute ascending paralysis.</p>
+
+<p><b>Langerhans’ cells.</b> Star-shaped cells in
+the deeper part of the stratum germinativum
+of the epidermis.</p>
+
+<p><b>lanolin.</b> An oily substance extracted
+from the wool of sheep; adeps lanae.</p>
+
+<p><b>larynx.</b> The organ of voice production.</p>
+
+<p><b>larvae.</b> The worm-like forms of insects
+on issuing from the egg.</p>
+
+<p><b>Lassar’s paste.</b> An ointment containing
+salicylic acid, talcum, zinc oxide and
+vaseline; it is used for eczema.</p>
+
+<p><b>lateral.</b> On the side, as distinguished
+from medial.</p>
+
+<p><b>lathyrism.</b> Lupinosis; poisoning by flour
+adulterated with chick-pea.</p>
+
+<p><b>lead.</b> A metallic element.</p>
+
+<p><b>lead and opium wash.</b> A solution of lead
+acetate and tr. opium in water; used
+to allay pain.</p>
+
+<p><span class="pagenum" id="Page_421">[Pg 421]</span></p>
+
+<p><b>lead neuritis.</b> Inflammation of the
+nerves, due to poisoning by lead.</p>
+
+<p><b>lead palsy.</b> Paralysis of the extensor
+muscles of the wrist, due to poisoning
+by lead; wrist drop.</p>
+
+<p><b>leprosy.</b> A chronic disease believed to be
+due to the presence of the bacillus
+leprae, or Hansen’s bacillus. It occurs
+in two forms; tubercular, affecting the
+skin; anesthetic, affecting the nerves.</p>
+
+<p><b>lesion.</b> A more or less circumscribed
+pathologic change in the tissues.</p>
+
+<p><b>lethal.</b> Fatal, mortal, causing death.</p>
+
+<p><b>leucocyte.</b> A white blood cell.</p>
+
+<p><b>leuconychia.</b> The occurrence of white
+spots or patches under the nails.</p>
+
+<p><b>leucorrhea.</b> A discharge from the vagina
+of a white, viscid fluid containing
+mucous and pus cells.</p>
+
+<p><b>leverage.</b> The mechanical power gained
+by using a lever.</p>
+
+<p><b>lichen planus.</b> A skin disease occurring
+on the soles of the feet.</p>
+
+<p><b>ligaments.</b> Bands of fibrous tissue connecting
+two or more bones.</p>
+
+<p><b>ligation.</b> The application of a ligature.</p>
+
+<p><b>ligature.</b> A thread, wire or piece of catgut,
+tied tightly around a blood vessel,
+a pedicle or a tumor in order to constrict
+it.</p>
+
+<p><b>limewater.</b> A solution of calcium
+hydroxide.</p>
+
+<p><b>line of demarcation.</b> A zone of inflammatory
+reaction separating a healthy
+from a gangrenous area.</p>
+
+<p><b>liniment.</b> A solution of a medicament in
+mucilage, starch or other substance,
+in combination with the white of egg.</p>
+
+<p><b>linseed.</b> Flaxseed; used in making
+poultices.</p>
+
+<p><b>lint.</b> A soft, absorbent material used in
+surgical dressings.</p>
+
+<p><b>lipoma.</b> A tumor of fatty tissue.</p>
+
+<p><b>liquor ferri subsulphate.</b> Monsel’s solution.</p>
+
+<p><b>liquor potassae.</b> A 5% solution of potassium
+hydroxide.</p>
+
+<p><b>lisle.</b> A material woven from cotton and
+silk.</p>
+
+<p><b>liter.</b> A measure of capacity equal to a
+trifle over a quart; 1000 cubic centimeter.</p>
+
+<p><b>lithemia.</b> The presence of uric acid, in
+excess, in the blood.</p>
+
+<p><b>Lobstein’s disease.</b> Constitutional fragility
+of the bones, fractures being produced
+by slight injuries.</p>
+
+<p><b>locomotion.</b> Movement from one place to
+another.</p>
+
+<p><b>longitudinal.</b> Running lengthwise; in the
+direction of the long axis of the body.</p>
+
+<p><b>lordosis.</b> Curvature of the spine with the
+convexity looking anteriorally.</p>
+
+<p><b>lues.</b> A plague or pestilence; specifically,
+syphilis.</p>
+
+<p><b>luetin skin reaction.</b> The reaction of the
+skin in a specific test for syphilis.</p>
+
+<p><b>lumen.</b> The space in the interior of a
+tubular structure, such as an artery.</p>
+
+<p><b>lunula.</b> The opaque whitish semi-lunar
+area near the root of the nail.</p>
+
+<p><b>lycopodium.</b> Vegetable sulphur. A yellow
+tasteless powder used as a dusting
+powder.</p>
+
+<p><b>lymphangitis.</b> Inflammation of the
+lymphatic vessels.</p>
+
+<p><b>lymph.</b> A clear light, straw-colored
+fluid, which circulates in the lymph
+spaces or lymphatic vessels of the
+body.</p>
+
+<p><b>lymphatics.</b> A series of vessels acting as
+auxiliaries to the venous system, and
+containing the lymph.</p>
+
+<p><b>lysis.</b> The gradual subsidence of the
+symptoms of an acute disease.</p>
+
+<p><b>lysol.</b> Trade name of a mixture of soaps
+and phenols, used as a disinfectant
+dressing and hand-wash.</p>
+
+
+<p class="center bolden" id="M">
+  M
+</p>
+
+<p><b>M.</b> Abbreviation for (1) mille, a thousand;
+(2) in prescriptions, for misce,
+mix; (3) minim, a drop; (4) meter,
+French measure.</p>
+
+<p><b>macerate.</b> To soften by soaking or steeping.</p>
+
+<p><b>maceration.</b> Softening by the action of
+a liquid.</p>
+
+<p><b>mackintosh.</b> A waterproof cloth or tissue
+used for surgical dressings.</p>
+
+<p><b>macrodactylism.</b> Abnormal size of a
+finger or of a toe.</p>
+
+<p><b>macroscopic.</b> Observable to the naked
+eye, in contradistinction to microscopic.</p>
+
+<p><b>maculae.</b> Small spots or patches on the
+skin, not elevated above the general
+surface.</p>
+
+<p><b>Madura foot.</b> Mycetoma; a disease occurring
+in the East Indies, characterized
+by large subcutaneous tubercles
+and nodules which break down and
+discharge pus.</p>
+
+<p><b>mal.</b> A prefix meaning bad. (Exam.
+malposition—bad position).</p>
+
+<p><b>malalignment.</b> Not in normal position.</p>
+
+<p><b>malaria.</b> A disease caused by the presence
+of a protozoan parasite (plasmodium)
+of the red blood cells.</p>
+
+<p><b>malignant.</b> Resistant to treatment; occurring
+in severe form; tending to grow
+worse, and (in the case of a tumor) to
+recur after removal. Not benign.</p>
+
+<p><b>malingerer.</b> One who feigns disease.</p>
+
+<p><b>malpractice.</b> Mistreatment of a patient’s
+ills through carelessness, ignorance or
+criminal intent.</p>
+
+<p><b>malleolus.</b> One of the two rounded
+prominences on either side of the
+ankle joint.</p>
+
+<p><b>manicure.</b> To care for the hands and
+finger-nails, cosmetically.</p>
+
+<p><b>marasmus.</b> Extreme emaciation occurring
+in children.</p>
+
+<p><b>massage.</b> A scientific method of manipulation
+of the body by rubbing, pinching,
+kneading, tapping, etc.</p>
+
+<p><b>masseur.</b> A male who massages.</p>
+
+<p><b>masseuse.</b> A female who massages.</p>
+
+<p><b>massotherapy.</b> The therapeutic uses of
+massage.</p>
+
+<p><b>materia medica.</b> The branch of medicine
+which treats of the origin, preparation,
+doses and modes of administration of
+drugs.</p>
+
+<p><b>matrix.</b> The formative portion of a nail.</p>
+
+<p><b>maximum.</b> The highest limit, the greatest
+amount possible in contradistinction
+to minimum, the least limit.</p>
+
+<p><b>M.Cp.</b> Abbreviation of Master of Chiropody.</p>
+
+<p><b>mechanotherapy.</b> Treatment of disease
+by means of apparatus or mechanical
+appliances.</p>
+
+<p><b>medicament.</b> A medicine; a remedy.</p>
+
+<p><b>medicine.</b> The art of preventing or
+curing disease. A drug.</p>
+
+<p><b>medullated.</b> Having a soft marrow-like
+structure, especially in the centre of a
+part.</p>
+
+<p><span class="pagenum" id="Page_422">[Pg 422]</span></p>
+
+<p><b>megalodactylism.</b> Abnormal size of a
+finger or toe.</p>
+
+<p><b>membrana propria.</b> The basement layer
+of the epidermis, and separating it
+from the true skin.</p>
+
+<p><b>membrane.</b> A thin sheet or layer of
+tissue serving as a covering or envelope
+of a part.</p>
+
+<p><b>meningeal.</b> Relating to the meninges or
+membranous envelope of the brain and
+spinal cord.</p>
+
+<p><b>menthol.</b> A camphor obtained from oil
+of peppermint.</p>
+
+<p><b>mercuric chloride.</b> Corrosive sublimate.</p>
+
+<p><b>mercury.</b> An element (quicksilver), compounds
+of which are used in podiatry.</p>
+
+<p><b>metabolism.</b> Tissue change, the sum of
+the chemical changes whereby the
+function of nutrition is regulated.</p>
+
+<p><b>metacarpal.</b> Referring to the long bones
+of the hand between the carpus and
+the phalanges.</p>
+
+<p><b>metacarpophalangeal.</b> Relating to the
+metacarpus and the phalanges.</p>
+
+<p><b>metamorphosis.</b> A change in form,
+structure, or function.</p>
+
+<p><b>metastasis.</b> The shifting of a disease
+from one part of the body to another.</p>
+
+<p><b>metatarsal.</b> Relating to the bones in
+front of the tarsus, and called the
+metatarsal bones; they are five in number.</p>
+
+<p><b>metatarsalgia.</b> Pain in the metatarsal
+region.</p>
+
+<p><b>metatarsophalangeal.</b> Between the
+metatarsal and phalanx.</p>
+
+<p><b>meter.</b> A measure of length the equivalent
+of 39.4 inches.</p>
+
+<p><b>methyl.</b> The radical of wood alcohol.</p>
+
+<p><b>methylene blue.</b> A compound of methylene,
+used as a caustic in treating
+verruca.</p>
+
+<p><b>microbe.</b> A minute one-celled creation,
+animal or vegetable; a microorganism.</p>
+
+<p><b>microorganism.</b> A microscopic plant or
+animal, a bacterium or protozoan.</p>
+
+<p><b>microscopic.</b> Of minute size, visible only
+through a microscope; the reverse of
+macroscopic.</p>
+
+<p><b>miliaria.</b> An eruption of minute vesicles
+due to retention of fluid at the mouth
+of the sweat glands.</p>
+
+<p><b>miliary.</b> Representing a millet seed in
+size.</p>
+
+<p><b>milligram.</b> One-thousandth of a gram—1-65
+grain.</p>
+
+<p><b>milliliter.</b> One-thousandth of a liter—about
+15 minims.</p>
+
+<p><b>millimeter.</b> One-thousandth of a meter
+1-25 inch.</p>
+
+<p><b>milliampere.</b> An electric unit of current-strength,
+the thousandth of an
+ampere.</p>
+
+<p><b>milliamperemeter.</b> An instrument used
+for measuring milliamperes of electric
+current.</p>
+
+<p><b>millet seed.</b> A small seed of the millet
+plant; a grain.</p>
+
+<p><b>minim.</b> One-sixtieth of a fluid drachm,
+equivalent to about one drop of water.</p>
+
+<p><b>misce.</b> Mix; the character which directs
+the druggist to mix the ingredients of
+a prescription.</p>
+
+<p><b>mistura.</b> A pharmacal mixture.</p>
+
+<p><b>mobility.</b> The quality of being movable.</p>
+
+<p><b>molecular.</b> Relating to the smallest
+possible unit of existence of any substance.</p>
+
+<p><b>moleskin.</b> An adhesive substance used
+in shielding.</p>
+
+<p><b>mollifying.</b> Calming; softening.</p>
+
+<p><b>mono.</b> A prefix denoting the participation
+of a single element or part. (Syn.
+uni). (Exam. monodactyl—a single
+finger or toe).</p>
+
+<p><b>Monsel’s solution.</b> Liquor ferri subsulphatis.</p>
+
+<p><b>morbid.</b> Diseased; pathologic.</p>
+
+<p><b>morphine.</b> The chief active principle of
+opium.</p>
+
+<p><b>morphologic.</b> Relating to the structure
+of the tissues of the body.</p>
+
+<p><b>morphology.</b> The science which treats
+of the external configuration or the
+structure of animals and plants.</p>
+
+<p><b>Morton’s disease.</b> Morton’s neuralgia.</p>
+
+<p><b>Morton’s neuralgia.</b> A pain in the metatarsophalangeal
+joint of the fourth
+toe; also called Morton’s toe.</p>
+
+<p><b>motile.</b> Having the power of spontaneous
+movement.</p>
+
+<p><b>mucous.</b> Relating to mucous or to the
+mucous membrane (m. membrane), a
+membrane which secretes mucus, and
+lines the cavities connected with the
+outer air.</p>
+
+<p><b>multiple.</b> Occurring in several parts at
+the same time.</p>
+
+<p><b>mummification.</b> Dry gangrene, shriveling.</p>
+
+<p><b>muscle.</b> One of the contractile organs
+of the body, by which the movements
+of the various organs and parts are
+effected.</p>
+
+<p><b>muscle-corpuscle.</b> The nucleus of a
+muscle-fiber.</p>
+
+<p><b>muscle-fiber.</b> One of the cylindrical
+fibers, an inch or more in length and
+about 1-500 inch in diameter, composing
+voluntary muscle tissue.</p>
+
+<p><b>muscle-plasma.</b> The fluid portion of
+muscle tissue.</p>
+
+<p><b>musculature.</b> The arrangement of the
+muscles in a part or in the body as
+a whole.</p>
+
+<p><b>musculus.</b> Muscle. Important muscles of
+the foot.</p>
+
+<blockquote>
+<p><b>m.</b> Abductor hallucis.</p>
+
+<p><b>m.</b> Abductor obliquus hallucis.</p>
+
+<p><b>m.</b> Adductor transversis hallucis.</p>
+
+<p><b>m.</b> Extensor digitorum brevis.</p>
+
+<p><b>m.</b> Extensor digitorum longus.</p>
+
+<p><b>m.</b> Extensor hallucis longus.</p>
+
+<p><b>m.</b> Flexor accessorius.</p>
+
+<p><b>m.</b> Flexor brevis hallucis.</p>
+
+<p><b>m.</b> Flexor brevis minimi digiti.</p>
+
+<p><b>m.</b> Flexor digitorum brevis.</p>
+
+<p><b>m.</b> Flexor digitorum longus.</p>
+
+<p><b>m.</b> Flexor hallucis longus.</p>
+
+<p><b>m.</b> Gastrocnemius.</p>
+
+<p><b>m.</b> Interosseous dorsalis.</p>
+
+<p><b>m.</b> Interosseous plantaris.</p>
+
+<p><b>m.</b> Lumbricalis (4).</p>
+
+<p><b>m.</b> Peroneus brevis.</p>
+
+<p><b>m.</b> Peroneus longus.</p>
+
+<p><b>m.</b> Peroneus tertius.</p>
+
+<p><b>m.</b> Plantaris.</p>
+
+<p><b>m.</b> Soleus.</p>
+
+<p><b>m.</b> Tibialis anticus.</p>
+
+<p><b>m.</b> Tibialis posticus.</p>
+</blockquote>
+
+<p><b>mustard.</b> The dried, ripe seeds of the
+white or black mustard plant.</p>
+
+<p><b>mycetoma.</b> Madura foot; a disease of
+the foot occurring in the East Indies.</p>
+
+<p><b>myelitis.</b> Inflammation of the spinal
+cord, or of the bone marrow (osteomyelitis).</p>
+
+<p><span class="pagenum" id="Page_423">[Pg 423]</span></p>
+
+<p><b>myeloma.</b> A tumor due to hyperplasia
+of the bone marrow.</p>
+
+<p><b>myocellulitis.</b> Inflammation of muscle
+and cellular tissue.</p>
+
+<p><b>myoclonia.</b> Any disorder characterized
+by muscular twitching.</p>
+
+<p><b>myocyte.</b> A muscle cell.</p>
+
+<p><b>myodynia.</b> Muscle pain; myalgia.</p>
+
+<p><b>myology.</b> The branch of science which
+deals with muscles and their accessory
+parts.</p>
+
+<p><b>myositis.</b> Muscle inflammation.</p>
+
+<p><b>myotonia.</b> Any disorder characterized
+by tonic spasm or temporary rigidity
+of a muscle.</p>
+
+
+<p class="center bolden" id="N">
+  N
+</p>
+
+<p><b>naevus.</b> A congenital mark or discolored
+patch of the skin; a mole.</p>
+
+<p><b>nafalan.</b> A proprietary remedy containing
+Caucasian naphtha in a soap base.</p>
+
+<p><b>nail.</b> Unguis; the horny plate covering
+the dorsal surface of the distal half
+of the terminal phalanx of each finger
+and toe.</p>
+
+<p><b>nail bed.</b> A portion of the distal phalanx
+covered by the nail.</p>
+
+<p><b>nail fold.</b> A groove in the skin in which
+lie the margins and the proximal edge
+of the nail.</p>
+
+<p><b>nail groove.</b> A groove in the distal
+phalanx in which the nail lies.</p>
+
+<p><b>nail plate.</b> The horny substance which
+makes up the nail proper.</p>
+
+<p><b>nanomelous.</b> Having very small extremities.</p>
+
+<p><b>narcosis.</b> Stupor or general anesthesia
+produced by some narcotic drug.</p>
+
+<p><b>narcotic.</b> Relating to or causing narcosis;
+an agent which produces narcosis.</p>
+
+<p><b>navicular.</b> One of the bones of the
+tarsus of the foot.</p>
+
+<p><b>nebulizer.</b> An atomizer; a vaporizer; an
+apparatus for throwing a liquid in a
+fine spray.</p>
+
+<p><b>necrosis.</b> Local death; the death of
+more or less extensive groups of cells.</p>
+
+<p><b>neo.</b> A prefix noting new or recent.
+(Exam. neoplasm—new growth).</p>
+
+<p><b>neoplasm.</b> A new growth; tumor.</p>
+
+<p><b>nephritis.</b> Inflammation of the kidney.</p>
+
+<p><b>nerve.</b> A collection of fibres in the form
+of a whitish cord through which
+stimuli are transmitted from the central
+nervous system to the periphery,
+or the reverse.</p>
+
+<p><b>nervousness.</b> A condition of unrest and
+of irritability to the nervous system.</p>
+
+<p><b>nervus.</b> Nerve; a whitish cord made up
+of nerve fibres.</p>
+
+<p><b>nerves of the foot</b>:</p>
+
+<blockquote>
+<p><b>n.</b> musculocutaneus; musculo-cutaneous
+nerve (dorsal surface and in
+front of leg).</p>
+
+<p><b>n.</b> plantaris externus; external plantar
+nerve (plantar surface).</p>
+
+<p><b>n.</b> plantaris internus; internal plantar
+nerve (plantar surface).</p>
+
+<p><b>n.</b> saphenus externus; external saphenous
+nerve (dorsal surface and in
+front of leg).</p>
+
+<p><b>n.</b> tibialis anticus; anterior tibial
+nerve (dorsal surface and in front
+of leg).</p>
+
+<p><b>n.</b> tibialis posticus; posterior tibial
+nerve (back of leg).</p>
+</blockquote>
+
+<p><b>neuralgia.</b> Nerve-pain; pain of a severe,
+throbbing or stabbing character in the
+course of a nerve.</p>
+
+<p><b>neurasthenics.</b> Those suffering from
+neurasthenia, or nervous exhaustion.</p>
+
+<p><b>neuritis.</b> Inflammation of the nerves.</p>
+
+<p><b>neuro-fibrous.</b> Containing nerve fibres;
+said of an heloma.</p>
+
+<p><b>neuroma (plural neuromata).</b> A tumor
+made up of nerve tissue.</p>
+
+<p><b>N. F.</b> Abbreviation for National Formulary,
+a book issued by the American
+Pharmaceutical Association containing
+formulas of preparations not
+official in the Pharmacopeia.</p>
+
+<p><b>nitric acid.</b> HNO<sub>3</sub>. Employed as a
+caustic for verrucæ.</p>
+
+<p><b>nodule.</b> A small node or circumscribed
+swelling.</p>
+
+<p><b>Noguchi test.</b> A test for tabes dorsalis
+depending upon an albumin reaction of
+the spinal fluid; a test for syphilis—a
+modification of the Wassermann test.</p>
+
+<p><b>non.</b> A latin prefix denoting a negation
+or absence of the quality or fact expressed
+in the word to which it is prefixed.</p>
+
+<p><b>non-medullated.</b> Without a medulla or
+medullary substance.</p>
+
+<p><b>non-striated.</b> Without stripes or bands.</p>
+
+<p><b>normal.</b> Typical; usual; healthy.</p>
+
+<p><b>nostrum.</b> A quack remedy.</p>
+
+<p><b>novocaine.</b> A synthetic local anesthetic.</p>
+
+<p><b>noxious.</b> Injurious; harmful.</p>
+
+<p><b>nucleus.</b> The centre of functional activity
+of a cell; the central portion of an
+heloma.</p>
+
+<p><b>nutrient.</b> Carrying nourishment.</p>
+
+
+<p class="center bolden" id="O">
+  O
+</p>
+
+<p><b>obesity.</b> An abnormal increase of fat in
+the subcutaneous connective tissues;
+corpulence; fatness; general adiposis.</p>
+
+<p><b>obliterated.</b> Destroyed by the effects of
+time; effaced.</p>
+
+<p><b>occlusive.</b> Noting a dressing which excludes
+the air.</p>
+
+<p><b>official.</b> Authoritative; noting a drug or
+chemical found in the Pharmacopeia.</p>
+
+<p><b>ohm.</b> The unit of electric resistance.</p>
+
+<p><b>oid.</b> A suffix denoting resemblance to
+the thing indicated by the other part
+of the word. (Exam: osteoid—resembling
+bone).</p>
+
+<p><b>oil stone.</b> A hone upon which oil is
+used.</p>
+
+<p><b>oiled silk.</b> A waterproof substance used
+in surgical dressings.</p>
+
+<p><b>ointment.</b> A medicated fatty mixture
+with the consistency of butter, and
+employed externally.</p>
+
+<p><b>oligodactylia.</b> A deformity marked by
+fewer than five fingers or toes on each
+hand or foot.</p>
+
+<p><b>ology.</b> A suffix denoting a special
+branch of study. (Exam: podology—the
+branch of medical science which
+has to do with the feet in all their
+relations).</p>
+
+<p><b>oma.</b> A suffix noting a tumor or neoplasm.
+(Exam: neuroma—a nerve
+tumor).</p>
+
+<p><b>onychatrophia.</b> Atrophy of the nails.</p>
+
+<p><b>onychauxis.</b> Hypertrophy of the nails.</p>
+
+<p><b>onychia (onychitis).</b> Inflammation of
+the nail bed or matrix.</p>
+
+<p><b>onychocryptosis.</b> Ingrown toe nail.</p>
+
+<p><span class="pagenum" id="Page_424">[Pg 424]</span></p>
+
+<p><b>onychogryphosis.</b> Hypertrophy of the
+nails with curvature or deformity.</p>
+
+<p><b>onychoid.</b> Resembling a nail in structure
+or in form.</p>
+
+<p><b>onycholysis.</b> Loosening or shedding of
+the nails.</p>
+
+<p><b>onychoma.</b> A tumor arising from the
+nail bed.</p>
+
+<p><b>onychomalacia.</b> Absence of rigidity of
+the nails; hapalonychia.</p>
+
+<p><b>onychomycosis.</b> Any parasitic disease of
+the nails, such as tinea or favus.</p>
+
+<p><b>onychotrophy.</b> Nutrition of the nails.</p>
+
+<p><b>onychopathy.</b> Any disease of the nails;
+onychosis.</p>
+
+<p><b>onychophag.</b> A victim of the nail-biting
+habit.</p>
+
+<p><b>onychophosis.</b> Calloused nail groove.</p>
+
+<p><b>onycophyma.</b> Swelling or hypertrophy
+of the nails.</p>
+
+<p><b>onychoptosis.</b> Falling off of the nails.</p>
+
+<p><b>onychorrhexis.</b> Brittle nails.</p>
+
+<p><b>onyx.</b> The greek word for finger-nail or
+toe nail.</p>
+
+<p><b>oozing.</b> Flowing slowly; gradually
+escaping.</p>
+
+<p><b>operation.</b> Any surgical procedure.</p>
+
+<p><b>opisthotonos.</b> A tetanic spasm in which
+the spine and extremities are bent
+with convexity forward, the body
+resting on the head and heels.</p>
+
+<p><b>organ.</b> Any part of the body exercising
+a specific function.</p>
+
+<p><b>origin.</b> The less movable of the points
+of attachment of a muscle.</p>
+
+<p><b>orthoform.</b> A white crystalline powder
+used as a local anesthetic and antiseptic.</p>
+
+<p><b>orthopedics.</b> A branch of surgery which
+has to do with the treatment of
+chronic diseases of the joints and
+spine, and the correction of deformities.</p>
+
+<p><b>orthopedist.</b> One who practices orthopedics;
+orthopaedist.</p>
+
+<p><b>os.</b> A bone.</p>
+
+<p><b>os calcis.</b> The calcaneus; the heel bone.</p>
+
+<p><b>oscillate.</b> To vibrate.</p>
+
+<p><b>osis.</b> A suffix noting an Increase. (Exam.
+tuberculosis—an increase in tubercles).</p>
+
+<p><b>osmidrosis.</b> (See bromidrosis).</p>
+
+<p><b>osmosis.</b> The passage of certain fluids
+through an animal membrane or other
+porous substance.</p>
+
+<p><b>ossification.</b> The formation of bone.</p>
+
+<p><b>ossiferous.</b> Containing bone.</p>
+
+<p><b>ostealgia.</b> Bone pain.</p>
+
+<p><b>osteanabrosis.</b> Bone atrophy.</p>
+
+<p><b>osteanaphysis.</b> Bone reproduction.</p>
+
+<p><b>osteotomy.</b> Surgical removal of bone.</p>
+
+<p><b>osteitis.</b> Bone inflammation.</p>
+
+<p><b>osteoarthritis.</b> Inflammation of the
+articular extremity of a bone involving
+the contiguous joint structure.</p>
+
+<p><b>osteochondritis.</b> Inflammation of a bone
+and its cartilage.</p>
+
+<p><b>osteogenesis.</b> The formation of bone.</p>
+
+<p><b>osteoma.</b> A bone tumor.</p>
+
+<p><b>osteomyelitis.</b> Inflammation of the bone
+marrow.</p>
+
+<p><b>osteopsathyrosis.</b> Bone fragility; fragilitas
+ossium.</p>
+
+<p><b>osteotomy.</b> Bone cutting, usually by
+means of a saw or a chisel.</p>
+
+<p><b>ounce</b> (abr. oz.). A weight containing
+48.0 grains, apothecaries’ weight.</p>
+
+<p><b>oxidation.</b> A combination with oxygen.</p>
+
+<p><b>oxygen.</b> A gaseous element, symbol, O.</p>
+
+<p><b>ozone.</b> A condensed form of oxygen,
+containing three atoms in a molecule.</p>
+
+
+<p class="center bolden" id="P">
+  P
+</p>
+
+<p><b>pachyacria.</b> A bulbous thickening of the
+extremities of the fingers or toes.</p>
+
+<p><b>pachydactylous.</b> Abnormal thickness of
+fingers or of toes.</p>
+
+<p><b>pachydermia.</b> Elephantiasis.</p>
+
+<p><b>pachypodous.</b> Having large thick feet.</p>
+
+<p><b>pacinian.</b> Named after Filippo Pacini,
+an Italian anatomist, and noting
+especially the Pacinian body or corpuscle
+found in the skin, and which is
+a touch organ.</p>
+
+<p><b>palliative.</b> Mitigating; reducing the
+severity of; noting a method of treatment
+of a disease or of its symptoms.</p>
+
+<p><b>pallor.</b> Paleness.</p>
+
+<p><b>palpate.</b> Examining by feeling and
+pressing with the palms of the hands
+and with the fingers.</p>
+
+<p><b>pan.</b> A prefix implying all, entire.
+(Exam: panhidrosis—perspiration of
+the entire body).</p>
+
+<p><b>panaris.</b> Paronychia.</p>
+
+<p><b>papilla.</b> A conical elevation found beneath
+the epidermis, and containing
+capillary loops and nerve endings.</p>
+
+<p><b>papillary layer.</b> The outer connective
+tissue layer of the true skin, and made
+up of numbers of papillæ.</p>
+
+<p><b>papilloma.</b> A circumscribed overgrowth
+or hypertrophy of the papillæ of a
+cutaneous or mucous surface.</p>
+
+<p><b>papoid.</b> A digestive enzyme from the
+fruit of the pawpaw, resembling
+papain.</p>
+
+<p><b>papule.</b> A small circumscribed elevation
+of the skin containing no fluid; a
+pimple.</p>
+
+<p><b>papulosquamous.</b> Relating to both
+papules and scales.</p>
+
+<p><b>para.</b> A prefix denoting (1) a departure
+from normal; (2) an involvement of
+like parts. (Exam: (1) parachroma—abnormal
+coloration of the skin or
+other parts; (2) paraplegia—paralysis
+of both lower extremities).</p>
+
+<p><b>paraffin.</b> A white solid hydrocarbon,
+having the consistency of wax.</p>
+
+<p><b>paralysis.</b> Palsy; loss of power of voluntary
+movement in a muscle through
+injury or disease of its nerve supply;
+loss of any function.</p>
+
+<p><b>paralysis agitans.</b> Parkinson’s disease;
+shaking palsy; a disorder marked by
+muscular weakness, stiffness and
+tremor.</p>
+
+<p><b>paralysis, pseudo-bulbar.</b> Paralysis of the
+lips and tongue due to a cerebral
+lesion.</p>
+
+<p><b>paralyzant.</b> Causing paralysis; any
+agent causing paralysis.</p>
+
+<p><b>paramyoclonus multiplex.</b> An affection
+characterized by sharp, frequently repeated
+clonic, muscular contractions.</p>
+
+<p><b>paraplegia.</b> Paralysis of both lower extremities
+and also of more or less of
+the trunk.</p>
+
+<p><b>parasite.</b> An animal or vegetable organism
+which lives on or in another
+from which it draws its nourishment.</p>
+
+<p><b>parasiticide.</b> Destructive to parasites.</p>
+
+<p><b>paresis.</b> Cortical paralysis.</p>
+
+<p><b>paresthesia.</b> An abnormal sensation,
+such as burning, pricking, numbness,
+etc.</p>
+
+<p><b>paretic.</b> Relating to, or suffering from
+paresis.</p>
+
+<p><span class="pagenum" id="Page_425">[Pg 425]</span></p>
+
+<p><b>paronychia.</b> Inflammation of the tissues
+around the nail, felon; panaris; whitlow.</p>
+
+<p><b>parresine.</b> A paraffin preparation used
+for burns.</p>
+
+<p><b>passive.</b> Not active.</p>
+
+<p><b>pathogenic.</b> Causing disease.</p>
+
+<p><b>pathognomonic.</b> Characteristic of a disease,
+noting certain typical symptoms.</p>
+
+<p><b>pathology.</b> The science that deals with
+the change in function or in structure
+of an organ or tissue in a diseased
+state.</p>
+
+<p><b>pedal.</b> Relating to the feet.</p>
+
+<p><b>pedarthrocace.</b> Joint disease in children.</p>
+
+<p><b>pediculis corporis.</b> The body louse.</p>
+
+<p><b>pedicure.</b> One who treats the feet cosmetically.</p>
+
+<p><b>pedunculated.</b> Stalked, having a
+peduncle; not sessile.</p>
+
+<p><b>pellagra.</b> An affection characterized by
+gastro-intestinal disturbances and mental
+disorders.</p>
+
+<p><b>pelma.</b> The sole of the foot.</p>
+
+<p><b>pelmatogram.</b> An imprint of the sole of
+the foot made by resting the inked
+foot on a sheet of paper, or by pressing
+the greased foot on a plaster of Paris
+paste.</p>
+
+<p><b>pelvis.</b> Any basin-like or cup-shaped
+cavity.</p>
+
+<p><b>pemphigus.</b> An infection of the skin
+characterized by the production of
+bullae.</p>
+
+<p><b>per.</b> A prefix denoting through. (Exam:
+perennial—lasting through several
+years).</p>
+
+<p><b>perforating.</b> Piercing with one or more
+holes.</p>
+
+<p><b>peri.</b> A prefix denoting around or about.
+(Exam: periosteum—around the bone).</p>
+
+<p><b>periarthritis.</b> Inflammation of the parts
+surrounding a joint.</p>
+
+<p><b>periodic.</b> Recurring at regular intervals.</p>
+
+<p><b>perionychia.</b> (See paronychia.)</p>
+
+<p><b>periosteum.</b> The thick fibrous membrane
+covering the entire surface of a bone
+except its articular cartilage.</p>
+
+<p><b>periphery.</b> The outer part or surface;
+away from the centre.</p>
+
+<p><b>periphlebitis.</b> Inflammation of the outer
+coat of a vein or of the tissues surrounding
+a vein.</p>
+
+<p><b>pernio.</b> Chilblains; chimatlon mild.</p>
+
+<p><b>perodactylus.</b> A monster with defective
+fingers and toes.</p>
+
+<p><b>peronei.</b> Relating to the peroneus
+muscles.</p>
+
+<p><b>peropus.</b> A monster with defective feet.</p>
+
+<p><b>peroxide of hydrogen.</b> Oxygenated water,
+H<sub>2</sub>O<sub>2</sub>, used as an antiseptic and deodorant.</p>
+
+<p><b>perspiration.</b> The excretion of fluid by
+the sweat glands. The fluid excreted
+by the sweat glands; transpiration.</p>
+
+<p><b>perverted.</b> Turned from what is normal
+or proper.</p>
+
+<p><b>pes</b>, <b>gen. pedis</b>, <b>pl. pedes</b>. The foot.</p>
+
+<p><b>pes cavus.</b> Hollow-foot.</p>
+
+<p><b>pes planus.</b> Flat foot.</p>
+
+<p><b>petrogen.</b> The proprietary name of refined
+mineral oil, used as a base for
+remedial agents. <b>p. iodine.</b> Iodine
+mixed with petrogen.</p>
+
+<p><b>petrolatum.</b> Vaseline; a yellowish mixture
+of the softer members of the
+paraffin or methane series of the
+hydrocarbons, obtained from petroleum
+as an intermediate product in its distillation.</p>
+
+<p><b>phadena.</b> A sloughing ulcer.</p>
+
+<p><b>phagocytosis.</b> The process of ingestion
+and digestion by the cells; the substances
+ingested are other cells,
+bacteria, bits of necrosed tissue,
+foreign particles, etc.</p>
+
+<p><b>phalanges.</b> Long bones of the fingers or
+toes, fourteen in number, two on each
+great toe and three on each of the remaining
+toes.</p>
+
+<p><b>phenol.</b> Carbolic acid.</p>
+
+<p><b>phenomenon.</b> A symptom; any unusual
+fact or occurrence.</p>
+
+<p><b>phlebitis.</b> Inflammation of a vein.</p>
+
+<p><b>phlegmon.</b> Acute suppurative inflammation
+of the subcutaneous connective
+tissue.</p>
+
+<p><b>phosphoridrosis.</b> Phosphorescent sweating.</p>
+
+<p><b>physical.</b> Relating to the body as distinguished
+from the mind.</p>
+
+<p><b>physics.</b> The branch of science which
+deals with the phenomena of matter.</p>
+
+<p><b>physiology.</b> The science that treats of
+the functions of the organs and tissues
+of the human body.</p>
+
+<p><b>picric acid.</b> A yellowish, crystalline
+powder used in burns and eczema.</p>
+
+<p><b>pigment.</b> Coloring matter; the coloring
+matter found in the epidermis.</p>
+
+<p><b>pilocarpin.</b> An alkaloid obtained from
+the leaves of pilocarpus; used externally
+to stimulate the growth of hair.</p>
+
+<p><b>pit.</b> Any natural depression on the surface
+of the body.</p>
+
+<p><b>pityriasis.</b> A dermatosis marked by
+branny desquamation; <b>p. rubra pilaris</b>,
+an eruption of papules surrounding the
+hair follicles.</p>
+
+<p><b>plantar.</b> Relating to the sole of the foot.</p>
+
+<p><b>plantar flexion.</b> A term used to indicate
+extension of the foot forward at the
+ankle joint.</p>
+
+<p><b>plaster.</b> A solid preparation which can
+be spread when heated and which becomes
+adhesive at the temperature of
+the body.</p>
+
+<p><b>plaster of Paris.</b> Gypsum, calcium sulphate;
+used in podiatry for dressings
+and to make casts.</p>
+
+<p><b>plasticity.</b> The capability of being
+formed or moulded.</p>
+
+<p><b>platinum.</b> A silver white metal.</p>
+
+<p><b>pledget.</b> A small mass or tuft of wool,
+cotton or lint.</p>
+
+<p><b>plexiform.</b> Resembling a plexus or network.</p>
+
+<p><b>plexus.</b> A network or interjoining of
+structures in the body, especially of
+veins, nerves or lymphatics.</p>
+
+<p><b>pliability.</b> The capability of being pliable
+or flexible.</p>
+
+<p><b>plumbism.</b> Lead poisoning.</p>
+
+<p><b>podagra.</b> Gout, especially of the great
+toe.</p>
+
+<p><b>podalgia.</b> Pain in the foot.</p>
+
+<p><b>podarthritis.</b> Inflammation of any of
+the tarsal or metatarsal joints.</p>
+
+<p><b>podiatrist.</b> One who practises podiatry.</p>
+
+<p><b>podiatry.</b> The scientific care of the foot
+in health and in disease.</p>
+
+<p><b>poisoning.</b> Administering of poison;
+state of being poisoned.</p>
+
+<p><b>policeman’s heel.</b> A painful condition of
+the inferior surface of the os calcis.</p>
+
+<p><b>poliomyelitis.</b> Inflammation of the grey
+matter of the spinal cord.</p>
+
+<p><span class="pagenum" id="Page_426">[Pg 426]</span></p>
+
+<p><b>poly.</b> A prefix conveying the notion of
+multiplicity. (Exam.: polyarthritis—simultaneous
+inflammation of several
+joints).</p>
+
+<p><b>polydactylism.</b> More than five digits on
+either the hand or the foot.</p>
+
+<p><b>polyneuritis.</b> Multiple neuritis.</p>
+
+<p><b>polynuclear.</b> Multinuclear, having more
+than one nucleus.</p>
+
+<p><b>pompholyx.</b> An inflammatory eruption
+of the skin of the hands and feet,
+accompanied by itching and burning.</p>
+
+<p><b>popliteal.</b> Relating to the posterior surface
+of the knee.</p>
+
+<p><b>positive pole.</b> Anode; the chemically
+active pole of an electric battery, the
+one connected with the electronegative
+element.</p>
+
+<p><b>pore.</b> One of the minute openings of the
+sweat glands of the skin.</p>
+
+<p><b>post.</b> A prefix denoting after. (Exam.:
+postmortem—after death).</p>
+
+<p><b>posterior.</b> Behind or after.</p>
+
+<p><b>post-operative.</b> Following a surgical
+operation.</p>
+
+<p><b>posture.</b> The term applied to the position
+of the body in space.</p>
+
+<p><b>potassium hydroxide.</b> Caustic potash, a
+white crystalline mass used in solution
+form to treat verruca.</p>
+
+<p><b>potassium iodide.</b> A white, crystalline
+powder used in the internal treatment
+of syphilis.</p>
+
+<p><b>potassium permanganate.</b> A violet substance
+used as a deodorant in bromidrosis.</p>
+
+<p><b>potential cautery.</b> A caustic; an agent
+such as potassium hydroxide which
+forms an eschar without the agency
+of actual fire.</p>
+
+<p><b>potentiality.</b> A state of tension in an
+electric source.</p>
+
+<p><b>poultice.</b> Cataplasma; a soft mush prepared
+by wetting absorbent substances
+with fluids and usually applied hot to
+the surface.</p>
+
+<p><b>pre.</b> A prefix to words formed from
+Latin roots, denoting anterior or before.
+(Exam.: prepatellar—in front of
+the patella or knee cap).</p>
+
+<p><b>precursor.</b> Forerunner.</p>
+
+<p><b>predisposing.</b> Affecting the body in
+such a way as to render it vulnerable
+to the action of the exciting cause.</p>
+
+<p><b>pregnancy.</b> Gestation; the state of a
+female after conception until the birth
+of the child.</p>
+
+<p><b>prescription.</b> A written formula for the
+preparation and administration of any
+remedy or remedies.</p>
+
+<p><b>process.</b> A projection or outgrowth.</p>
+
+<p><b>profuse.</b> Exuberant; liberal to excess.</p>
+
+<p><b>prognosis.</b> The foretelling of the probable
+course of a disease.</p>
+
+<p><b>progression.</b> Advance; the act of walking.</p>
+
+<p><b>proliferation.</b> Exuberant growth by reproduction
+of similar cells.</p>
+
+<p><b>prophylaxis.</b> The prevention of disease.</p>
+
+<p><b>propulsion.</b> The tendency to fall forward
+that causes festination in paralysis
+agitans.</p>
+
+<p><b>protonuclein.</b> Trade name of a nuclein
+preparation derived from lymphoid
+tissue.</p>
+
+<p><b>protoplasm.</b> Living matter, of which
+animal and vegetable tissues are
+formed.</p>
+
+<p><b>prototype.</b> The primitive form.</p>
+
+<p><b>proud flesh.</b> Exuberant granulations; a
+fungus growth from a granulating
+surface which shows no tendency
+toward cicatrization.</p>
+
+<p><b>proximal.</b> Nearest the trunk or point of
+origin; opposed to distal.</p>
+
+<p><b>pruritus.</b> Itching.</p>
+
+<p><b>pseudo.</b> A prefix denoting a resemblance,
+like. (Exam.: pseudomania—pretended
+insanity).</p>
+
+<p><b>pseudoarthritis.</b> Hysteric joint inflammation.</p>
+
+<p><b>pseudoankylosis.</b> False ankylosis, fibrous
+ankylosis.</p>
+
+<p><b>pseudo-hypertrophic paralysis.</b> Progressive
+muscular atrophy, a disease of
+childhood in which fat takes the place
+of wasted muscle.</p>
+
+<p><b>pseudo-tabetic (pseudataxic).</b> False wasting;
+false locomotor ataxia.</p>
+
+<p><b>psoriasis.</b> A skin disease characterized
+by the formation of white scales over
+rounded, red patches. It appears
+mostly on the extensor surfaces of the
+elbows and knees.</p>
+
+<p><b>psychosis.</b> A disorder of the mind;
+<b>p. polyneuritica</b>, psychosis associated
+with polyneuritis characterized by
+failure of memory, hallucinations, and
+imaginary reminiscences.</p>
+
+<p><b>pterygium.</b> A forward growth of the
+eponychium with adherence to the
+surface of the nail.</p>
+
+<p><b>puncture.</b> To make a hole with a small
+pointed object, such as a needle.</p>
+
+<p><b>purpura.</b> An affection characterized by
+hemorrhage into the skin.</p>
+
+<p><b>purulent.</b> Suppurating, containing or
+forming pus.</p>
+
+<p><b>pus.</b> A fluid product of inflammation,
+consisting of exuded serum, leucocytes
+and the débris of dead cells.</p>
+
+<p><b>pustule.</b> A small circumscribed elevation
+on the skin, containing pus.</p>
+
+<p><b>puttees.</b> Leather leggings worn by
+soldiers and others who ride horses.</p>
+
+<p><b>putrefaction.</b> Decomposition; the cleavage
+or splitting up of the molecules of
+a protein, resulting in the formation
+of other substances of less complex
+constitution, accompanied by the formation
+of ammoniac and sulphur
+gases.</p>
+
+<p><b>pyemia.</b> The presence of pus in the
+blood.</p>
+
+<p><b>pyogenic.</b> Pus-forming; relating to pus
+formation.</p>
+
+<p><b>pyrogallic acid.</b> A substance obtained
+from gallic acid; used in podiatry in
+the treatment of verruca.</p>
+
+<p><b>pyrogallol.</b> Pyrogallic acid.</p>
+
+<p><b>pyroxylin.</b> Gun cotton, an ethereal solution
+of which makes collodion.</p>
+
+
+<p class="center bolden" id="Q">
+  Q
+</p>
+
+<p><b>quinine and urea hydrochloride.</b> A mixture
+of quinine, as its name indicates,
+used as a local anesthetic.</p>
+
+
+<p class="center bolden" id="R">
+  R
+</p>
+
+<p><b>radical.</b> As a radical operation, one
+which removes every trace of possibly
+diseased tissue, or makes recurrence
+impossible.</p>
+
+<p><b>radiograph.</b> An X-ray machine.</p>
+
+<p><b>radiogram.</b> An X-ray picture.</p>
+
+<p><b>radiography.</b> The science of obtaining
+X-ray pictures.</p>
+
+<p><span class="pagenum" id="Page_427">[Pg 427]</span></p>
+
+<p><b>radioscopy.</b> Fluoroscopy.</p>
+
+<p><b>radix.</b> The hard, usually central portion
+of a corn, root. <b>r. unguis.</b> The root
+of the nail.</p>
+
+<p><b>rancid.</b> Characterizing an oil or other
+fat which is decomposing.</p>
+
+<p><b>rational.</b> Reasonable; not delirious or
+comatose.</p>
+
+<p><b>rays.</b> Lines of light, heat or other forms
+of radioactivity. <b>alpha rays.</b> Rays
+charged with positive electricity. <b>beta
+rays.</b> Rays charged with negative electricity.
+<b>gamma rays.</b> Waves of motion
+not charged with electricity.</p>
+
+<p><b>Raynaud’s disease.</b> Symmetrical gangrene
+of the extremities.</p>
+
+<p><b>receptacle.</b> A storage place.</p>
+
+<p><b>R.</b> The abbreviation of the latin word
+recipe—take, used as the superscription
+of a prescription.</p>
+
+<p><b>recumbent.</b> Lying down.</p>
+
+<p><b>recurrent.</b> Returning; applied to symptoms.</p>
+
+<p><b>redintol.</b> A paraffin preparation used
+for burns.</p>
+
+<p><b>reduce.</b> To replace, as a fracture or a
+dislocation.</p>
+
+<p><b>redundant.</b> Exuberant, more than normal.</p>
+
+<p><b>reenforcement.</b> Augmented enforcement,
+as of a bandage or a dressing.</p>
+
+<p><b>reflex.</b> A reaction; an involuntary movement
+or exercise of function in a part.</p>
+
+<blockquote>
+<p><b>ankle r.</b>, ankle-jerk; a sudden contraction
+of the calf muscles, extending
+the foot when the tendo Achillis is
+tapped, the subject kneeling on a
+chair with the foot hanging loosely.</p>
+
+<p><b>Babinski’s r.</b>; extension of the toes
+follows tickling of the sole; usually
+a sign of organic disease of the
+pyramidal tracts.</p>
+
+<p><b>patellar r.</b>, a sudden contraction of the
+anterior muscles of the thigh from a
+tap on the patellar tendon, which
+brings up the foot, the subject being
+seated on the edge of a chair with
+legs loosely crossed; knee-jerk.</p>
+
+<p><b>plantar r.</b>; a flexion of the toes following
+scratching or tickling the sole of
+the foot.</p>
+
+<p><b>tarsophalangeal, r.</b>; flexion of the 2nd
+and 3rd (sometimes 2nd to 5th) toes
+when the dorsum of the foot is
+lightly tapped, indicating an organic
+lesion of the motor nerve-centres.</p>
+
+<p><b>tendo Achillis r.</b>; a contraction of the
+calf muscles when the tendo calcaneus
+is sharply struck.</p>
+
+<p><b>toe r.</b>; strong passive flexion of the
+great toe excites contraction of the
+flexor muscles in the leg; sudden
+passive extension causes rhythmical
+contraction of the great toe—toe-clonus.</p>
+</blockquote>
+
+<p><b>regeneration.</b> Reproduction or repair of
+lost or injured parts.</p>
+
+<p><b>relapse.</b> Return of a disease after it has
+once spent its force.</p>
+
+<p><b>relax.</b> To loosen; to slacken.</p>
+
+<p><b>remedy.</b> An agent applied to cure a
+disease or to alleviate its symptoms.</p>
+
+<p><b>renal.</b> Relating to the kidneys.</p>
+
+<p><b>repair.</b> Restoration after injury.</p>
+
+<p><b>resect.</b> To cut off, especially to cut off
+the articular ends of a bone or bones
+forming a joint.</p>
+
+<p><b>resin.</b> The residue after the distillation
+of turpentine.</p>
+
+<p><b>resolution.</b> The arrest of an inflammatory
+process without suppuration; the
+absorption or breaking down and removal
+of the products of inflammation.</p>
+
+<p><b>resonator.</b> An apparatus for producing
+sounds.</p>
+
+<p><b>resorcin.</b> A phenol derivative used for
+ulcers.</p>
+
+<p><b>respiration.</b> A function common to all
+living plants or animals, consisting in
+man in the taking in of oxygen and
+the throwing off of the products of
+oxidation.</p>
+
+<p><b>resorption.</b> Removal of an exudate, a
+blood clot, pus, etc., by absorption.</p>
+
+<p><b>rete Malpighii.</b> Stratum germinativum,
+the lowest layers of cells of the epidermis;
+the reproducing cells of the epidermis.</p>
+
+<p><b>reticular layer.</b> The inner layer of the
+corium, composed of connective tissue
+bundles.</p>
+
+<p><b>retrogressive.</b> Degenerative; a reversal
+of metabolic changes.</p>
+
+<p><b>retropulsion.</b> An involuntary backward
+running or walking occurring in certain
+nervous affections; a pushing back
+of any part.</p>
+
+<p><b>reversed.</b> Turned backward or in an
+opposite direction.</p>
+
+<p><b>rheostat.</b> A resistance coil; an instrument
+used to regulate the degree of
+resistance in an electric current.</p>
+
+<p><b>rickets.</b> Rachitis, a disease occurring in
+infants and young children; it is characterized
+by softening of the bones,
+etc.</p>
+
+<p><b>ridge.</b> A linear bone elevation.</p>
+
+<p><b>rigid.</b> Stiff; inflexible.</p>
+
+<p><b>rigor.</b> Rigidity.</p>
+
+<blockquote>
+<p><b>rigor mortis.</b>; stiffening of the body from
+one to seven hours after death.</p>
+</blockquote>
+
+<p><b>Roentgen rays.</b> X-rays.</p>
+
+<p><b>roentgenography.</b> Radiography.</p>
+
+<p><b>roentgenoscopy.</b> Fluoroscopy.</p>
+
+<p><b>roentgenotherapy.</b> The treatment of disease
+by the X-rays.</p>
+
+<p><b>root.</b> In anatomy, the base, foundation
+or beginning of any part; radix.</p>
+
+<blockquote>
+<p><b>radix unguis</b>; the root of the nail.</p>
+</blockquote>
+
+<p><b>rotary file.</b> An instrument used for
+grinding nails.</p>
+
+<p><b>rubefacient.</b> A mild counter-irritant
+which reddens the skin.</p>
+
+<p><b>rubor.</b> Redness; one of the classical
+symptoms of inflammation.</p>
+
+<p><b>ruby lamp.</b> A lamp colored red, and
+used in the dark room for developing
+purposes. It does not affect the sensitized
+plates.</p>
+
+<p><b>runaround.</b> A superficial paronychia.</p>
+
+<p><b>rupture.</b> A tear or solution of continuity.</p>
+
+
+<p class="center bolden" id="S">
+  S
+</p>
+
+<p><b>S.</b> Abbreviation of Latin, signa, remark,
+the usual introduction to the directions
+in a prescription.</p>
+
+<p><b>sac.</b> A pouch, a bursa; the capsule of a
+tumor, the envelop of a cyst.</p>
+
+<p><b>sacro-iliac disease.</b> A disease occurring
+in the region of the sacrum and ilium.</p>
+
+<p><b>salicylic acid.</b> An acid derived from the
+oil of wintergreen. Largely used in
+podiatry to remove helomata and
+verrucæ.</p>
+
+<p><b>saline solution.</b> A solution of sodium
+chloride and water in the proportion
+in which it exists in the blood.</p>
+
+<p><b>salol.</b> Phenyl salicylate.</p>
+
+<p><span class="pagenum" id="Page_428">[Pg 428]</span></p>
+
+<p><b>saltatory.</b> Relating to or marked by
+dancing or leaping.</p>
+
+<p><b>salvarsan.</b> Trade name of Ehrlich’s 606,
+employed in the treatment of syphilis.</p>
+
+<p><b>salve.</b> An ointment, ceratum, unguentum.</p>
+
+<p><b>sandal.</b> An old form of footgear.</p>
+
+<p><b>sanguineous.</b> Relating to the blood.</p>
+
+<p><b>sapo.</b> Soap.</p>
+
+<p><b>saponaceous.</b> Soapy; resembling soap.</p>
+
+<p><b>sapremia.</b> Septicemia.</p>
+
+<p><b>sarcoma.</b> A malignant connective tissue
+neoplasm.</p>
+
+<p><b>saturated.</b> Impregnated to the greatest
+possible extent; said of a solution; a
+liquid holding all of a given solute
+that it can dissolve.</p>
+
+<p><b>saturnism.</b> Lead poisoning.</p>
+
+<p><b>scab.</b> A crust formed by the drying of
+the pus on the surface of an ulcer or
+excoriation.</p>
+
+<p><b>scalloped.</b> Cut in curves.</p>
+
+<p><b>scalpel.</b> A pointed knife with a convex
+edge.</p>
+
+<p><b>scarfskin.</b> Epidermis.</p>
+
+<p><b>scar tissue.</b> White fibrous tissue formed
+in the healing of wounds; cicatrix.</p>
+
+<p><b>scarify.</b> To make a number of superficial
+incisions in the skin.</p>
+
+<p><b>scarlet red.</b> An organic dye-stuff used
+in ointment form as an antiseptic and
+as a stimulant in the treatment of
+ulcers.</p>
+
+<p><b>sciatic.</b> Relating to sciatica.</p>
+
+<p><b>sciatica.</b> Sciatic neuritis. Neuralgia of
+the sciatic nerve.</p>
+
+<p><b>sclerodactylia.</b> Scleroderma affecting the
+digits of the hands or feet.</p>
+
+<p><b>scleroderma.</b> A hardening and thickening
+of the skin with loss of elasticity.</p>
+
+<p><b>scleronychia.</b> Induration and thickening
+of the nails.</p>
+
+<p><b>sclerosis.</b> Induration or hardening, of
+chronic inflammatory origin.</p>
+
+<p><b>scoliosis.</b> Lateral curvature of the spine.</p>
+
+<p><b>scorbutus.</b> Scurvy.</p>
+
+<p><b>scrofula.</b> A constitutional state, occurring
+in the young and marked by a lack
+of tissue resisting power.</p>
+
+<p><b>scurvy.</b> A disease marked by inanition,
+debility, anemia, edema of the dependent
+parts; a spongy condition, sometimes
+with ulceration of the gums and
+hemorrhages into the skin and from
+the mucous membranes.</p>
+
+<p><b>sebaceous.</b> Carrying or producing sebum.</p>
+
+<p><b>sebum.</b> The fluid excreted by the sebaceous
+glands of the skin.</p>
+
+<p><b>seborrhea.</b> Overaction of the sebaceous
+glands.</p>
+
+<p><b>secondary.</b> One of the symptoms of
+syphilis, following the development of
+the chancre.</p>
+
+<p><b>secretion.</b> The product (solid, liquid or
+gaseous) of cellular or glandular activity.
+A secretion is stored up in or
+utilized by the animal or plant in
+which it is produced, thereby differing
+from an excretion which is intended to
+be expelled from the body.</p>
+
+<p><b>secretory.</b> Relating to secretion or to
+the secretions.</p>
+
+<p><b>sedative.</b> An agent which quiets nervous
+excitement.</p>
+
+<p><b>semi.</b> A prefix denoting one-half or
+partly. (Exam. semi-flexion—midway
+between flexion and extension).</p>
+
+<p><b>semis.</b> One-half; noted in prescription
+writing as ss.</p>
+
+<p><b>senility.</b> Old age.</p>
+
+<p><b>sensitized.</b> Rendered sensitive.</p>
+
+<p><b>sensory.</b> Relating to sensation.</p>
+
+<p><b>septic.</b> Unclean, contaminated with bacteria.</p>
+
+<p><b>septicemia.</b> A systemic disease caused
+by the presence of microorganisms or
+their toxins in the blood; sepsis.</p>
+
+<p><b>septum.</b> A thin wall dividing two cavities
+or masses of softer tissue.</p>
+
+<p><b>sequestrum.</b> A piece of necrosed bone
+which has become separated from the
+surrounding healthy osseous tissue.</p>
+
+<p><b>serofibrinous.</b> Noting an exudate composed
+of serum and fibrin.</p>
+
+<p><b>sero-purulent.</b> Containing both serum and
+pus.</p>
+
+<p><b>serous.</b> Relating to, containing or producing
+serum.</p>
+
+<p><b>serpiginous.</b> Noting an ulcer or other
+cutaneous lesion which extends gradually
+over the surface on one side while
+usually healing on the other.</p>
+
+<p><b>serrated.</b> Notched, toothed.</p>
+
+<p><b>serum.</b> A clear, watery fluid that
+moistens the surface of serous membranes.
+The fluid portion of the blood
+obtained after coagulation.</p>
+
+<p><b>sesamoid.</b> Resembling in size or shape a
+grain of sesame; an oval nodule of
+bone or fibro-cartilage in a tendon playing
+over a joint surface; most common
+in the metacarpo and metatarsophalangeal
+articulations and other joints of
+the fingers and toes.</p>
+
+<p><b>sessile.</b> Having a broad base of attachment,
+not pedunculated.</p>
+
+<p><b>sheath.</b> Any enveloping structure, such
+as the membranous covering of a
+muscle, nerve or blood vessel.</p>
+
+<p><b>sheepskin.</b> Prepared skin of the sheep,
+used for shields.</p>
+
+<p><b>shield.</b> An agent used in podiatry to
+protect a part from friction or pressure.</p>
+
+<p><b>shock.</b> A sudden physical or mental disturbance.</p>
+
+<p><b>silver.</b> Argentum; a metal of lustrous
+white color.</p>
+
+<blockquote>
+<p><b>s. nitrate</b>; largely used in podiatry as
+a caustic, escharotic and stimulant.</p>
+
+<p><b>s. stick</b>; fused silver nitrate in stick
+form.</p>
+</blockquote>
+
+<p><b>sinew.</b> Tendon.</p>
+
+<p><b>sinister.</b> Of evil import, of bad prognosis;
+Latin for left, in contradistinction
+to dexter, meaning right.</p>
+
+<p><b>sinistrapodeal.</b> Left footed.</p>
+
+<p><b>sinuous.</b> Tortuous, bending in several
+directions.</p>
+
+<p><b>sinus.</b> A tortuous tract opening on a
+free surface and leading down to an
+abscess cavity.</p>
+
+<p><b>sirenomelia.</b> A monstrosity having two
+lower limbs fused in one.</p>
+
+<p><b>skiagram.</b> A print made from a photographic
+plate exposed to the action of
+the X-rays.</p>
+
+<p><b>skiagraphy.</b> Radiography.</p>
+
+<p><b>skiascopy.</b> Fluoroscopy.</p>
+
+<p><b>skin.</b> The membranous covering of the
+body, cutis, integumentum.</p>
+
+<p><b>skin grafting.</b> The placing of bits of
+epidermis or larger strips of the entire
+skin on a denuded surface in order to
+supply defects or to stimulate a new
+skin growth.</p>
+
+<p><b>skiving.</b> The process of thinning shields
+at their borders.</p>
+
+<p><b>skiving knife.</b> An instrument used for
+skiving.</p>
+
+<p><b>slough.</b> Necrosed tissue separated from
+the living structure.</p>
+
+<p><span class="pagenum" id="Page_429">[Pg 429]</span></p>
+
+<p><b>sodium.</b> A metallic element. The following
+salts of sodium are used in podiatry.</p>
+
+<blockquote>
+<p><b>s. bicarbonate</b>; used as a dusting
+powder in acidity of the skin.</p>
+
+<p><b>s. borate</b>; (borax) used as an antiseptic.</p>
+
+<p><b>s. chloride</b>; (common salt) used as
+an antiseptic.</p>
+
+<p><b>s. ethylate</b>; used as a caustic in
+verruca.</p>
+
+<p><b>s. hydroxide</b>; (caustic soda) used as
+a caustic.</p>
+
+<p><b>s. sulphide</b>; used to remove superfluous
+hair.</p>
+</blockquote>
+
+<p><b>soggy.</b> Soaked; wet.</p>
+
+<p><b>sole.</b> The under part of the foot, the
+plantar surface.</p>
+
+<p><b>solution.</b> The incorporation of a solid or
+gas in a fluid.</p>
+
+<p><b>spasm.</b> An involuntary convulsive
+muscular contraction; cramp.</p>
+
+<p><b>spastic.</b> Spasmodic, convulsive.</p>
+
+<p><b>spatula.</b> A flat blade used for spreading
+plasters and ointments.</p>
+
+<p><b>spatulate.</b> Shaped like a spatula.</p>
+
+<p><b>specific.</b> Relating to an individual infectious
+disease, one caused by a special
+microorganism; in a special restricted
+sense, syphilis.</p>
+
+<p><b>sphacelous.</b> Necrotic, gangrenous, sloughing.</p>
+
+<p><b>spheroidal.</b> Resembling a sphere.</p>
+
+<p><b>spica.</b> A form of bandage with overlapping
+turns.</p>
+
+<p><b>spinal.</b> Relating to the vertebral column.</p>
+
+<p><b>spiral.</b> Coiled; winding around a center.</p>
+
+<p><b>spiritus (spirit).</b> An alcoholic solution of
+a gaseous or volatile substance.</p>
+
+<p><b>Spirochaeta pallida.</b> The protozoan
+which when present in the blood indicates
+syphilis.</p>
+
+<p><b>splay-foot.</b> Flat foot, talipes valgus.</p>
+
+<p><b>splint.</b> An apparatus for rendering a
+part immobile, as in fractures.</p>
+
+<p><b>spontaneous.</b> Occurring without external
+stimulation.</p>
+
+<p><b>sporadic.</b> Occurring singly; neither endemic
+nor epidemic.</p>
+
+<p><b>spur.</b> A dull spine or projection from a
+bone.</p>
+
+<p><b>staphylococcus.</b> A group of cocci in
+which the individuals are arranged in
+irregular masses somewhat resembling
+a bunch of grapes.</p>
+
+<p><b>stasis.</b> Stagnation of the blood or other
+fluids.</p>
+
+<p><b>static.</b> In a state of equilibrium or rest;
+not in action.</p>
+
+<p><b>static ataxia.</b> Inability to preserve
+equilibrium in standing through loss of
+the deep sensibility.</p>
+
+<p><b>station.</b> Power of standing more or less
+firmly on one’s feet.</p>
+
+<p><b>stereognosis.</b> Ascertaining the form of
+an object by means of touch.</p>
+
+<p><b>sterile.</b> Surgically clean; free from bacteria.</p>
+
+<p><b>sterilization.</b> The act of making a person
+or thing sterile.</p>
+
+<p><b>sterilizer.</b> An apparatus for making
+anything aseptic or germ free.</p>
+
+<p><b>stimulant.</b> An agent that arouses organic
+activity.</p>
+
+<p><b>stimulation.</b> The arousing of the body
+or any of its parts or organs to increased
+functional activity.</p>
+
+<p><b>stovaine.</b> A local anesthetic, used especially
+to induce spinal anesthesia.</p>
+
+<p><b>stratum.</b> Layer.</p>
+
+<p><b>streptococcus.</b> A group of cocci in which
+the arrangement resembles chains.</p>
+
+<p><b>streptococcus viridans.</b> A form of streptococcus
+which grows in green colonies
+and is not hemolytic; the bacterium
+responsible for most focal infections in
+the teeth.</p>
+
+<p><b>striated.</b> Striped.</p>
+
+<p><b>stroma.</b> The framework made of connective
+tissue.</p>
+
+<p><b>strychnine.</b> An alkaloid of nux vomica.</p>
+
+<p><b>stump-foot.</b> Club-foot.</p>
+
+<p><b>styptic.</b> Astringent, hemostatic.</p>
+
+<p><b>sub.</b> A prefix denoting beneath, less
+than normal or typical; inferior; corresponds
+to hypo. (Exam. subastragular—under
+the astragalus).</p>
+
+<p><b>subacute.</b> Not frankly acute, yet not
+chronic, noting the course of a disease.</p>
+
+<p><b>subcutaneous.</b> Beneath the skin.</p>
+
+<p><b>subluxation.</b> An incomplete luxation or
+dislocation.</p>
+
+<p><b>sudamina.</b> Minute vesicles due to retention
+of fluid at the mouth of a sweat
+follicle.</p>
+
+<p><b>sudoriferous.</b> Carrying or producing
+sweat.</p>
+
+<p><b>sulphur.</b> Brimstone; a chemical element;
+used in ointment form as a stimulant.</p>
+
+<p><b>super.</b> A prefix signifying in excess,
+above, superior, same as supra and
+hyper. (Exam. supertension—extreme
+tension).</p>
+
+<p><b>superficial.</b> Near the surface; cursory,
+not thorough.</p>
+
+<p><b>superfluous.</b> More than sufficient.</p>
+
+<p><b>supernumerary.</b> More than normal in
+number.</p>
+
+<p><b>supersaturated.</b> Said of a solution which
+holds more than a normal quantity of
+a solute, and caused by heating the
+liquid.</p>
+
+<p><b>suppurate.</b> To form pus.</p>
+
+<p><b>supra.</b> A prefix denoting a position
+above. (Exam. supracostal—above the
+ribs).</p>
+
+<p><b>surgery.</b> The branch of medicine which
+has to do with the treatment of disease
+by means of operative procedures.</p>
+
+<p><b>suture.</b> The surgical uniting of two surfaces
+by means of stitches, with silk
+thread, catgut, wire, etc., the material
+by which the two surfaces are held in
+apposition.</p>
+
+<p><b>swab.</b> A tuft of cotton or other like
+material attached to the end of a stick
+or wire; used for cleansing cavities or
+applying remedies.</p>
+
+<p><b>sweat gland.</b> One of the tubular coil-glands
+in the corium and subcutaneous
+connective tissue, secreting sweat.</p>
+
+<p><b>swell-foot.</b> Swelling and redness of the
+metatarsus, with pain and disability,
+due to sprain of the ligaments which
+are frequently detached from the
+bones.</p>
+
+<p><b>symptomatology.</b> The science of the
+symptoms of disease.</p>
+
+<p><b>symptoms.</b> Any morbid phenomenon or
+departure from the normal in function,
+appearance or sensation experienced by
+the patient and indicative of disease.
+<b>Objective s.</b>, one which is evident to
+the observer. <b>Subjective s.</b>, one apparent
+only to the patient.</p>
+
+<p><b>synarthrosis.</b> A fixed articulation.</p>
+
+<p><b>syndactylous.</b> Having webbed fingers or
+toes.</p>
+
+<p><span class="pagenum" id="Page_430">[Pg 430]</span></p>
+
+<p><b>synonyms.</b> Words having the same
+meaning as others.</p>
+
+<p><b>synovia.</b> A clear fluid secreted by a
+synovial membrane and used to lubricate
+the joints.</p>
+
+<p><b>synovial membrane.</b> The lining membrane
+of a joint, secreting the synovia.</p>
+
+<p><b>synthetic.</b> Relating to the formation of
+chemical compounds by the union of
+simpler compounds.</p>
+
+<p><b>syphilide.</b> Any skin lesion of syphilitic
+origin.</p>
+
+<p><b>syphilis.</b> An infectious disease spread
+by inoculation, usually by sexual intercourse,
+and due to the spirochaeta
+pallida.</p>
+
+<p><b>syphiloderma.</b> Syphilis of the skin.</p>
+
+<p><b>syringe.</b> An instrument for injecting
+fluids.</p>
+
+<p><b>syringomyelia.</b> The presence of cavities
+in the spinal cord due to the breaking
+down of gliomatous new formations.</p>
+
+<p><b>systemic.</b> Relating to the entire organism
+as distinguished from any of its
+individual parts.</p>
+
+<p><b>systremma.</b> A muscular cramp in the
+calf of the leg.</p>
+
+
+<p class="center bolden" id="T">
+  T
+</p>
+
+<p><b>tabes dorsalis.</b> Locomotor ataxia, a disease
+of the spinal ganglia and roots
+usually found in middle age and often
+the sequel of syphilis.</p>
+
+<p><b>tactile.</b> Relating to touch or to the sense
+of touch.</p>
+
+<p><b>talipes.</b> Kyllosis; club-foot in general.</p>
+
+<blockquote>
+<p><b>t. calcaneovalgus</b>; t. calcaneus and t.
+valgus, combined;</p>
+
+<p><b>t. calcaneovarus</b>; t. calcaneus and t.
+varus, combined;</p>
+
+<p><b>t. calcaneus</b>; permanent dorsal flexion
+of the foot, so that the weight of the
+body rests on the heel, only;</p>
+
+<p><b>t. cavus</b>; hollow-foot, an exaggeration
+of the normal arch of the foot.</p>
+
+<p><b>t. equinovalgus</b>; t. equinus and t. valgus,
+combined;</p>
+
+<p><b>t. equinovarus</b>; t. equinus and t. varus,
+combined;</p>
+
+<p><b>t. equinus</b>; permanent extension of the
+foot so that only the ball rests on
+the ground;</p>
+
+<p><b>t. percavus</b>; an extreme degree of t.
+vagus;</p>
+
+<p><b>t. planovalgus</b>; t. valgus;</p>
+
+<p><b>t. planus</b>; flat foot, splay-foot—a condition
+in which the arch of the foot
+is broken down, the entire sole touching
+the ground;</p>
+
+<p><b>t. spasmodicus</b>; a temporary distortion
+of the foot, usually t. equinus, due
+to muscular spasm;</p>
+
+<p><b>t. vagus</b>; permanent eversion of the
+foot, the inner side alone of the sole
+resting on the ground;</p>
+
+<p><b>t. varus</b>; inversion of the foot, the
+outer side of the foot only touching
+the ground.</p>
+</blockquote>
+
+<p><b>talus.</b> Ankle bone, astragalus.</p>
+
+<p><b>tampon.</b> To plug a canal with gauze,
+cotton wool or other substance; the
+substance used for the above purpose is
+also known by the same name.</p>
+
+<p><b>tangent.</b> A straight line that touches or
+meets a circle or curve, but does not
+cut it.</p>
+
+<p><b>tannoform.</b> Trade name of a compound
+of tannin with ferric aldehyde.</p>
+
+<p><b>tarsal.</b> Relating to a tarsus in any sense.</p>
+
+<p><b>tarsalgia.</b> Podalgia; policeman’s disease;
+pain in the tarsus usually due to incipient
+flat foot or to a shortening of
+the tendo Achillis.</p>
+
+<p><b>tarsometatarsal.</b> Relating to the tarsal
+and metatarsal bones of the foot or
+region.</p>
+
+<p><b>tarsophalangeal.</b> Relating to the tarsus
+and the phalanges.</p>
+
+<p><b>tarsus.</b> The root of the foot, or instep.</p>
+
+<p><b>T. B. C. (tuberculosis).</b> A specific disease
+caused by the presence of bacillus
+tuberculosis; it may affect almost any
+tissue or organ of the body, the most
+common seats of the disease being the
+lungs and joints.</p>
+
+<p><b>teat.</b> Any nipple-like protuberance.</p>
+
+<p><b>technic.</b> The manner of performance of
+any surgical operation.</p>
+
+<p><b>temper.</b> Elasticity or hardness in steel.</p>
+
+<p><b>tenalgia.</b> Pain referred to a tendon.</p>
+
+<p><b>tendo Achillis.</b> The tendon of insertion
+of the gastrocnemius and the soleus
+muscles into the tuberosity of the os
+calcis.</p>
+
+<p><b>tendon.</b> A fibrous cord or band which
+connects the muscle to its bony attachment.</p>
+
+<p><b>tenotomy.</b> The surgical division of a
+tendon.</p>
+
+<p><b>tension.</b> The act of stretching.</p>
+
+<p><b>tepid.</b> Lukewarm, for a bath, 86°F.</p>
+
+<p><b>tertiary.</b> The final stages of syphilis.</p>
+
+<p><b>tetanus.</b> An infectious disease marked
+by painful tonic muscular contractions;
+caused by the toxin of bacillus tetani
+acting upon the central nervous system.</p>
+
+<p><b>tetany.</b> A disorder marked by intermittent
+tonic muscular contractions.</p>
+
+<p><b>tetradactyl.</b> Having only four fingers or
+toes on a hand or foot.</p>
+
+<p><b>therapeutic.</b> Relating to the treatment of
+disease; curative.</p>
+
+<p><b>thermal.</b> Relating to warmth or heat.</p>
+
+<p><b>thermocautery.</b> The actual cautery;
+destruction of tissue by heat.</p>
+
+<p><b>Thiersch’s solution.</b> An antiseptic solution
+containing boric acid and salicylic
+acid.</p>
+
+<p><b>Thomsen’s disease.</b> Myotonia congenita.
+An hereditary disease marked by momentary
+tonic spasms which occur
+when a voluntary movement is attempted.</p>
+
+<p><b>thrombosis.</b> Formation or presence of a
+thrombus.</p>
+
+<p><b>thrombus.</b> A plug more or less completely
+occluding a blood vessel or one
+of the cavities of the heart.</p>
+
+<p><b>tibia.</b> Shin-bone; the inner and larger
+of the two bones of the leg.</p>
+
+<p><b>tinctura.</b> An alcoholic solution or extract
+of a non-volatile vegetable substance;
+a tincture.</p>
+
+<blockquote>
+<p><b>t. arnicae</b>; used for sprains and
+bruises;</p>
+
+<p><b>t. benzoini comp.</b>; used for sunburn,
+chimatlon, etc.;</p>
+
+<p><b>t. calendulae</b>; used for sprains and
+bruises;</p>
+
+<p><b>t. cresolis saponata</b>; used as an antiseptic;</p>
+
+<p><b>t. ferri chloridi</b>;</p>
+
+<p><b>t. iodi</b>;</p>
+
+<p><b>t. iodi (Churchill)</b>;</p>
+
+<p><b>t. iodi decolorata</b>;</p>
+
+<p><b>t. saponis viridis</b>.</p>
+</blockquote>
+
+<p><b>tinea unguium.</b> Ringworm of the nail.</p>
+
+<p><b>tip-foot.</b> Talipes equinus.</p>
+
+<p><span class="pagenum" id="Page_431">[Pg 431]</span></p>
+
+<p><b>tissue.</b> A collection of cells or of cell
+derivatives forming a definite structure.</p>
+
+<p><b>titubation.</b> A staggering or stumbling in
+trying to walk, due to spinal lesion;
+restlessness.</p>
+
+<p><b>toe.</b> Digitus pedis, one of the digits of
+the feet.</p>
+
+<blockquote>
+<p><b>great t.</b>, the toe on the inner, tibial
+side of the foot corresponding to the
+thumb.</p>
+
+<p><b>hammer t.</b>, permanent flexion at the
+mid-phalangeal joint.</p>
+</blockquote>
+
+<p><b>toe drop.</b> A drooping of the anterior
+portion of the foot, due to paralysis.</p>
+
+<p><b>toe separator.</b> An instrument used for
+separating the toes.</p>
+
+<p><b>toe webs.</b> The skin at the base of the toes.</p>
+
+<p><b>tonic.</b> In a state of continuous, unremitting
+action, noting especially a
+muscular contraction. Increasing physical
+or mental tone or strength, invigorating.
+A remedy given or applied
+to tone up the system.</p>
+
+<p><b>touch corpuscles.</b> Special bodies found in
+the true skin, especially at the ends
+of the fingers, and used for the sense
+of touch.</p>
+
+<p><b>tourniquet.</b> An instrument for arresting
+the flow of blood through a part.</p>
+
+<p><b>toxemia.</b> Blood-poisoning; the presence
+of toxins in the blood.</p>
+
+<p><b>toxic.</b> Poisonous. Relating to a toxin.</p>
+
+<p><b>toxin.</b> A poisonous substance of undetermined
+chemical nature, developed
+during the growth of pathogenic bacteria.</p>
+
+<p><b>transient.</b> Not permanent; coming and
+going.</p>
+
+<p><b>transition.</b> Passage from one condition
+or one part to another.</p>
+
+<p><b>trauma.</b> A wound or injury.</p>
+
+<p><b>traumatic.</b> Relating to or caused by a
+wound or injury.</p>
+
+<p><b>tremor.</b> Trembling, shaking; a disorder
+of the muscular tonus or loss of equilibrium,
+the normal inappreciable tonic
+contractions being exaggerated.</p>
+
+<p><b>trench foot.</b> A disease of the present
+war. See full description in the body
+of the book as per index.</p>
+
+<p><b>tropacocaine.</b> An alkaloid obtained from
+Java coca leaves; a local anesthetic.</p>
+
+<p><b>trophic.</b> Relating to or dependent upon
+nutrition.</p>
+
+<p><b>tuberculosis.</b> A specific disease caused
+by the bacillus tuberculosis; it may
+affect any tissue of the body.</p>
+
+<p><b>tumor.</b> Neoplasm; a circumscribed
+growth, not inflammatory in character.</p>
+
+<p><b>tungsten.</b> A metallic element, symbol
+W, atomic weight 184, occurring as a
+gray powder of metallic lustre. A
+form of incandescent electric lamp is
+made of a tungsten filament.</p>
+
+<p><b>turpentine.</b> Terebinthina. Prepared in
+the form of oil and of spirit for external
+applications.</p>
+
+<p><b>tyloma.</b> Callosity, tylosis.</p>
+
+<p><b>tyroma.</b> A caseous (cheese-like) tumor.</p>
+
+<p><b>typhoid.</b> Typhus-like; stuporous from
+fever; same as typhoid fever.</p>
+
+
+<p class="center bolden" id="U">
+  U
+</p>
+
+<p><b>ulcer.</b> A circumscribed open sore which
+shown no tendency to heal; ulcus.</p>
+
+<p><b>uncinariasis.</b> Hookworm disease.</p>
+
+<p><b>undertoe.</b> Displacement of the great toe
+beneath the second toe.</p>
+
+<p><b>ungual.</b> Relating to the nail.</p>
+
+<p><b>unguentum.</b> Ointment, salve.</p>
+
+<blockquote>
+<p><b>u.</b> acidi borici, boric acid ointment;
+used in burns and abrasions.</p>
+
+<p><b>u.</b> acidi salicylici, salicylic acid ointment;
+used as a disintegrant.</p>
+
+<p><b>u.</b> acidi carbolici, carbolic acid or
+phenol ointment; used in burns and
+in superficial wounds.</p>
+
+<p><b>u.</b> balsam Peruvianum, balsam of
+Peru ointment; stimulating.</p>
+
+<p><b>u.</b> camphorae, camphor ointment;
+stimulating.</p>
+
+<p><b>u.</b> cantharidis, cantharidal ointment;
+rubefacient.</p>
+
+<p><b>u.</b> capsici, capsicum ointment; rubefacient.</p>
+
+<p><b>u.</b> creosoti, creosote ointment; applied
+to chilblains, indolent ulcers and
+various skin affections.</p>
+
+<p><b>u.</b> diachylon, Hebra’s lead ointment;
+employed in hyperidrosis.</p>
+
+<p><b>u.</b> hamamelidis, witch hazel ointment;
+a soothing application.</p>
+
+<p><b>u.</b> hydrargyri ammoniati, white precipitate
+ointment; applied in chronic
+skin conditions and in tubercular
+syphilides.</p>
+
+<p><b>u.</b> hydrargyri oxide rubri, red precipitate
+ointment; used in the treatment
+of indolent ulcers.</p>
+
+<p><b>u.</b> ichthyoli, ichthyol ointment; emollient.</p>
+
+<p><b>u.</b> iodi, iodine ointment; used in chilblains
+and in glandular enlargements.</p>
+
+<p><b>u.</b> picus compositum, compound tar
+ointment; employed in wounds and
+in burns.</p>
+
+<p><b>u.</b> plumbi acetatis, lead acetate ointment;
+astringent application to
+burns and superficial inflammations.</p>
+
+<p><b>u.</b> resorcini compositum, “soothing
+ointment”; astringent and antiseptic.</p>
+
+<p><b>u.</b> scarlet red, scarlet red ointment;
+stimulating.</p>
+
+<p><b>u.</b> sulphuris, sulphur ointment; used
+in scabies.</p>
+
+<p><b>u.</b> zinci oxidi, ointment of zinc oxide;
+a soothing mild astringent application
+in skin diseases, burns and
+abrasions.</p>
+</blockquote>
+
+<p><b>unguis.</b> Nail; a thin, horny, transparent
+plate covering the dorsal surface of the
+distal end of each terminal phalanx of
+fingers and toes.</p>
+
+<p><b>Unverricht’s progressive myoclonus.</b> See
+Thomsen’s disease.</p>
+
+<p><b>uric acidemia.</b> See lithemia.</p>
+
+<p><b>uridrosis.</b> The excretion of urea or uric
+acid in the sweat.</p>
+
+<p><b>union.</b> The joining together of the opposing
+parts of a wound.</p>
+
+<p><b>unofficial.</b> Not official; said of a remedial
+agent not described in the pharmacopeia.</p>
+
+<p><b>uremia.</b> An auto-intoxication occurring
+in certain cases of nephritis or in
+anuria from any cause.</p>
+
+<p><b>U. S. P.</b> Abbreviation for the United
+States Pharmacopeia.</p>
+
+
+<p class="center bolden" id="V">
+  V
+</p>
+
+<p><b>vacuum.</b> A space from which the air
+has been practically extracted.</p>
+
+<p><b>valgus.</b> Bending outward; noting a condition
+of the great toe, in which it is
+bent outward; knock-knees; see talipes
+valgus.</p>
+
+<p><span class="pagenum" id="Page_432">[Pg 432]</span></p>
+
+<p><b>vanadium chloride.</b> A yellowish substance
+used in bromidrosis.</p>
+
+<p><b>varicose.</b> Relating to or affected with
+large and tortuous veins.</p>
+
+<p><b>variola.</b> Smallpox.</p>
+
+<p><b>varix.</b> An enlarged and tortuous vein,
+artery or lymphatic vessel.</p>
+
+<p><b>vascular.</b> Relating to or containing
+blood vessels.</p>
+
+<p><b>vasoconstrictors.</b> Agents which cause
+narrowing of the blood vessels; nerves,
+stimulation of which cause vascular
+constriction.</p>
+
+<p><b>vasodilators.</b> Agents which cause dilatation
+of the blood vessels; a nerve,
+stimulation of which results in dilatation
+of the blood vessels.</p>
+
+<p><b>vasomotor.</b> The nerves which have the
+power of dilating or constricting the
+blood vessels.</p>
+
+<p><b>vein.</b> A blood vessel conveying blood
+towards the heart. Lat. vena.</p>
+
+<p><b>veins of the foot</b>:</p>
+
+<blockquote>
+<p><b>v.</b> plantaris interna; internal plantar
+vein (plantar surface, deep).</p>
+
+<p><b>v.</b> plantaris externa; external plantar
+vein (plantar surface, deep).</p>
+
+<p><b>v.</b> saphena brevis; external or short
+saphenous vein (dorsal surface,
+superficial).</p>
+
+<p><b>v.</b> saphena longa; internal or long
+saphenous vein (dorsal surface,
+superficial).</p>
+
+<p><b>v.</b> tibialis anticus; anterior tibial
+vein (dorsal surface, deep).</p>
+
+<blockquote>
+<p>No veins on the superficial plantar
+surface.</p>
+</blockquote>
+</blockquote>
+
+<p><b>verbatim.</b> Word for word.</p>
+
+<p><b>vermiform appendix.</b> A blind sac of the
+intestine, extending from the head of
+the cecum.</p>
+
+<p><b>verruca.</b> A circumscribed overgrowth of
+the layers of the skin, including those
+of the derma (plural, verrucæ).</p>
+
+<p><b>vertebral caries.</b> Molecular death of the
+bones of the spinal column.</p>
+
+<p><b>vertigo.</b> Dizziness, giddiness.</p>
+
+<p><b>vesicant.</b> An agent which when applied
+to the skin produces a blister.</p>
+
+<p><b>vesicle.</b> A small circumscribed elevation
+on the skin, containing non-purulent
+fluid; a blister.</p>
+
+<p><b>vesicular.</b> Relating to a vesicle; containing
+vesicles.</p>
+
+<p><b>vibration.</b> A shaking, oscillation.</p>
+
+<p><b>vice versa.</b> The terms in the case being
+reversed.</p>
+
+<p><b>virulent.</b> Extremely poisonous.</p>
+
+<p><b>vocational.</b> Referring to occupation.</p>
+
+<p><b>volatile.</b> Not permanent; evaporating
+spontaneously.</p>
+
+<p><b>voltage.</b> The electromotive force of a
+current expressed in volts.</p>
+
+<p><b>vulcanizing.</b> Adhering rubber by means
+of heat.</p>
+
+
+<p class="center bolden" id="W">
+  W
+</p>
+
+<p><b>wart.</b> A circumscribed hypertrophy of
+the papillæ of the corium. (See
+verruca).</p>
+
+<p><b>Wassermann test.</b> A diagnostic test for
+syphilis, based upon the theory of
+complement fixation.</p>
+
+<p><b>web.</b> The skin found at the base of the
+fingers or toes.</p>
+
+<p><b>wheal.</b> An acute, circumscribed elevation
+of the skin due to edema in the
+derma.</p>
+
+<p><b>whitlow.</b> Felon, paronychia, inflammation
+of the tissues around the nail.</p>
+
+<p><b>whorl.</b> A set of organs arranged in a
+circle around an axis.</p>
+
+<p><b>wick.</b> A piece of gauze or other material
+used for draining cavities.</p>
+
+<p><b>wipe.</b> A piece of gauze or cotton used
+in wiping instruments.</p>
+
+<p><b>wool fat.</b> Adeps lanae. Used as an embrocation
+in podiatry. Lanolin.</p>
+
+<p><b>Woulfe’s bottle.</b> A bottle with two or
+three necks, for working with gases
+(washing, drying, etc.).</p>
+
+<p><b>wound.</b> Loss in continuity upon the surfaces
+of the body.</p>
+
+<p><b>wrist drop.</b> Paralysis of the extensors of
+the wrist and fingers.</p>
+
+
+<p class="center bolden" id="X">
+  X
+</p>
+
+<p><b>X-rays.</b> Roentgen rays.</p>
+
+<p><b>xystus.</b> Scraped lint; lint made by
+scraping linen with a sharp instrument.</p>
+
+
+<p class="center bolden" id="Z">
+  Z
+</p>
+
+<p><b>Zander’s system.</b> Treatment by means
+of mechanical apparatus giving passive
+movements.</p>
+
+<p><b>zinc oxide.</b> A white powder used as an
+astringent.</p>
+
+<p><b>zinc stearate.</b> A white powder used as
+an antiseptic dusting powder.</p>
+
+<p><b>zymotic.</b> Relating to fermentation;
+noting an infectious disease.</p>
+
+<hr class="tb">
+
+<p>(We are obligated to Stedman’s Practical
+Medical Dictionary for many of the
+definitions of medical terms above noted—Editor).</p>
+
+
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+
+<p><span class="pagenum" id="Page_433">[Pg 433]</span></p>
+
+
+  <h2 class="nobreak" id="CROSS_REFERENCE_INDEX">
+    CROSS REFERENCE INDEX
+  </h2>
+</div>
+
+
+<nav>
+<ul class="index">
+  <li class="ifrst">A</li>
+
+  <li class="indx">Acetanilid, <a href="#Page_296">296</a></li>
+
+  <li class="indx">Acetic acid, <a href="#Page_191">191</a></li>
+
+  <li class="indx">Acriflavin, <a href="#Page_34">34</a></li>
+
+  <li class="indx">Actinotherapy, <a href="#Page_385">385</a></li>
+
+  <li class="indx">Adenoids, <a href="#Page_379">379</a></li>
+
+  <li class="indx">Adipose tissue, <a href="#Page_14">14</a></li>
+
+  <li class="indx">Advent of foot clothing, <a href="#Page_47">47</a></li>
+
+  <li class="indx">Alcohol, <a href="#Page_27">27</a>, <a href="#Page_131">131</a>, <a href="#Page_198">198</a>, <a href="#Page_215">215</a>, <a href="#Page_218">218</a>, <a href="#Page_225">225</a>,
+    <a href="#Page_228">228</a>, <a href="#Page_250">250</a>, <a href="#Page_253">253</a>, <a href="#Page_273">273</a>, <a href="#Page_275">275</a>, <a href="#Page_301">301</a>,
+    <a href="#Page_331">331</a>, <a href="#Page_334">334</a></li>
+
+  <li class="indx">Aluminum acetate, <a href="#Page_219">219</a>, <a href="#Page_224">224</a>, <a href="#Page_225">225</a>, <a href="#Page_289">289</a>, <a href="#Page_295">295</a></li>
+
+  <li class="indx">Aluminum chloride, <a href="#Page_301">301</a></li>
+
+  <li class="indx">Alternate foot bath, <a href="#Page_53">53</a>, <a href="#Page_299">299</a></li>
+
+  <li class="indx">Alternating current, <a href="#Page_386">386</a></li>
+
+  <li class="indx">Alypin, <a href="#Page_144">144</a></li>
+
+  <li class="indx">Ambrene, <a href="#Page_70">70</a></li>
+
+  <li class="indx">Ammoniated mercury, <a href="#Page_29">29</a>, <a href="#Page_221">221</a>, <a href="#Page_254">254</a></li>
+
+  <li class="indx">Anidrosis, <a href="#Page_303">303</a></li>
+  <li class="isub1">definition of, <a href="#Page_303">303</a></li>
+  <li class="isub1">derivation of, <a href="#Page_303">303</a></li>
+  <li class="isub1">etiology of, <a href="#Page_303">303</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_303">303</a></li>
+  <li class="isub1">synonyms of, <a href="#Page_303">303</a></li>
+  <li class="isub1">treatment of, <a href="#Page_303">303</a></li>
+
+  <li class="indx">Anterior arch, <a href="#Page_184">184</a></li>
+
+  <li class="indx">Antisepsis, <a href="#Page_19">19</a>, <a href="#Page_20">20</a>, <a href="#Page_21">21</a>, <a href="#Page_24">24</a>, <a href="#Page_33">33</a></li>
+
+  <li class="indx">Antiseptics, general, <a href="#Page_24">24</a></li>
+  <li class="isub1">chlorinated lime, <a href="#Page_26">26</a></li>
+  <li class="isub1">formaldehyde, <a href="#Page_25">25</a></li>
+  <li class="isub1">heat, <a href="#Page_25">25</a></li>
+  <li class="isub1">lime, <a href="#Page_25">25</a></li>
+  <li class="isub1">sublimed sulphur, <a href="#Page_26">26</a></li>
+  <li class="isub1">sunlight, <a href="#Page_24">24</a></li>
+
+  <li class="indx">Antiseptics, local, <a href="#Page_26">26</a></li>
+  <li class="isub1">alcohol, <a href="#Page_27">27</a></li>
+  <li class="isub1">balsam of Peru, <a href="#Page_27">27</a></li>
+  <li class="isub1">borate of sodium, <a href="#Page_27">27</a></li>
+  <li class="isub1">borax, <a href="#Page_27">27</a></li>
+  <li class="isub1">boric acid, <a href="#Page_27">27</a></li>
+  <li class="isub1">boroglycerine, <a href="#Page_27">27</a></li>
+  <li class="isub1">bichloride of mercury, <a href="#Page_29">29</a></li>
+  <li class="isub1">calomel, <a href="#Page_29">29</a></li>
+  <li class="isub1">Dakin solution, <a href="#Page_27">27</a></li>
+  <li class="isub1">di-chloramin-T, <a href="#Page_28">28</a></li>
+  <li class="isub1">glycerinum, <a href="#Page_28">28</a></li>
+  <li class="isub1">hydrogen dioxide, <a href="#Page_28">28</a></li>
+  <li class="isub2">peroxide, <a href="#Page_28">28</a></li>
+  <li class="isub1">iodoform, <a href="#Page_29">29</a></li>
+  <li class="isub1">iodine, <a href="#Page_28">28</a></li>
+  <li class="isub1">liquor alumini acetatis, <a href="#Page_27">27</a></li>
+  <li class="isub2">cresolis compositas, <a href="#Page_29">29</a></li>
+  <li class="isub1">lysol, <a href="#Page_30">30</a></li>
+  <li class="isub1">mercuric chloride, <a href="#Page_29">29</a></li>
+  <li class="isub1">mercurous chloride, <a href="#Page_29">29</a></li>
+  <li class="isub1">peroxide of hydrogen, <a href="#Page_28">28</a></li>
+  <li class="isub1">potassium permanganate, <a href="#Page_30">30</a></li>
+  <li class="isub1">sulphur, <a href="#Page_30">30</a></li>
+  <li class="isub1">phenol, <a href="#Page_29">29</a></li>
+  <li class="isub1">thymol, <a href="#Page_30">30</a></li>
+  <li class="isub1">thymol iodide, <a href="#Page_30">30</a></li>
+  <li class="isub1">unguentum hydrargyri, <a href="#Page_29">29</a></li>
+  <li class="isub2">hydrargyri ammoniatum, <a href="#Page_29">29</a></li>
+  <li class="isub1">sulphuris, <a href="#Page_30">30</a></li>
+
+  <li class="indx">Apothesine, <a href="#Page_148">148</a></li>
+
+  <li class="indx">Applicators, <a href="#Page_91">91</a></li>
+
+  <li class="indx">Areolar tissue, <a href="#Page_14">14</a></li>
+
+  <li class="indx">Aristol, <a href="#Page_30">30</a>, <a href="#Page_220">220</a>, <a href="#Page_249">249</a>, <a href="#Page_262">262</a>, <a href="#Page_320">320</a>, <a href="#Page_332">332</a>,
+    <a href="#Page_334">334</a></li>
+
+  <li class="indx">Arsphenamine, <a href="#Page_378">378</a></li>
+
+  <li class="indx">Arteriosclerosis, <a href="#Page_404">404</a></li>
+
+  <li class="indx">Arthritis, <a href="#Page_402">402</a></li>
+
+  <li class="indx">Asepsis, <a href="#Page_19">19</a>, <a href="#Page_32">32</a></li>
+
+  <li class="indx">Aseptic gauze, <a href="#Page_62">62</a></li>
+
+  <li class="indx">Atrophy of the nails, <a href="#Page_244">244</a></li>
+
+
+  <li class="ifrst">B</li>
+
+  <li class="indx">Bacillus aërogenes capsulatus, <a href="#Page_369">369</a></li>
+
+  <li class="indx">Baking, <a href="#Page_273">273</a></li>
+
+  <li class="indx">Balsam of Peru, <a href="#Page_27">27</a>, <a href="#Page_180">180</a>, <a href="#Page_193">193</a>, <a href="#Page_198">198</a>, <a href="#Page_199">199</a>,
+    <a href="#Page_221">221</a>, <a href="#Page_247">247</a>, <a href="#Page_262">262</a>, <a href="#Page_277">277</a>, <a href="#Page_295">295</a>, <a href="#Page_320">320</a>,
+    <a href="#Page_327">327</a>, <a href="#Page_332">332</a>, <a href="#Page_335">335</a></li>
+
+  <li class="indx">Bandage scissors, <a href="#Page_89">89</a></li>
+
+  <li class="indx">Bandages, description of, <a href="#Page_75">75</a>, <a href="#Page_76">76</a>, <a href="#Page_77">77</a></li>
+
+  <li class="indx">Bandaging, <a href="#Page_73">73</a></li>
+
+  <li class="indx">Belgian hone, <a href="#Page_92">92</a></li>
+
+  <li class="indx">Belladonna, <a href="#Page_298">298</a>, <a href="#Page_299">299</a></li>
+
+  <li class="indx">Benzoated collodion, <a href="#Page_69">69</a></li>
+
+  <li class="indx">Bichloride of Mercury, <a href="#Page_29">29</a>, <a href="#Page_199">199</a>, <a href="#Page_218">218</a>, <a href="#Page_273">273</a>, <a href="#Page_274">274</a>,
+    <a href="#Page_289">289</a>, <a href="#Page_318">318</a>, <a href="#Page_328">328</a>, <a href="#Page_334">334</a></li>
+
+  <li class="indx">Bismuth subgallate, <a href="#Page_220">220</a>, <a href="#Page_249">249</a>, <a href="#Page_262">262</a>, <a href="#Page_313">313</a>, <a href="#Page_332">332</a></li>
+
+  <li class="indx">Bismuth subnitrate, <a href="#Page_220">220</a>, <a href="#Page_249">249</a>, <a href="#Page_262">262</a>, <a href="#Page_313">313</a>, <a href="#Page_332">332</a></li>
+
+  <li class="indx">Blebs, <a href="#Page_248">248</a>, <a href="#Page_251">251</a>, <a href="#Page_289">289</a>, <a href="#Page_333">333</a></li>
+  <li class="isub1">treatment of, <a href="#Page_334">334</a></li>
+
+  <li class="indx">Blisters, <a href="#Page_248">248</a>, <a href="#Page_251">251</a></li>
+  <li class="isub1">definition of, <a href="#Page_251">251</a></li>
+  <li class="isub1">etiology of, <a href="#Page_251">251</a></li>
+  <li class="isub1">pathology of, <a href="#Page_252">252</a></li>
+  <li class="isub1">prognosis of, <a href="#Page_256">256</a></li>
+  <li class="isub1">treatment of, <a href="#Page_253">253</a></li>
+  <li class="isub2">ordinary conditions, <a href="#Page_252">252</a></li>
+  <li class="isub2">broken conditions, <a href="#Page_254">254</a></li>
+  <li class="isub1">usual points of location of, <a href="#Page_252">252</a></li>
+
+  <li class="indx">Bones of the foot, <a href="#Page_50">50</a></li>
+  <li class="isub1">borate of sodium, <a href="#Page_27">27</a>, <a href="#Page_362">362</a></li>
+
+  <li class="indx">Borated gauze, <a href="#Page_63">63</a></li>
+
+  <li class="indx">Borax, <a href="#Page_27">27</a>, <a href="#Page_362">362</a></li>
+
+  <li class="indx">Boric acid, <a href="#Page_27">27</a>, <a href="#Page_220">220</a>, <a href="#Page_225">225</a>, <a href="#Page_239">239</a>, <a href="#Page_273">273</a>, <a href="#Page_275">275</a>,
+    <a href="#Page_302">302</a>, <a href="#Page_303">303</a>, <a href="#Page_318">318</a>, <a href="#Page_320">320</a>, <a href="#Page_334">334</a></li>
+
+  <li class="indx">Boroglycerine, <a href="#Page_27">27</a>, <a href="#Page_312">312</a></li>
+
+  <li class="indx">Brilliant Green, <a href="#Page_35">35</a></li>
+
+  <li class="indx">Bromidrosis, <a href="#Page_302">302</a></li>
+  <li class="isub1">definition of, <a href="#Page_302">302</a></li>
+  <li class="isub1">derivation of, <a href="#Page_302">302</a></li>
+  <li class="isub1">etiology of, <a href="#Page_302">302</a></li>
+  <li class="isub1">pathology of, <a href="#Page_302">302</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_302">302</a></li>
+  <li class="isub1">synonyms of, <a href="#Page_302">302</a></li>
+  <li class="isub1">treatment of, <a href="#Page_302">302</a></li>
+
+  <li class="indx">Buckskin, <a href="#Page_97">97</a></li>
+
+  <li class="indx">Bullae, <a href="#Page_248">248</a>, <a href="#Page_251">251</a>, <a href="#Page_289">289</a></li>
+
+  <li class="indx">Burns, <a href="#Page_248">248</a>, <a href="#Page_256">256</a></li>
+  <li class="isub1">definition of, <a href="#Page_256">256</a></li>
+  <li class="isub1">pathology of, <a href="#Page_257">257</a></li>
+  <li class="isub1">treatment of, <a href="#Page_257">257</a></li>
+
+  <li class="indx">Burnt alum, <a href="#Page_226">226</a></li>
+
+  <li class="indx">Burow’s solution, <a href="#Page_318">318</a></li>
+
+  <li class="indx">Burs, <a href="#Page_91">91</a></li>
+
+  <li class="indx">Bursitis, <a href="#Page_263">263</a></li>
+  <li class="isub1">definition of, <a href="#Page_263">263</a></li>
+  <li class="isub1">characteristics of, <a href="#Page_265">265</a>, <a href="#Page_266">266</a></li>
+  <li class="isub1">etiology of, <a href="#Page_264">264</a></li>
+  <li class="isub1">location of, <a href="#Page_264">264</a></li>
+  <li class="isub1">pathology of, <a href="#Page_265">265</a></li>
+  <li class="isub1">removal of pressure for, <a href="#Page_268">268</a></li>
+  <li class="isub1">rest for, <a href="#Page_268">268</a></li>
+  <li class="isub1">strapping of, <a href="#Page_269">269</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_265">265</a></li>
+  <li class="isub2">objective, <a href="#Page_265">265</a></li>
+  <li class="isub2">subjective, <a href="#Page_265">265</a></li>
+  <li class="isub1">treatment of, <a href="#Page_266">266</a></li>
+  <li class="isub2">non-radical, <a href="#Page_267">267</a></li>
+  <li class="isub2">palliative, <a href="#Page_267">267</a></li>
+  <li class="isub2">radical, <a href="#Page_267">267</a></li>
+
+
+  <li class="ifrst">C</li>
+
+  <li class="indx">California College of Chiropody, <a href="#Page_5">5</a></li>
+
+  <li class="indx">Callositas, <a href="#Page_182">182</a></li>
+  <li class="isub1">definition of, <a href="#Page_182">182</a></li>
+  <li class="isub1">derivation of, <a href="#Page_182">182</a></li>
+  <li class="isub1">diagnosis of, <a href="#Page_183">183</a></li>
+  <li class="isub1">etiology of, <a href="#Page_182">182</a></li>
+  <li class="isub1">pathology of, <a href="#Page_183">183</a></li>
+  <li class="isub1">prognosis of, <a href="#Page_183">183</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_182">182</a></li>
+  <li class="isub1">synonyms of, <a href="#Page_182">182</a></li>
+  <li class="isub1">treatment of, <a href="#Page_184">184</a></li>
+
+  <li class="indx">Callosity, <a href="#Page_182">182</a></li>
+
+  <li class="indx">Callous, <a href="#Page_182">182</a></li>
+
+  <li class="indx">Callous ulcer, <a href="#Page_306">306</a>, <a href="#Page_314">314</a></li>
+  <li class="isub1">differential diagnosis, <a href="#Page_316">316</a></li>
+  <li class="isub1">etiology of, <a href="#Page_315">315</a></li>
+  <li class="isub1">general causes, <a href="#Page_315">315</a></li>
+  <li class="isub1">local causes, <a href="#Page_315">315</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_315">315</a></li>
+  <li class="isub1">treatment of, <a href="#Page_317">317</a></li>
+  <li class="isub2">cleansing, <a href="#Page_318">318</a></li>
+  <li class="isub2">sterilization, <a href="#Page_318">318</a></li>
+
+  <li class="indx">Calloused nail groove, <a href="#Page_205">205</a>, <a href="#Page_237">237</a></li>
+  <li class="isub1">definition of, <a href="#Page_205">205</a></li>
+  <li class="isub1">etiology of, <a href="#Page_206">206</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_206">206</a></li>
+  <li class="isub1">treatment of, <a href="#Page_206">206</a></li>
+  <li class="isub2">surgical, <a href="#Page_207">207</a></li>
+  <li class="isub2">medical, <a href="#Page_208">208</a></li>
+
+  <li class="indx">Callus, <a href="#Page_182">182</a></li>
+
+  <li class="indx">Calomel, <a href="#Page_29">29</a>, <a href="#Page_320">320</a></li>
+
+  <li class="indx">Calamine lotion, <a href="#Page_302">302</a></li>
+
+  <li class="indx">Camphor, <a href="#Page_361">361</a>, <a href="#Page_362">362</a>, <a href="#Page_363">363</a></li>
+
+  <li class="indx">Camphorated oil, <a href="#Page_365">365</a></li>
+
+  <li class="indx">Camphorated soap liniment, <a href="#Page_290">290</a></li>
+
+  <li class="indx">Cannabis indica, <a href="#Page_277">277</a></li>
+
+  <li class="indx">Capsicum, <a href="#Page_279">279</a></li>
+
+  <li class="indx">Carbon dioxide pencil, <a href="#Page_179">179</a>, <a href="#Page_191">191</a>, <a href="#Page_203">203</a></li>
+
+  <li class="indx">Carbon dioxide snow, <a href="#Page_145">145</a></li>
+
+  <li class="indx">Carrel method, <a href="#Page_21">21</a></li>
+
+  <li class="indx">Catalepsy, <a href="#Page_355">355</a></li>
+
+  <li class="indx">Chamois, <a href="#Page_97">97</a></li>
+
+  <li class="indx">Chauffeur’s foot, <a href="#Page_340">340</a></li>
+  <li class="isub1">etiology of, <a href="#Page_340">340</a></li>
+  <li class="isub1">treatment of, <a href="#Page_341">341</a></li>
+
+  <li class="indx">Chicago School of Chiropody, <a href="#Page_5">5</a></li>
+
+  <li class="indx">Chilblains, <a href="#Page_283">283</a></li>
+
+  <li class="indx">Chimatlon mild, <a href="#Page_283">283</a></li>
+  <li class="isub1">definition of, <a href="#Page_283">283</a></li>
+  <li class="isub1">derivation of, <a href="#Page_283">283</a></li>
+  <li class="isub1">diagnosis of, <a href="#Page_286">286</a></li>
+  <li class="isub1">differential diagnosis of, <a href="#Page_288">288</a></li>
+  <li class="isub1"><span class="pagenum" id="Page_434">[Pg 434]</span>etiology of, <a href="#Page_283">283</a></li>
+  <li class="isub1">pathology of, <a href="#Page_285">285</a></li>
+  <li class="isub1">predisposition to, <a href="#Page_284">284</a></li>
+  <li class="isub1">prognosis of, <a href="#Page_288">288</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_284">284</a></li>
+  <li class="isub1">synonyms of, <a href="#Page_283">283</a></li>
+  <li class="isub1">treatment of, <a href="#Page_288">288</a></li>
+
+  <li class="indx">Chimatlon severe, <a href="#Page_291">291</a></li>
+  <li class="isub1">definition of, <a href="#Page_291">291</a></li>
+  <li class="isub1">derivation of, <a href="#Page_291">291</a></li>
+  <li class="isub1">diagnosis of, <a href="#Page_293">293</a></li>
+  <li class="isub1">etiology of, <a href="#Page_291">291</a></li>
+  <li class="isub1">pathology of, <a href="#Page_292">292</a></li>
+  <li class="isub1">prognosis of, <a href="#Page_294">294</a></li>
+  <li class="isub1">recurrence of, <a href="#Page_294">294</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_292">292</a></li>
+  <li class="isub1">synonyms of, <a href="#Page_291">291</a></li>
+  <li class="isub1">treatment of, <a href="#Page_294">294</a></li>
+
+  <li class="indx">Chiropodists of America, <a href="#Page_2">2</a></li>
+
+  <li class="indx">Chisel, <a href="#Page_81">81</a></li>
+
+  <li class="indx">Chlorazene, <a href="#Page_37">37</a>, <a href="#Page_168">168</a></li>
+
+  <li class="indx">Chlorinated lime, <a href="#Page_26">26</a></li>
+
+  <li class="indx">Chromic acid, <a href="#Page_301">301</a>, <a href="#Page_303">303</a></li>
+
+  <li class="indx">Chromidrosis, <a href="#Page_304">304</a></li>
+  <li class="isub1">definition of, <a href="#Page_304">304</a></li>
+
+  <li class="indx">Clippers, <a href="#Page_86">86</a></li>
+
+  <li class="indx">Cocaine, <a href="#Page_143">143</a></li>
+
+  <li class="indx">Cocoon dressing, <a href="#Page_65">65</a>, <a href="#Page_184">184</a>, <a href="#Page_335">335</a></li>
+
+  <li class="indx">Cold applications, <a href="#Page_271">271</a></li>
+
+  <li class="indx">Collodial silver, <a href="#Page_363">363</a></li>
+  <li class="isub1">gold, <a href="#Page_364">364</a></li>
+
+  <li class="indx">Collodion, <a href="#Page_68">68</a></li>
+  <li class="isub1">benzoated, <a href="#Page_69">69</a></li>
+  <li class="isub1">ichthyolated, <a href="#Page_69">69</a></li>
+  <li class="isub1">iodized, <a href="#Page_69">69</a></li>
+  <li class="isub1">medicated, <a href="#Page_68">68</a></li>
+  <li class="isub1">salicylated, <a href="#Page_70">70</a></li>
+
+  <li class="indx">Colorado Pedic Society, <a href="#Page_9">9</a></li>
+
+  <li class="indx">Connecticut Pedic Society, <a href="#Page_9">9</a></li>
+
+  <li class="indx">Copper sulphate, <a href="#Page_320">320</a></li>
+
+  <li class="indx">Corium, <a href="#Page_13">13</a></li>
+
+  <li class="indx">Corns, <a href="#Page_149">149</a></li>
+
+  <li class="indx">Corrosive sublimate gauze, <a href="#Page_62">62</a></li>
+
+  <li class="indx">Cotton, <a href="#Page_64">64</a></li>
+
+  <li class="indx">Counter-irritation, <a href="#Page_270">270</a>, <a href="#Page_278">278</a></li>
+
+  <li class="indx">Creolin, <a href="#Page_318">318</a></li>
+
+  <li class="indx">Cutaneous manifestations of super-acidity, <a href="#Page_329">329</a></li>
+  <li class="isub1">characteristics of, <a href="#Page_329">329</a></li>
+  <li class="isub1">definition of, <a href="#Page_329">329</a></li>
+  <li class="isub1">etiology of, <a href="#Page_330">330</a></li>
+
+  <li class="indx">Cuticle scissors, <a href="#Page_89">89</a></li>
+
+
+  <li class="ifrst">D</li>
+
+  <li class="indx">Dancer’s foot, <a href="#Page_341">341</a></li>
+  <li class="isub1">treatment of, <a href="#Page_341">341</a></li>
+
+  <li class="indx">Dakin solution, <a href="#Page_21">21</a>, <a href="#Page_27">27</a>, <a href="#Page_35">35</a>, <a href="#Page_168">168</a>, <a href="#Page_318">318</a></li>
+
+  <li class="indx">Deodorant, <a href="#Page_26">26</a></li>
+
+  <li class="indx">Derma, <a href="#Page_13">13</a></li>
+  <li class="isub1">blood supply of, <a href="#Page_14">14</a></li>
+
+  <li class="indx">Dermatitis calorica, <a href="#Page_291">291</a></li>
+
+  <li class="indx">Dermatitis congelationes, <a href="#Page_283">283</a></li>
+
+  <li class="indx">Dermatol, <a href="#Page_220">220</a>, <a href="#Page_320">320</a>, <a href="#Page_334">334</a></li>
+
+  <li class="indx">Diachylon, <a href="#Page_300">300</a></li>
+
+  <li class="indx">Diagnosis of radiographs, <a href="#Page_397">397</a></li>
+
+  <li class="indx">Di-chloramin-T, <a href="#Page_28">28</a>, <a href="#Page_37">37</a></li>
+
+  <li class="indx">Direct cautery, <a href="#Page_191">191</a>, <a href="#Page_202">202</a>, <a href="#Page_222">222</a>, <a href="#Page_224">224</a></li>
+
+  <li class="indx">Direct current, <a href="#Page_386">386</a></li>
+
+  <li class="indx">Disinfectant, <a href="#Page_26">26</a></li>
+
+  <li class="indx">Dressings, <a href="#Page_60">60</a>, <a href="#Page_218">218</a>, <a href="#Page_258">258</a></li>
+  <li class="isub1">moist, <a href="#Page_60">60</a></li>
+  <li class="isub1">evaporating moist, <a href="#Page_60">60</a></li>
+  <li class="isub1">non-evaporating moist, <a href="#Page_60">60</a></li>
+  <li class="isub1">occlusive, <a href="#Page_61">61</a></li>
+  <li class="isub1">dry, <a href="#Page_61">61</a></li>
+  <li class="isub1">ointment, <a href="#Page_61">61</a></li>
+
+  <li class="indx">Drill, <a href="#Page_90">90</a></li>
+
+  <li class="indx">Dry dressings, <a href="#Page_61">61</a>, <a href="#Page_220">220</a>, <a href="#Page_312">312</a></li>
+
+  <li class="indx">Duck shield, <a href="#Page_173">173</a></li>
+
+
+  <li class="ifrst">E</li>
+
+  <li class="indx">Electric experiments, <a href="#Page_385">385</a></li>
+
+  <li class="indx">Electricity, <a href="#Page_270">270</a>, <a href="#Page_280">280</a>, <a href="#Page_296">296</a></li>
+
+  <li class="indx">Electrolysis, <a href="#Page_178">178</a>, <a href="#Page_191">191</a>, <a href="#Page_200">200</a></li>
+
+  <li class="indx">Ephidrosis, <a href="#Page_297">297</a></li>
+
+  <li class="indx">Epidermis, <a href="#Page_12">12</a></li>
+
+  <li class="indx">Epithelioma, <a href="#Page_189">189</a></li>
+
+  <li class="indx">Ergot, <a href="#Page_298">298</a></li>
+
+  <li class="indx">Erythema pernio, <a href="#Page_283">283</a></li>
+
+  <li class="indx">Ethyl bromide, <a href="#Page_145">145</a></li>
+
+  <li class="indx">Ethyl chloride, <a href="#Page_145">145</a></li>
+
+  <li class="indx">Ethylate of soda, <a href="#Page_196">196</a></li>
+
+  <li class="indx">Evaporating moist dressings, <a href="#Page_60">60</a></li>
+
+  <li class="indx">Excavator, <a href="#Page_84">84</a></li>
+
+  <li class="indx">Excessive sweating, <a href="#Page_297">297</a></li>
+
+  <li class="indx">Excision, <a href="#Page_191">191</a>, <a href="#Page_198">198</a>, <a href="#Page_222">222</a></li>
+
+  <li class="indx">Exostosis, <a href="#Page_399">399</a></li>
+
+
+  <li class="ifrst">F</li>
+
+  <li class="indx">Fabrics for dressings, <a href="#Page_62">62</a></li>
+
+  <li class="indx">Faradic Current, <a href="#Page_281">281</a>, <a href="#Page_290">290</a>, <a href="#Page_296">296</a>, <a href="#Page_304">304</a></li>
+
+  <li class="indx">Felon, <a href="#Page_239">239</a></li>
+
+  <li class="indx">Felt, <a href="#Page_98">98</a></li>
+
+  <li class="indx">Felt, adhesive, <a href="#Page_99">99</a></li>
+
+  <li class="indx">Ferri subsulphate, <a href="#Page_227">227</a>, <a href="#Page_232">232</a></li>
+
+  <li class="indx">Ferric chloride, <a href="#Page_232">232</a></li>
+
+  <li class="indx">Fish skin, <a href="#Page_73">73</a></li>
+
+  <li class="indx">Fissured toe webs, <a href="#Page_171">171</a></li>
+
+  <li class="indx">Fissures, <a href="#Page_248">248</a>, <a href="#Page_330">330</a></li>
+  <li class="isub1">definition of, <a href="#Page_248">248</a></li>
+  <li class="isub1">etiology of, <a href="#Page_248">248</a></li>
+  <li class="isub1">treatment of, <a href="#Page_248">248</a>, <a href="#Page_331">331</a></li>
+  <li class="isub1">technic, <a href="#Page_249">249</a></li>
+
+  <li class="indx">Flat foot, <a href="#Page_340">340</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_340">340</a></li>
+  <li class="isub1">treatment of, <a href="#Page_340">340</a></li>
+
+  <li class="indx">Flavin, <a href="#Page_34">34</a></li>
+
+  <li class="indx">Fluoroscopy, <a href="#Page_385">385</a></li>
+
+  <li class="indx">Focal infection, <a href="#Page_379">379</a></li>
+  <li class="isub1">modes of, <a href="#Page_380">380</a></li>
+  <li class="isub1">relationship between the foot and, <a href="#Page_380">380</a></li>
+  <li class="isub1">treatment of, <a href="#Page_381">381</a></li>
+
+  <li class="indx">Foot care of adolescents, <a href="#Page_55">55</a></li>
+
+  <li class="indx">Foot care of adults, <a href="#Page_56">56</a></li>
+
+  <li class="indx">Foot care of infants, <a href="#Page_53">53</a></li>
+
+  <li class="indx">Foot care of soldiers, <a href="#Page_57">57</a></li>
+
+  <li class="indx">Footgear, modern, <a href="#Page_47">47</a></li>
+
+  <li class="indx">Forceps, <a href="#Page_85">85</a>, <a href="#Page_88">88</a></li>
+
+  <li class="indx">Formaldehyde, <a href="#Page_25">25</a>, <a href="#Page_44">44</a>, <a href="#Page_299">299</a>, <a href="#Page_301">301</a></li>
+
+  <li class="indx">Formalin, <a href="#Page_319">319</a></li>
+
+  <li class="indx">Fractures, <a href="#Page_399">399</a></li>
+  <li class="isub1">comminuted, <a href="#Page_400">400</a></li>
+  <li class="isub1">complete, <a href="#Page_400">400</a></li>
+  <li class="isub1">compound, <a href="#Page_402">402</a></li>
+  <li class="isub1">compression, <a href="#Page_400">400</a></li>
+  <li class="isub1">crushing, <a href="#Page_400">400</a></li>
+  <li class="isub1">impacted, <a href="#Page_400">400</a></li>
+  <li class="isub1">incomplete, <a href="#Page_399">399</a></li>
+  <li class="isub1">multiple, <a href="#Page_400">400</a></li>
+  <li class="isub1">simple, <a href="#Page_400">400</a></li>
+
+  <li class="indx">Freezing method of anesthesia, <a href="#Page_146">146</a></li>
+
+  <li class="indx">Frost bite, <a href="#Page_291">291</a></li>
+
+  <li class="indx">Fulguration, <a href="#Page_177">177</a>, <a href="#Page_191">191</a>, <a href="#Page_199">199</a></li>
+
+
+  <li class="ifrst">G</li>
+
+  <li class="indx">Gall bladder, <a href="#Page_379">379</a></li>
+
+  <li class="indx">Gallic acid, <a href="#Page_298">298</a>, <a href="#Page_332">332</a></li>
+
+  <li class="indx">Galvanic current, <a href="#Page_304">304</a></li>
+
+  <li class="indx">Gangrene, <a href="#Page_293">293</a>, <a href="#Page_294">294</a></li>
+
+  <li class="indx">Gas gangrene, <a href="#Page_365">365</a>, <a href="#Page_368">368</a>, <a href="#Page_369">369</a></li>
+
+  <li class="indx">Gas infection, <a href="#Page_369">369</a></li>
+  <li class="isub1">antitoxin for, <a href="#Page_372">372</a></li>
+  <li class="isub1">bacteriologic diagnosis, <a href="#Page_372">372</a></li>
+  <li class="isub1">destruction of bacillus, <a href="#Page_371">371</a></li>
+  <li class="isub1">etiology of, <a href="#Page_369">369</a></li>
+  <li class="isub1">removal of necrotic tissue, <a href="#Page_371">371</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_370">370</a></li>
+  <li class="isub1">treatment of, <a href="#Page_370">370</a></li>
+
+  <li class="indx">Gauze, <a href="#Page_62">62</a></li>
+  <li class="isub1">borated, <a href="#Page_63">63</a></li>
+  <li class="isub1">corrosive sublimate, <a href="#Page_62">62</a></li>
+  <li class="isub1">iodoform, <a href="#Page_62">62</a></li>
+  <li class="isub1">plain aseptic, <a href="#Page_62">62</a></li>
+  <li class="isub1">squares, <a href="#Page_63">63</a>, <a href="#Page_64">64</a>, <a href="#Page_219">219</a>, <a href="#Page_314">314</a></li>
+  <li class="isub1">uses of, <a href="#Page_63">63</a></li>
+
+  <li class="indx">Geissler air pump, <a href="#Page_386">386</a></li>
+
+  <li class="indx">Glands, <a href="#Page_14">14</a></li>
+
+  <li class="indx">Glossary, <a href="#Page_411">411</a></li>
+
+  <li class="indx">Glycerinum, <a href="#Page_28">28</a></li>
+
+  <li class="indx">Golfer’s foot, <a href="#Page_341">341</a></li>
+
+  <li class="indx">Gonorrheal heel, <a href="#Page_380">380</a></li>
+
+  <li class="indx">Ground itch, <a href="#Page_368">368</a></li>
+  <li class="isub1">treatment of, <a href="#Page_369">369</a></li>
+
+  <li class="indx">Guaiacol, <a href="#Page_290">290</a></li>
+
+  <li class="indx">Gutta percha tissue, <a href="#Page_72">72</a></li>
+
+
+  <li class="ifrst">H</li>
+
+  <li class="indx">Hard corn, <a href="#Page_150">150</a></li>
+
+  <li class="indx">Heat, <a href="#Page_25">25</a></li>
+
+  <li class="indx">Heloma, <a href="#Page_149">149</a></li>
+  <li class="isub1">definition of, <a href="#Page_150">150</a></li>
+  <li class="isub1">derivation of, <a href="#Page_149">149</a></li>
+  <li class="isub1">synonyms of, <a href="#Page_150">150</a></li>
+
+  <li class="indx">Heloma disseminatum, <a href="#Page_179">179</a></li>
+  <li class="isub1">definition of, <a href="#Page_179">179</a></li>
+  <li class="isub1">diagnosis of, <a href="#Page_180">180</a></li>
+  <li class="isub1">etiology of, <a href="#Page_179">179</a></li>
+  <li class="isub1">pathology of, <a href="#Page_180">180</a></li>
+  <li class="isub1">prognosis of, <a href="#Page_180">180</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_179">179</a></li>
+  <li class="isub1">treatment of, <a href="#Page_179">179</a></li>
+
+  <li class="indx">Heloma durum, <a href="#Page_150">150</a></li>
+  <li class="isub1">diagnosis of, <a href="#Page_154">154</a></li>
+  <li class="isub1">etiology of, <a href="#Page_151">151</a></li>
+  <li class="isub1">pathology of, <a href="#Page_152">152</a>, <a href="#Page_153">153</a></li>
+  <li class="isub1">prognosis of, <a href="#Page_155">155</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_150">150</a></li>
+  <li class="isub1">treatment of, <a href="#Page_156">156</a></li>
+  <li class="isub2">dissection, <a href="#Page_160">160</a></li>
+  <li class="isub2">non-radical, <a href="#Page_159">159</a></li>
+  <li class="isub2">palliative, <a href="#Page_157">157</a></li>
+  <li class="isub2">preventive, <a href="#Page_156">156</a></li>
+  <li class="isub2">operative, <a href="#Page_158">158</a></li>
+  <li class="isub2">radical, <a href="#Page_158">158</a></li>
+  <li class="isub2">shaving, <a href="#Page_159">159</a></li>
+
+  <li class="indx">Heloma miliare, <a href="#Page_179">179</a></li>
+
+  <li class="indx">Heloma molle, <a href="#Page_169">169</a></li>
+  <li class="isub1">definition of, <a href="#Page_169">169</a></li>
+  <li class="isub1">diagnosis of, <a href="#Page_170">170</a></li>
+  <li class="isub1">etiology of, <a href="#Page_170">170</a></li>
+  <li class="isub1">pathology of, <a href="#Page_170">170</a></li>
+  <li class="isub1">prognosis of, <a href="#Page_171">171</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_169">169</a></li>
+  <li class="isub1">treatment of, <a href="#Page_172">172</a></li>
+
+  <li class="indx">Heloma vasculare, <a href="#Page_174">174</a>, <a href="#Page_190">190</a></li>
+  <li class="isub1">diagnosis of, <a href="#Page_175">175</a></li>
+  <li class="isub1">etiology of, <a href="#Page_174">174</a></li>
+  <li class="isub1">pathology of, <a href="#Page_174">174</a></li>
+  <li class="isub1">prognosis of, <a href="#Page_175">175</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_174">174</a></li>
+  <li class="isub1">treatment of, <a href="#Page_175">175</a></li>
+
+  <li class="indx"><span class="pagenum" id="Page_435">[Pg 435]</span>Helotomon, <a href="#Page_81">81</a></li>
+
+  <li class="indx">Hematidrosis, <a href="#Page_304">304</a></li>
+  <li class="isub1">definition of, <a href="#Page_304">304</a></li>
+
+  <li class="indx">Hemorrhage, <a href="#Page_31">31</a></li>
+
+  <li class="indx">Hidrosis, <a href="#Page_297">297</a></li>
+
+  <li class="indx">High frequency current, <a href="#Page_177">177</a>, <a href="#Page_199">199</a>, <a href="#Page_281">281</a>, <a href="#Page_290">290</a>, <a href="#Page_296">296</a></li>
+
+  <li class="indx">High heels, <a href="#Page_48">48</a></li>
+
+  <li class="indx">Honing, <a href="#Page_92">92</a></li>
+
+  <li class="indx">Hookworm, <a href="#Page_368">368</a></li>
+
+  <li class="indx">Hot applications, <a href="#Page_270">270</a>, <a href="#Page_304">304</a></li>
+
+  <li class="indx">Hydradenitis, <a href="#Page_305">305</a></li>
+  <li class="isub1">definition of, <a href="#Page_305">305</a></li>
+
+  <li class="indx">Hydrogen dioxide, <a href="#Page_28">28</a></li>
+
+  <li class="indx">Hydrogen peroxide, <a href="#Page_28">28</a>, <a href="#Page_218">218</a>, <a href="#Page_228">228</a>, <a href="#Page_289">289</a></li>
+
+  <li class="indx">Hydrocystoma, <a href="#Page_304">304</a></li>
+  <li class="isub1">definition of, <a href="#Page_304">304</a></li>
+
+  <li class="indx">Hydrotherapy, <a href="#Page_270">270</a></li>
+
+  <li class="indx">Hygiene of the foot, <a href="#Page_51">51-59</a></li>
+
+  <li class="indx">Hyperidrosis, <a href="#Page_297">297</a></li>
+  <li class="isub1">definition of, <a href="#Page_297">297</a></li>
+  <li class="isub1">derivation of, <a href="#Page_297">297</a></li>
+  <li class="isub1">etiology of, <a href="#Page_297">297</a></li>
+  <li class="isub1">pathology of, <a href="#Page_297">297</a></li>
+  <li class="isub1">prognosis of, <a href="#Page_298">298</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_298">298</a></li>
+  <li class="isub1">synonyms of, <a href="#Page_297">297</a></li>
+  <li class="isub1">treatment of, <a href="#Page_298">298</a></li>
+
+  <li class="indx">Hypodermic method of anesthesia, <a href="#Page_145">145</a></li>
+
+  <li class="indx">Hypodermic syringe, <a href="#Page_90">90</a>, <a href="#Page_146">146</a></li>
+  <li class="isub1">uses of, <a href="#Page_147">147</a></li>
+
+
+  <li class="ifrst">I</li>
+
+  <li class="indx">Ichthyol, <a href="#Page_180">180</a>, <a href="#Page_193">193</a>, <a href="#Page_198">198</a>, <a href="#Page_199">199</a>, <a href="#Page_251">251</a>, <a href="#Page_254">254</a>,
+    <a href="#Page_262">262</a>, <a href="#Page_276">276</a>, <a href="#Page_290">290</a>, <a href="#Page_295">295</a>, <a href="#Page_296">296</a>, <a href="#Page_320">320</a>,
+    <a href="#Page_332">332</a></li>
+
+  <li class="indx">Ichthyolated collodion, <a href="#Page_69">69</a></li>
+
+  <li class="indx">Idrosis, <a href="#Page_297">297</a></li>
+
+  <li class="indx">Illinois College of Chiropody, <a href="#Page_5">5</a></li>
+
+  <li class="indx">Illinois Pedic Association, <a href="#Page_8">8</a></li>
+
+  <li class="indx">Impervious coverings, <a href="#Page_72">72</a></li>
+
+  <li class="indx">Incorporated Society of Chiropodists (England), <a href="#Page_6">6</a></li>
+
+  <li class="indx">Indolent ulcer, <a href="#Page_306">306</a>, <a href="#Page_314">314</a></li>
+  <li class="isub1">etiology of, <a href="#Page_315">315</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_315">315</a></li>
+
+  <li class="indx">Infection, <a href="#Page_213">213</a></li>
+  <li class="isub1">treatment of, <a href="#Page_227">227</a></li>
+
+  <li class="indx">Infected heloma, <a href="#Page_167">167</a></li>
+
+  <li class="indx">Inflammation, symptoms of, <a href="#Page_177">177</a></li>
+
+  <li class="indx">Ingrown nail clippers, <a href="#Page_86">86</a></li>
+
+  <li class="indx">Ingrown nail forceps, <a href="#Page_85">85</a></li>
+
+  <li class="indx">Ingrown toe nail, <a href="#Page_205">205</a>, <a href="#Page_210">210</a>, <a href="#Page_237">237</a></li>
+
+  <li class="indx">Instruments, <a href="#Page_78">78</a></li>
+  <li class="isub1">applicators, <a href="#Page_91">91</a></li>
+  <li class="isub1">burs, <a href="#Page_91">91</a></li>
+  <li class="isub1">care of, <a href="#Page_92">92</a></li>
+  <li class="isub1">chisel, <a href="#Page_81">81</a></li>
+  <li class="isub1">excavator, <a href="#Page_84">84</a></li>
+  <li class="isub1">helotomon, <a href="#Page_81">81</a></li>
+  <li class="isub1">history of, <a href="#Page_79">79</a></li>
+  <li class="isub1">honing of, <a href="#Page_92">92</a></li>
+  <li class="isub2">Belgian hone, <a href="#Page_92">92</a></li>
+  <li class="isub2">oil stone, <a href="#Page_93">93</a></li>
+  <li class="isub2">Swatty hone, <a href="#Page_93">93</a></li>
+  <li class="isub2">technic, <a href="#Page_93">93</a></li>
+  <li class="isub1">hypodermic syringe, <a href="#Page_90">90</a></li>
+  <li class="isub1">ingrown nail clippers, <a href="#Page_86">86</a></li>
+  <li class="isub2">forceps, <a href="#Page_85">85</a></li>
+  <li class="isub1">iris tooth forceps, <a href="#Page_88">88</a></li>
+  <li class="isub1">nail chisel, <a href="#Page_82">82</a></li>
+  <li class="isub2">clippers, <a href="#Page_86">86</a></li>
+  <li class="isub2">file, <a href="#Page_91">91</a></li>
+  <li class="isub2">groove gouge, <a href="#Page_83">83</a></li>
+  <li class="isub2">scraper, <a href="#Page_84">84</a></li>
+  <li class="isub1">polishing, <a href="#Page_94">94</a></li>
+  <li class="isub1">rotary file, <a href="#Page_90">90</a></li>
+  <li class="isub1">scalpel, <a href="#Page_80">80</a></li>
+  <li class="isub1">scissors, <a href="#Page_88">88</a></li>
+  <li class="isub2">bandage, <a href="#Page_89">89</a></li>
+  <li class="isub2">cuticle, <a href="#Page_89">89</a></li>
+  <li class="isub1">selection and care of, <a href="#Page_7">7</a></li>
+  <li class="isub1">skiving knife, <a href="#Page_92">92</a></li>
+  <li class="isub1">soft corn spoon, <a href="#Page_83">83</a></li>
+  <li class="isub1">spatula, <a href="#Page_84">84</a></li>
+  <li class="isub1">special, for ingrown nail, <a href="#Page_85">85</a></li>
+  <li class="isub1">standardization of, <a href="#Page_80">80</a></li>
+  <li class="isub1">thumb forceps, <a href="#Page_86">86</a></li>
+  <li class="isub1">toe separators, <a href="#Page_91">91</a></li>
+  <li class="isub1">wiping of, <a href="#Page_95">95</a></li>
+
+  <li class="indx">Iodoform, <a href="#Page_29">29</a>, <a href="#Page_320">320</a></li>
+
+  <li class="indx">Iodoform gauze, <a href="#Page_62">62</a></li>
+
+  <li class="indx">Iodine, <a href="#Page_28">28</a>, <a href="#Page_215">215</a>, <a href="#Page_295">295</a></li>
+
+  <li class="indx">Iodized collodion, <a href="#Page_69">69</a></li>
+
+  <li class="indx">Iris tooth forceps, <a href="#Page_88">88</a></li>
+
+
+  <li class="ifrst">J</li>
+
+  <li class="indx">Jaborandi, <a href="#Page_304">304</a></li>
+
+
+  <li class="ifrst">L</li>
+
+  <li class="indx">Lamb’s wool, <a href="#Page_99">99</a></li>
+
+  <li class="indx">Lanolin, <a href="#Page_276">276</a></li>
+
+  <li class="indx">Lassar’s paste, <a href="#Page_320">320</a></li>
+
+  <li class="indx">Laws governing chiropody</li>
+  <li class="isub1">New York, <a href="#Page_3">3</a></li>
+  <li class="isub1">California, <a href="#Page_8">8</a></li>
+
+  <li class="indx">Lead and opium wash, <a href="#Page_273">273</a>, <a href="#Page_275">275</a>, <a href="#Page_318">318</a></li>
+
+  <li class="indx">Lewi, Maurice J., <a href="#Page_4">4</a></li>
+
+  <li class="indx">Lime, <a href="#Page_25">25</a></li>
+
+  <li class="indx">Lint, <a href="#Page_66">66</a></li>
+  <li class="isub1">shielding, <a href="#Page_67">67</a></li>
+
+  <li class="indx">Liquor alumini acetatis, <a href="#Page_27">27</a>, <a href="#Page_273">273</a>, <a href="#Page_274">274</a></li>
+
+  <li class="indx">Liquor cresolis compositas, <a href="#Page_29">29</a></li>
+
+  <li class="indx">Lister, Joseph, <a href="#Page_22">22</a></li>
+
+  <li class="indx">Local anesthesia, <a href="#Page_143">143</a>, <a href="#Page_158">158</a>, <a href="#Page_198">198</a></li>
+  <li class="isub1">reaction of, <a href="#Page_148">148</a></li>
+  <li class="isub1">technic of, <a href="#Page_145">145</a></li>
+
+  <li class="indx">Locomotion as an aid in diagnosis, <a href="#Page_343">343</a></li>
+  <li class="isub1">classification of gaits, <a href="#Page_347">347</a></li>
+  <li class="isub2">Ataxic gait, <a href="#Page_352">352</a></li>
+  <li class="isub3">static ataxic, <a href="#Page_352">352</a></li>
+  <li class="isub4">static spinal ataxic, <a href="#Page_353">353</a></li>
+  <li class="isub3">cerebellar, <a href="#Page_353">353</a></li>
+  <li class="isub4">titubating, <a href="#Page_353">353</a></li>
+  <li class="isub4">reeling or staggering, <a href="#Page_354">354</a></li>
+  <li class="isub2">Choreic, <a href="#Page_354">354</a></li>
+  <li class="isub3">festination, <a href="#Page_354">354</a></li>
+  <li class="isub3">hysteria, <a href="#Page_355">355</a></li>
+  <li class="isub3">myotonia, <a href="#Page_355">355</a></li>
+  <li class="isub3">saltatory, <a href="#Page_355">355</a></li>
+  <li class="isub3">stumbling, <a href="#Page_354">354</a></li>
+  <li class="isub2">Paretic gait, <a href="#Page_347">347</a></li>
+  <li class="isub3">mild, <a href="#Page_347">347</a></li>
+  <li class="isub4">Charlie Chaplin, <a href="#Page_349">349</a></li>
+  <li class="isub4">hobbling, <a href="#Page_347">347</a></li>
+  <li class="isub4">intermittent limping, <a href="#Page_348">348</a></li>
+  <li class="isub4">pompous, <a href="#Page_347">347</a></li>
+  <li class="isub4">shuffling, <a href="#Page_348">348</a></li>
+  <li class="isub4">tottering, <a href="#Page_348">348</a></li>
+  <li class="isub4">waddling, <a href="#Page_348">348</a></li>
+  <li class="isub4">wobbly, <a href="#Page_348">348</a></li>
+  <li class="isub3">moderate or flaccid, <a href="#Page_349">349</a></li>
+  <li class="isub4">prancing, <a href="#Page_350">350</a></li>
+  <li class="isub4">steppage, <a href="#Page_349">349</a></li>
+  <li class="isub3">spastic or severe, <a href="#Page_350">350</a></li>
+  <li class="isub4">cross-legged, <a href="#Page_351">351</a></li>
+  <li class="isub4">dragging, <a href="#Page_352">352</a></li>
+  <li class="isub4">dromedary, <a href="#Page_352">352</a></li>
+  <li class="isub4">ill-defined spastic, <a href="#Page_352">352</a></li>
+  <li class="isub4">mowing or hemiplegic, <a href="#Page_351">351</a></li>
+  <li class="isub4">small step, <a href="#Page_351">351</a></li>
+  <li class="isub1">elements of, <a href="#Page_343">343</a></li>
+  <li class="isub2">gait, <a href="#Page_344">344</a></li>
+  <li class="isub2">posture, <a href="#Page_343">343</a></li>
+  <li class="isub2">station, <a href="#Page_344">344</a></li>
+  <li class="isub1">methods of diagnosis, <a href="#Page_345">345</a></li>
+  <li class="isub2">ichnogram, <a href="#Page_345">345</a></li>
+  <li class="isub2">observation, <a href="#Page_345">345</a></li>
+
+  <li class="indx">Lymphatics, <a href="#Page_15">15</a></li>
+
+  <li class="indx">Lysol, <a href="#Page_30">30</a>, <a href="#Page_318">318</a></li>
+
+
+  <li class="ifrst">M</li>
+
+  <li class="indx">Massage, <a href="#Page_250">250</a>, <a href="#Page_270">270</a>, <a href="#Page_279">279</a>, <a href="#Page_289">289</a>, <a href="#Page_296">296</a>, <a href="#Page_304">304</a></li>
+
+  <li class="indx">Mazamorro, <a href="#Page_368">368</a></li>
+
+  <li class="indx">Medicated collodion, <a href="#Page_69">69</a></li>
+
+  <li class="indx">Menthol, <a href="#Page_276">276</a></li>
+
+  <li class="indx">Mercuric chloride, <a href="#Page_29">29</a>, <a href="#Page_273">273</a>, <a href="#Page_274">274</a></li>
+
+  <li class="indx">Mercurous chloride, <a href="#Page_29">29</a></li>
+
+  <li class="indx">Mercury, <a href="#Page_378">378</a></li>
+
+  <li class="indx">Metatarsalgia, <a href="#Page_139">139</a>, <a href="#Page_141">141</a>, <a href="#Page_382">382</a></li>
+  <li class="isub1">treatment of, <a href="#Page_383">383</a></li>
+
+  <li class="indx">Methylene blue, <a href="#Page_196">196</a></li>
+
+  <li class="indx">Miliaria, <a href="#Page_304">304</a></li>
+  <li class="isub1">definition of, <a href="#Page_304">304</a></li>
+
+  <li class="indx">Miscellaneous foot lesions, <a href="#Page_357">357</a></li>
+
+  <li class="indx">Moist dressings, <a href="#Page_60">60</a>, <a href="#Page_270">270</a>, <a href="#Page_273">273</a></li>
+
+  <li class="indx">Moleskin, <a href="#Page_195">195</a></li>
+
+  <li class="indx">Moleskin, adhesive, <a href="#Page_97">97</a></li>
+
+  <li class="indx">Monochloracetic acid, <a href="#Page_191">191</a></li>
+
+  <li class="indx">Monsel’s solution, <a href="#Page_227">227</a>, <a href="#Page_232">232</a></li>
+
+  <li class="indx">Morton’s neuralgia, <a href="#Page_382">382</a></li>
+
+  <li class="indx">Morton’s toe, <a href="#Page_139">139</a>, <a href="#Page_140">140</a>, <a href="#Page_382">382</a></li>
+  <li class="isub1">treatment of, <a href="#Page_382">382</a></li>
+
+  <li class="indx">Muscles, <a href="#Page_15">15</a></li>
+
+  <li class="indx">Mustard, <a href="#Page_279">279</a></li>
+
+
+  <li class="ifrst">N</li>
+
+  <li class="indx">Nail chisel, <a href="#Page_82">82</a>, <a href="#Page_215">215</a></li>
+
+  <li class="indx">Nail clippers, <a href="#Page_86">86</a></li>
+
+  <li class="indx">Nail file, <a href="#Page_91">91</a></li>
+
+  <li class="indx">Nail groove gouge, <a href="#Page_83">83</a></li>
+
+  <li class="indx">Nail matrix, <a href="#Page_16">16</a></li>
+
+  <li class="indx">Nails, <a href="#Page_16">16</a>, <a href="#Page_50">50</a></li>
+
+  <li class="indx">Nail scraper, <a href="#Page_84">84</a></li>
+
+  <li class="indx">Naked foot, <a href="#Page_46">46</a></li>
+
+  <li class="indx">National Association of Chiropodists, <a href="#Page_3">3</a>, <a href="#Page_9">9</a>, <a href="#Page_10">10</a></li>
+
+  <li class="indx">Necrosis, <a href="#Page_293">293</a></li>
+
+  <li class="indx">Nerves, <a href="#Page_15">15</a></li>
+  <li class="isub1">medullated nerve fibres, <a href="#Page_15">15</a></li>
+  <li class="isub1">non-medullated nerve fibres, <a href="#Page_15">15</a></li>
+
+  <li class="indx">Nitric acid, <a href="#Page_176">176</a>, <a href="#Page_191">191</a>, <a href="#Page_194">194</a>, <a href="#Page_225">225</a></li>
+
+  <li class="indx">Non-evaporating moist dressings, <a href="#Page_60">60</a></li>
+
+  <li class="indx">Novocaine, <a href="#Page_144">144</a>, <a href="#Page_198">198</a>, <a href="#Page_216">216</a></li>
+
+
+  <li class="ifrst">O</li>
+
+  <li class="indx">Occlusive dressings, <a href="#Page_61">61</a></li>
+
+  <li class="indx">Office, <a href="#Page_405">405</a></li>
+  <li class="isub1">accessories, <a href="#Page_409">409</a></li>
+  <li class="isub1">cabinet, <a href="#Page_408">408</a></li>
+  <li class="isub1">chair, <a href="#Page_407">407</a></li>
+  <li class="isub1">cleanliness of, <a href="#Page_405">405</a></li>
+  <li class="isub1">comfort of patient, <a href="#Page_405">405</a></li>
+  <li class="isub1"><span class="pagenum" id="Page_436">[Pg 436]</span>equipment, <a href="#Page_406">406</a></li>
+  <li class="isub1">operating room, <a href="#Page_406">406</a></li>
+  <li class="isub1">rotary file, <a href="#Page_409">409</a></li>
+  <li class="isub1">sterilizer, <a href="#Page_408">408</a></li>
+  <li class="isub1">waiting room, <a href="#Page_405">405</a></li>
+
+  <li class="indx">Office equipment, <a href="#Page_405">405</a>, <a href="#Page_406">406</a></li>
+
+  <li class="indx">Ohio College of Chiropody, <a href="#Page_5">5</a></li>
+
+  <li class="indx">Oil stone, <a href="#Page_93">93</a></li>
+
+  <li class="indx">Oiled silk, <a href="#Page_72">72</a></li>
+
+  <li class="indx">Ointment dressings, <a href="#Page_61">61</a>, <a href="#Page_220">220</a>, <a href="#Page_270">270</a>, <a href="#Page_275">275</a>, <a href="#Page_313">313</a></li>
+
+  <li class="indx">Onychatrophia, <a href="#Page_244">244</a></li>
+  <li class="isub1">derivation of, <a href="#Page_244">244</a></li>
+  <li class="isub1">diagnosis of, <a href="#Page_246">246</a></li>
+  <li class="isub1">etiology of, <a href="#Page_244">244</a></li>
+  <li class="isub1">pathology of, <a href="#Page_245">245</a></li>
+  <li class="isub1">treatment of, <a href="#Page_246">246</a></li>
+
+  <li class="indx">Onychauxis, <a href="#Page_241">241</a></li>
+  <li class="isub1">derivation of, <a href="#Page_241">241</a></li>
+  <li class="isub1">diagnosis of, <a href="#Page_242">242</a></li>
+  <li class="isub1">etiology of, <a href="#Page_241">241</a></li>
+  <li class="isub1">pathology of, <a href="#Page_242">242</a></li>
+  <li class="isub1">treatment of, <a href="#Page_243">243</a></li>
+  <li class="isub2">palliative, <a href="#Page_243">243</a></li>
+  <li class="isub2">radical, <a href="#Page_244">244</a></li>
+
+  <li class="indx">Onychia, <a href="#Page_238">238</a></li>
+  <li class="isub1">derivation of, <a href="#Page_238">238</a></li>
+  <li class="isub1">diagnosis of, <a href="#Page_238">238</a></li>
+  <li class="isub1">etiology of, <a href="#Page_238">238</a></li>
+  <li class="isub1">pathology of, <a href="#Page_238">238</a></li>
+  <li class="isub1">treatment of, <a href="#Page_238">238</a></li>
+
+  <li class="indx">Onychitis, <a href="#Page_238">238</a></li>
+
+  <li class="indx">Onychocryptosis, <a href="#Page_210">210</a>, <a href="#Page_237">237</a></li>
+  <li class="isub1">definition of, <a href="#Page_210">210</a></li>
+  <li class="isub1">derivation of, <a href="#Page_237">237</a></li>
+  <li class="isub1">etiology of, <a href="#Page_210">210</a></li>
+  <li class="isub1">complications, <a href="#Page_212">212</a></li>
+  <li class="isub1">prognosis of, <a href="#Page_229">229</a></li>
+  <li class="isub1">treatment of, <a href="#Page_214">214</a></li>
+  <li class="isub2">allowing nail to grow long, <a href="#Page_234">234</a></li>
+  <li class="isub2">complicated cases, <a href="#Page_221">221</a></li>
+  <li class="isub2">excision, <a href="#Page_222">222</a></li>
+  <li class="isub2">method of procedure, <a href="#Page_223">223</a></li>
+  <li class="isub2">no lateral cutting, <a href="#Page_235">235</a></li>
+  <li class="isub2">palliative method, <a href="#Page_216">216</a></li>
+  <li class="isub2">proper boots and hosiery, <a href="#Page_235">235</a></li>
+  <li class="isub2">packing, <a href="#Page_233">233</a></li>
+  <li class="isub2">prophylaxis, <a href="#Page_230">230</a></li>
+  <li class="isub2">radical method, <a href="#Page_216">216</a></li>
+  <li class="isub2">uncomplicated cases, <a href="#Page_215">215</a></li>
+
+  <li class="indx">Onychophosis, <a href="#Page_237">237</a></li>
+
+  <li class="indx">Onychoptosis, <a href="#Page_247">247</a></li>
+
+  <li class="indx">Onychorrhexis, <a href="#Page_247">247</a></li>
+
+  <li class="indx">Onychygrophosis, <a href="#Page_241">241</a></li>
+
+  <li class="indx">Orthoform, <a href="#Page_320">320</a></li>
+
+  <li class="indx">Osmidrosis, <a href="#Page_302">302</a></li>
+
+  <li class="indx">Oxygen, <a href="#Page_300">300</a>, <a href="#Page_366">366</a></li>
+
+
+  <li class="ifrst">P</li>
+
+  <li class="indx">Painful feet in women, <a href="#Page_381">381</a></li>
+
+  <li class="indx">Panaris, <a href="#Page_239">239</a></li>
+
+  <li class="indx">Panighao, <a href="#Page_368">368</a></li>
+
+  <li class="indx">Papillary layer, <a href="#Page_13">13</a></li>
+
+  <li class="indx">Papilloma, <a href="#Page_185">185</a></li>
+
+  <li class="indx">Paraffin No. 7., <a href="#Page_70">70</a></li>
+
+  <li class="indx">Paraffin No. 7-11., <a href="#Page_70">70</a></li>
+
+  <li class="indx">Paraffin preparations, <a href="#Page_70">70</a>, <a href="#Page_258">258</a></li>
+  <li class="isub1">application of, <a href="#Page_71">71</a></li>
+  <li class="isub1">conclusions, <a href="#Page_261">261</a></li>
+  <li class="isub1">precautions in using, <a href="#Page_258">258</a></li>
+  <li class="isub1">removing dressings of, <a href="#Page_259">259</a></li>
+
+  <li class="indx">Parresine, <a href="#Page_71">71</a></li>
+
+  <li class="indx">Paronychia, <a href="#Page_239">239</a></li>
+  <li class="isub1">derivation of, <a href="#Page_239">239</a></li>
+  <li class="isub1">diagnosis of, <a href="#Page_240">240</a></li>
+  <li class="isub1">etiology of, <a href="#Page_239">239</a></li>
+  <li class="isub1">pathology of, <a href="#Page_240">240</a></li>
+  <li class="isub1">synonyms of, <a href="#Page_239">239</a></li>
+  <li class="isub1">treatment of, <a href="#Page_240">240</a></li>
+
+  <li class="indx">Paronychitis, <a href="#Page_239">239</a></li>
+
+  <li class="indx">Pasteur, <a href="#Page_22">22</a></li>
+
+  <li class="indx">Pasteur serum, <a href="#Page_365">365</a></li>
+
+  <li class="indx">Pedic items, <a href="#Page_2">2</a></li>
+
+  <li class="indx">Pedic Society, State of California, <a href="#Page_7">7</a></li>
+
+  <li class="indx">Pedic Society, New York State, <a href="#Page_1">1</a></li>
+  <li class="isub1">officers, <a href="#Page_1">1</a></li>
+
+  <li class="indx">Perforating ulcer, <a href="#Page_324">324</a></li>
+  <li class="isub1">characteristics of, <a href="#Page_325">325</a></li>
+  <li class="isub1">etiology of, <a href="#Page_324">324</a></li>
+  <li class="isub1">prognosis of, <a href="#Page_327">327</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_326">326</a></li>
+  <li class="isub1">treatment of, <a href="#Page_326">326</a></li>
+
+  <li class="indx">Periostitis, <a href="#Page_397">397</a></li>
+
+  <li class="indx">Pernio, <a href="#Page_291">291</a></li>
+
+  <li class="indx">Peroxide of hydrogen, <a href="#Page_28">28</a></li>
+
+  <li class="indx">Petrogen camphor, <a href="#Page_280">280</a></li>
+  <li class="isub1">iodine, <a href="#Page_280">280</a></li>
+
+  <li class="indx">Phenol, <a href="#Page_29">29</a>, <a href="#Page_198">198</a>, <a href="#Page_289">289</a>, <a href="#Page_302">302</a></li>
+
+  <li class="indx">Pilocarpin, <a href="#Page_304">304</a></li>
+
+  <li class="indx">Plaster, <a href="#Page_105">105</a>, <a href="#Page_106">106</a>, <a href="#Page_107">107</a>, <a href="#Page_117">117</a>, <a href="#Page_120">120</a></li>
+
+  <li class="indx">Plaster of Paris bandage, <a href="#Page_74">74</a></li>
+
+  <li class="indx">Podiatrist, <a href="#Page_2">2</a></li>
+
+  <li class="indx">Podiatrists office, <a href="#Page_405">405</a></li>
+
+  <li class="indx">Policeman’s heel, <a href="#Page_341">341</a></li>
+  <li class="isub1">treatment of, <a href="#Page_341">341</a></li>
+
+  <li class="indx">Polyidrosis, <a href="#Page_297">297</a></li>
+
+  <li class="indx">Potassium hydroxide, <a href="#Page_176">176</a>, <a href="#Page_184">184</a>, <a href="#Page_191">191</a>, <a href="#Page_195">195</a>, <a href="#Page_196">196</a>,
+    <a href="#Page_209">209</a>, <a href="#Page_225">225</a></li>
+
+  <li class="indx">Potassium iodide, <a href="#Page_378">378</a></li>
+
+  <li class="indx">Potassium permanganate, <a href="#Page_30">30</a>, <a href="#Page_301">301</a>, <a href="#Page_303">303</a></li>
+
+  <li class="indx">Potential cautery, <a href="#Page_191">191</a>, <a href="#Page_192">192</a></li>
+
+  <li class="indx">Poultice, <a href="#Page_272">272</a></li>
+
+  <li class="indx">Pressure method of anesthesia, <a href="#Page_146">146</a></li>
+
+  <li class="indx">Proflavin, <a href="#Page_34">34</a></li>
+
+  <li class="indx">Protonuclein, <a href="#Page_320">320</a></li>
+
+  <li class="indx">Proud flesh, <a href="#Page_213">213</a>, <a href="#Page_216">216</a>, <a href="#Page_221">221</a>, <a href="#Page_251">251</a></li>
+
+  <li class="indx">Pruritis, <a href="#Page_333">333</a></li>
+
+  <li class="indx">Pyrogallic acid, <a href="#Page_191">191</a>, <a href="#Page_196">196</a></li>
+
+
+  <li class="ifrst">Q</li>
+
+  <li class="indx">Quinine and urea hydrochloride, <a href="#Page_144">144</a></li>
+
+
+  <li class="ifrst">R</li>
+
+  <li class="indx">Radiography, <a href="#Page_385">385-395</a></li>
+
+  <li class="indx">Radioscopy, <a href="#Page_385">385</a></li>
+
+  <li class="indx">Redintol, <a href="#Page_71">71</a></li>
+
+  <li class="indx">Reticular layer, <a href="#Page_14">14</a></li>
+
+  <li class="indx">Rhode Island Chiropody Society, <a href="#Page_9">9</a></li>
+
+  <li class="indx">Roentgenography, <a href="#Page_385">385</a></li>
+
+  <li class="indx">Roentgenology, <a href="#Page_385">385</a></li>
+
+  <li class="indx">Roentgenoscopy, <a href="#Page_385">385</a></li>
+
+  <li class="indx">Roentgenotherapy, <a href="#Page_385">385</a></li>
+
+  <li class="indx">Rotary file, <a href="#Page_90">90</a>, <a href="#Page_149">149</a></li>
+
+
+  <li class="ifrst">S</li>
+
+  <li class="indx">Salicylated collodion, <a href="#Page_70">70</a></li>
+
+  <li class="indx">Salicylic acid, <a href="#Page_173">173</a>, <a href="#Page_176">176</a>, <a href="#Page_181">181</a>, <a href="#Page_184">184</a>, <a href="#Page_191">191</a>,
+    <a href="#Page_197">197</a>, <a href="#Page_208">208</a>, <a href="#Page_232">232</a>, <a href="#Page_277">277</a>, <a href="#Page_378">378</a></li>
+
+  <li class="indx">Salvarsan, <a href="#Page_379">379</a></li>
+
+  <li class="indx">Sandal, <a href="#Page_47">47</a></li>
+
+  <li class="indx">San Francisco Chiropody Association, <a href="#Page_6">6</a></li>
+
+  <li class="indx">Scalpel, <a href="#Page_80">80</a></li>
+
+  <li class="indx">Scarlet red, <a href="#Page_221">221</a>, <a href="#Page_277">277</a>, <a href="#Page_314">314</a>, <a href="#Page_320">320</a>, <a href="#Page_327">327</a>,
+    <a href="#Page_332">332</a></li>
+
+  <li class="indx">School of Chiropody of New York, <a href="#Page_4">4</a></li>
+
+  <li class="indx">Scissors, <a href="#Page_88">88</a></li>
+
+  <li class="indx">Sebaceous glands, <a href="#Page_14">14</a>, <a href="#Page_15">15</a>, <a href="#Page_17">17</a></li>
+
+  <li class="indx">Seborrhea, <a href="#Page_305">305</a></li>
+  <li class="isub1">definition of, <a href="#Page_305">305</a></li>
+
+  <li class="indx">Seed corn, <a href="#Page_179">179</a></li>
+
+  <li class="indx">Sesamoid bones, <a href="#Page_402">402</a></li>
+
+  <li class="indx">Sheep skin, <a href="#Page_98">98</a></li>
+
+  <li class="indx">Shields and shielding, <a href="#Page_96">96</a>, <a href="#Page_173">173</a>, <a href="#Page_269">269</a></li>
+  <li class="isub1">adhesive substances, <a href="#Page_104">104</a></li>
+  <li class="isub1">aperture for, <a href="#Page_101">101</a></li>
+  <li class="isub1">definition, <a href="#Page_96">96</a></li>
+  <li class="isub1">location of parts to be shielded, <a href="#Page_100">100</a></li>
+  <li class="isub1">manufacture of, <a href="#Page_99">99</a></li>
+  <li class="isub1">materials, <a href="#Page_96">96</a></li>
+  <li class="isub2">adhesive felt, <a href="#Page_99">99</a></li>
+  <li class="isub2">adhesive moleskin, <a href="#Page_97">97</a></li>
+  <li class="isub2">buckskin, <a href="#Page_97">97</a></li>
+  <li class="isub2">chamois, <a href="#Page_97">97</a></li>
+  <li class="isub2">felt, <a href="#Page_98">98</a></li>
+  <li class="isub2">lamb’s wool, <a href="#Page_99">99</a></li>
+  <li class="isub2">sheepskin, <a href="#Page_98">98</a></li>
+  <li class="isub1">method of skiving, <a href="#Page_103">103</a></li>
+  <li class="isub1">preparation of, <a href="#Page_99">99</a></li>
+  <li class="isub1">skiving of, <a href="#Page_101">101</a></li>
+  <li class="isub1">strapping of, <a href="#Page_105">105</a>, <a href="#Page_107">107</a></li>
+  <li class="isub1">thickness of, <a href="#Page_100">100</a></li>
+
+  <li class="indx">Shielding, specific, <a href="#Page_107">107</a></li>
+  <li class="isub1">dorsal surfaces, <a href="#Page_138">138</a></li>
+  <li class="isub1">fifth toe, <a href="#Page_120">120</a></li>
+  <li class="isub2">built up, half-moon, <a href="#Page_127">127</a></li>
+  <li class="isub2">dorsal surface, <a href="#Page_120">120</a></li>
+  <li class="isub3">strapping for, <a href="#Page_121">121</a>, <a href="#Page_126">126</a></li>
+  <li class="isub2">lateral surfaces, <a href="#Page_128">128</a></li>
+  <li class="isub3">strapping for, <a href="#Page_128">128</a></li>
+  <li class="isub2">interdigital surfaces, <a href="#Page_128">128</a></li>
+  <li class="isub3">strapping for, <a href="#Page_128">128</a></li>
+  <li class="isub1">great toe, <a href="#Page_107">107</a>, <a href="#Page_113">113</a></li>
+  <li class="isub1">interdigital surfaces, <a href="#Page_118">118</a>, <a href="#Page_119">119</a></li>
+  <li class="isub2">strapping for, <a href="#Page_120">120</a></li>
+  <li class="isub1">intermediate toes, <a href="#Page_113">113</a></li>
+  <li class="isub2">dorsal surfaces, <a href="#Page_113">113</a>, <a href="#Page_115">115</a></li>
+  <li class="isub2">ends of, <a href="#Page_116">116</a></li>
+  <li class="isub2">strapping for, <a href="#Page_117">117</a></li>
+  <li class="isub1">lateral borders, <a href="#Page_137">137</a></li>
+  <li class="isub1">lateral plantar half-moon, <a href="#Page_136">136</a></li>
+  <li class="isub1">metatarsalgia, <a href="#Page_139">139</a>, <a href="#Page_141">141</a></li>
+  <li class="isub1">Morton’s toe, <a href="#Page_139">139</a>, <a href="#Page_140">140</a></li>
+  <li class="isub1">metatarsophalangeal articulation, <a href="#Page_130">130</a></li>
+  <li class="isub2">oval, <a href="#Page_130">130</a></li>
+  <li class="isub2">half-moon, <a href="#Page_131">131</a></li>
+  <li class="isub2">modified half-moon, <a href="#Page_132">132</a></li>
+  <li class="isub1">os calcis region, <a href="#Page_137">137</a></li>
+  <li class="isub1">plantar surfaces, <a href="#Page_132">132</a>, <a href="#Page_133">133</a></li>
+  <li class="isub2">strapping for, <a href="#Page_134">134</a>, <a href="#Page_135">135</a></li>
+
+  <li class="indx">Silver nitrate, <a href="#Page_191">191</a>, <a href="#Page_195">195</a>, <a href="#Page_226">226</a>, <a href="#Page_231">231</a>, <a href="#Page_248">248</a>,
+    <a href="#Page_249">249</a>, <a href="#Page_250">250</a>, <a href="#Page_256">256</a>, <a href="#Page_290">290</a>, <a href="#Page_319">319</a>, <a href="#Page_320">320</a>,
+    <a href="#Page_332">332</a></li>
+
+  <li class="indx">Simple ulcers, <a href="#Page_306">306</a>, <a href="#Page_311">311</a></li>
+  <li class="isub1">treatment of, <a href="#Page_311">311</a></li>
+
+  <li class="indx">Skiagraphy, <a href="#Page_385">385</a></li>
+
+  <li class="indx">Skiascopy, <a href="#Page_385">385</a></li>
+
+  <li class="indx">Skin, <a href="#Page_11">11</a></li>
+  <li class="isub1">anatomy of, <a href="#Page_12">12</a></li>
+  <li class="isub1">layers of, <a href="#Page_12">12</a></li>
+  <li class="isub1">physiology of, <a href="#Page_17">17</a></li>
+
+  <li class="indx">Skiving, <a href="#Page_101">101</a>, <a href="#Page_103">103</a></li>
+
+  <li class="indx"><span class="pagenum" id="Page_437">[Pg 437]</span>Skiving knife, <a href="#Page_92">92</a>, <a href="#Page_104">104</a></li>
+
+  <li class="indx">Spatula, <a href="#Page_84">84</a></li>
+
+  <li class="indx">Sodium bicarbonate, <a href="#Page_332">332</a></li>
+
+  <li class="indx">Sodium hydroxide, <a href="#Page_191">191</a></li>
+
+  <li class="indx">Soft corn, <a href="#Page_169">169</a></li>
+
+  <li class="indx">Soft corn spoon, <a href="#Page_83">83</a></li>
+
+  <li class="indx">Soft soap, <a href="#Page_362">362</a></li>
+
+  <li class="indx">Sterilization, <a href="#Page_39">39</a></li>
+  <li class="isub1">dressings, <a href="#Page_40">40</a></li>
+  <li class="isub1">field of operation, <a href="#Page_30">30</a>, <a href="#Page_40">40</a></li>
+  <li class="isub1">hands of operator, <a href="#Page_41">41</a></li>
+  <li class="isub1">instruments, <a href="#Page_39">39</a></li>
+
+  <li class="indx">Sterilizing apparatus, <a href="#Page_42">42</a></li>
+
+  <li class="indx">Sterilizers, <a href="#Page_42">42</a>, <a href="#Page_408">408</a></li>
+
+  <li class="indx">Strapping, <a href="#Page_105">105</a>, <a href="#Page_106">106</a>, <a href="#Page_107">107</a>, <a href="#Page_117">117</a>, <a href="#Page_120">120</a>, <a href="#Page_121">121</a>,
+    <a href="#Page_128">128</a>, <a href="#Page_134">134</a>, <a href="#Page_269">269</a></li>
+
+  <li class="indx">Stratum corneum, <a href="#Page_12">12</a></li>
+
+  <li class="indx">Stratum granulosum, <a href="#Page_12">12</a></li>
+
+  <li class="indx">Stratum lucidum, <a href="#Page_12">12</a></li>
+
+  <li class="indx">Stratum mucosum, <a href="#Page_13">13</a></li>
+
+  <li class="indx">Subcutaneous areolar tissue, <a href="#Page_14">14</a></li>
+
+  <li class="indx">Sublimed sulphur, <a href="#Page_26">26</a></li>
+
+  <li class="indx">Sudamen, <a href="#Page_304">304</a></li>
+  <li class="isub1">definition of, <a href="#Page_304">304</a></li>
+
+  <li class="indx">Sudorrhea, <a href="#Page_297">297</a></li>
+
+  <li class="indx">Sudatoria, <a href="#Page_297">297</a></li>
+
+  <li class="indx">Sudoriferous glands, <a href="#Page_15">15</a>, <a href="#Page_17">17</a>, <a href="#Page_49">49</a></li>
+
+  <li class="indx">Sulphur, <a href="#Page_30">30</a>, <a href="#Page_33">33</a>, <a href="#Page_299">299</a>, <a href="#Page_335">335</a></li>
+
+  <li class="indx">Sunlight, <a href="#Page_24">24</a></li>
+
+  <li class="indx">Sutures, <a href="#Page_198">198</a></li>
+
+  <li class="indx">Swatty hone, <a href="#Page_93">93</a></li>
+
+  <li class="indx">Syphilitic ulcer, <a href="#Page_327">327</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_327">327</a></li>
+  <li class="isub1">treatment of, <a href="#Page_328">328</a></li>
+
+  <li class="indx">Syphilis, <a href="#Page_189">189</a>, <a href="#Page_241">241</a>, <a href="#Page_373">373</a></li>
+  <li class="isub1">blood tests for, <a href="#Page_377">377</a></li>
+  <li class="isub2">Wassermann, <a href="#Page_377">377</a></li>
+  <li class="isub2">Noguchi, <a href="#Page_377">377</a></li>
+  <li class="isub2">luetin, <a href="#Page_378">378</a></li>
+  <li class="isub1">color of, <a href="#Page_374">374</a></li>
+  <li class="isub1">course and duration of, <a href="#Page_378">378</a></li>
+  <li class="isub1">definition of, <a href="#Page_373">373</a></li>
+  <li class="isub1">derivation of, <a href="#Page_373">373</a></li>
+  <li class="isub1">diagnosis of, <a href="#Page_374">374</a></li>
+  <li class="isub1">differential diagnosis of, <a href="#Page_377">377</a></li>
+  <li class="isub1">distribution of, <a href="#Page_374">374</a></li>
+  <li class="isub1">etiology of, <a href="#Page_373">373</a></li>
+  <li class="isub1">form of, <a href="#Page_374">374</a></li>
+  <li class="isub1">pathology of, <a href="#Page_373">373</a></li>
+  <li class="isub1">plantar syphilide, <a href="#Page_375">375</a></li>
+  <li class="isub1">synonyms of, <a href="#Page_373">373</a></li>
+  <li class="isub1">treatment of, <a href="#Page_378">378</a></li>
+
+
+  <li class="ifrst">T</li>
+
+  <li class="indx">Tannic acid, <a href="#Page_248">248</a>, <a href="#Page_332">332</a></li>
+
+  <li class="indx">Tannoform, <a href="#Page_249">249</a>, <a href="#Page_332">332</a></li>
+
+  <li class="indx">Teeth, <a href="#Page_379">379</a></li>
+
+  <li class="indx">Temple University, <a href="#Page_5">5</a></li>
+
+  <li class="indx">Tetanus, <a href="#Page_365">365</a></li>
+
+  <li class="indx">The First Institute of Podiatry, <a href="#Page_5">5</a></li>
+
+  <li class="indx">Thiersch’s solution, <a href="#Page_318">318</a></li>
+
+  <li class="indx">Thumb forceps, <a href="#Page_86">86</a></li>
+
+  <li class="indx">Thymol, <a href="#Page_30">30</a></li>
+
+  <li class="indx">Thymol iodide, <a href="#Page_30">30</a>, <a href="#Page_220">220</a>, <a href="#Page_249">249</a>, <a href="#Page_262">262</a>, <a href="#Page_312">312</a>,
+    <a href="#Page_332">332</a>, <a href="#Page_334">334</a></li>
+
+  <li class="indx">Tr. Benzoin Comp., <a href="#Page_249">249</a>, <a href="#Page_251">251</a>, <a href="#Page_289">289</a>, <a href="#Page_331">331</a></li>
+
+  <li class="indx">Tr. Iodine, <a href="#Page_184">184</a>, <a href="#Page_278">278</a></li>
+
+  <li class="indx">Toe separators, <a href="#Page_91">91</a></li>
+
+  <li class="indx">Tonsils, <a href="#Page_379">379</a></li>
+
+  <li class="indx">Trench fever, <a href="#Page_358">358</a></li>
+
+  <li class="indx">Trench foot, <a href="#Page_357">357</a></li>
+  <li class="isub1">complications in, <a href="#Page_365">365</a></li>
+  <li class="isub1">crust formation in, <a href="#Page_363">363</a></li>
+  <li class="isub1">etiology of, <a href="#Page_358">358</a></li>
+  <li class="isub1">extensive invasion in, <a href="#Page_364">364</a></li>
+  <li class="isub1">general treatment of, <a href="#Page_365">365</a></li>
+  <li class="isub1">prevention of, <a href="#Page_361">361</a></li>
+  <li class="isub1">prognosis of, <a href="#Page_360">360</a></li>
+  <li class="isub1">reparation stage of, <a href="#Page_365">365</a></li>
+  <li class="isub1">simple edematous, <a href="#Page_362">362</a></li>
+  <li class="isub1">stages of, <a href="#Page_357">357</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_359">359</a></li>
+  <li class="isub1">treatment of, <a href="#Page_360">360</a></li>
+  <li class="isub1">vesicular, <a href="#Page_363">363</a></li>
+
+  <li class="indx">Trichloracetic acid, <a href="#Page_191">191</a>, <a href="#Page_194">194</a></li>
+
+  <li class="indx">Turpentine, <a href="#Page_279">279</a></li>
+
+  <li class="indx">Tyloma, <a href="#Page_182">182</a></li>
+
+  <li class="indx">Tylosis, <a href="#Page_182">182</a></li>
+
+
+  <li class="ifrst">U</li>
+
+  <li class="indx">Ulcers, <a href="#Page_306">306</a></li>
+  <li class="isub1">callous, <a href="#Page_306">306</a></li>
+  <li class="isub1">definition of, <a href="#Page_306">306</a></li>
+  <li class="isub1">etiology of, <a href="#Page_306">306</a></li>
+  <li class="isub1">exciting causes of, <a href="#Page_308">308</a></li>
+  <li class="isub1">granulation of, <a href="#Page_310">310</a></li>
+  <li class="isub1">indolent, <a href="#Page_306">306</a></li>
+  <li class="isub1">pathology of, <a href="#Page_308">308</a></li>
+  <li class="isub1">perforating, <a href="#Page_306">306</a></li>
+  <li class="isub1">predisposing causes of, <a href="#Page_307">307</a></li>
+  <li class="isub1">simple, <a href="#Page_306">306</a></li>
+  <li class="isub1">syphilitic, <a href="#Page_306">306</a></li>
+  <li class="isub1">varicose, <a href="#Page_306">306</a></li>
+
+  <li class="indx">Uncinarial dermatitis, <a href="#Page_368">368</a></li>
+
+  <li class="indx">Ung. Acidi borici, <a href="#Page_313">313</a></li>
+
+  <li class="indx">Ung. Acidi tannici, <a href="#Page_313">313</a></li>
+
+  <li class="indx">Ung. Balsam of Peru, <a href="#Page_314">314</a></li>
+
+  <li class="indx">Ung. Eucalypti, <a href="#Page_314">314</a></li>
+
+  <li class="indx">Ung. hydrargyri, <a href="#Page_29">29</a></li>
+
+  <li class="indx">Unguentum hydrargyri ammoniati, <a href="#Page_29">29</a>, <a href="#Page_221">221</a>, <a href="#Page_313">313</a>, <a href="#Page_332">332</a></li>
+
+  <li class="indx">Unguentum sulphuris, <a href="#Page_30">30</a>, <a href="#Page_221">221</a>, <a href="#Page_262">262</a>, <a href="#Page_276">276</a></li>
+
+  <li class="indx">Ung. zinci oxidi, <a href="#Page_314">314</a></li>
+
+  <li class="indx">University of Massachusetts, <a href="#Page_5">5</a></li>
+
+  <li class="indx">Urethra, <a href="#Page_379">379</a></li>
+
+  <li class="indx">Uric acid diathesis, <a href="#Page_212">212</a></li>
+
+  <li class="indx">Uric acid and the nails, <a href="#Page_335">335</a></li>
+  <li class="isub1">changes in size and shape, <a href="#Page_336">336</a></li>
+  <li class="isub2">treatment of, <a href="#Page_337">337</a></li>
+  <li class="isub1">discoloration, <a href="#Page_335">335</a></li>
+  <li class="isub2">treatment of, <a href="#Page_335">335</a></li>
+  <li class="isub1">prognosis, <a href="#Page_337">337</a></li>
+  <li class="isub1">texture changes, <a href="#Page_336">336</a></li>
+  <li class="isub2">treatment of, <a href="#Page_336">336</a></li>
+
+  <li class="indx">Uridrosis, <a href="#Page_304">304</a></li>
+  <li class="isub1">definition of, <a href="#Page_304">304</a></li>
+
+  <li class="indx">Uterus, <a href="#Page_379">379</a></li>
+
+
+  <li class="ifrst">V</li>
+
+  <li class="indx">Vanadium chloride, <a href="#Page_300">300</a></li>
+
+  <li class="indx">Varicose ulcer, <a href="#Page_321">321</a></li>
+  <li class="isub1">bandaging for, <a href="#Page_324">324</a></li>
+  <li class="isub1">etiology of, <a href="#Page_321">321</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_322">322</a></li>
+  <li class="isub1">treatment of, <a href="#Page_322">322</a></li>
+
+  <li class="indx">Vascular corn, <a href="#Page_174">174</a></li>
+
+  <li class="indx">Venereal warts, <a href="#Page_190">190</a></li>
+
+  <li class="indx">Verruca, <a href="#Page_185">185</a></li>
+  <li class="isub1">definition of, <a href="#Page_185">185</a></li>
+  <li class="isub1">derivation of, <a href="#Page_185">185</a></li>
+  <li class="isub1">diagnosis of, <a href="#Page_189">189</a></li>
+  <li class="isub1">etiology of, <a href="#Page_185">185</a></li>
+  <li class="isub1">pathology of, <a href="#Page_187">187</a></li>
+  <li class="isub1">prognosis of, <a href="#Page_190">190</a></li>
+  <li class="isub1">synonyms of, <a href="#Page_185">185</a></li>
+  <li class="isub1">treatment of, <a href="#Page_191">191</a></li>
+  <li class="isub1">varieties of, <a href="#Page_188">188</a></li>
+  <li class="isub1">where found, <a href="#Page_187">187</a></li>
+
+  <li class="indx">Verruca arida, <a href="#Page_185">185</a>, <a href="#Page_188">188</a></li>
+
+  <li class="indx">Verruca humida, <a href="#Page_185">185</a>, <a href="#Page_189">189</a></li>
+
+  <li class="indx">Verruca vulgaris, <a href="#Page_188">188</a></li>
+
+  <li class="indx">Vibration, <a href="#Page_281">281</a></li>
+
+  <li class="indx">Vocational foot disorders, <a href="#Page_339">339</a></li>
+
+
+  <li class="ifrst">W</li>
+
+  <li class="indx">Walking, <a href="#Page_57">57</a></li>
+
+  <li class="indx">Water, <a href="#Page_52">52</a></li>
+  <li class="isub1">properties of, <a href="#Page_52">52</a></li>
+
+  <li class="indx">Water itch, <a href="#Page_368">368</a></li>
+
+  <li class="indx">Water pox, <a href="#Page_368">368</a></li>
+
+  <li class="indx">Water sores, <a href="#Page_368">368</a></li>
+
+  <li class="indx">Weak foot, <a href="#Page_339">339</a></li>
+  <li class="isub1">appearance of, <a href="#Page_339">339</a></li>
+  <li class="isub1">symptoms of, <a href="#Page_339">339</a></li>
+  <li class="isub1">treatment of, <a href="#Page_339">339</a></li>
+
+  <li class="indx">Welch bacillus, <a href="#Page_369">369</a></li>
+
+  <li class="indx">Wet dressings, <a href="#Page_60">60</a>, <a href="#Page_218">218</a>, <a href="#Page_239">239</a>, <a href="#Page_270">270</a>, <a href="#Page_273">273</a>,
+    <a href="#Page_311">311</a></li>
+
+  <li class="indx">White precipitate, <a href="#Page_29">29</a>, <a href="#Page_221">221</a>, <a href="#Page_254">254</a>, <a href="#Page_378">378</a></li>
+
+  <li class="indx">Whitlow, <a href="#Page_239">239</a></li>
+
+
+  <li class="ifrst">X</li>
+
+  <li class="indx">X-ray apparatus, <a href="#Page_388">388</a></li>
+  <li class="isub1">generator, <a href="#Page_388">388</a></li>
+  <li class="isub2">coil, <a href="#Page_390">390</a></li>
+  <li class="isub2">interrupterless, <a href="#Page_390">390</a></li>
+  <li class="isub1">tubes, <a href="#Page_391">391</a></li>
+  <li class="isub2">vacuum regulators, <a href="#Page_392">392</a></li>
+  <li class="isub1">tube stand, <a href="#Page_394">394</a></li>
+
+  <li class="indx">X-ray plates, <a href="#Page_394">394</a></li>
+  <li class="isub1">developing of, <a href="#Page_396">396</a></li>
+  <li class="isub1">fixing of, <a href="#Page_396">396</a></li>
+
+  <li class="indx">X-rays, <a href="#Page_300">300</a>, <a href="#Page_385">385</a>, <a href="#Page_394">394</a></li>
+  <li class="isub1">dangers of, <a href="#Page_387">387</a></li>
+  <li class="isub1">discovery of, <a href="#Page_386">386</a></li>
+  <li class="isub1">experiments leading up to, <a href="#Page_387">387</a></li>
+
+
+  <li class="ifrst">Z</li>
+
+  <li class="indx">Zinc oxide, <a href="#Page_261">261</a>, <a href="#Page_313">313</a>, <a href="#Page_320">320</a></li>
+
+  <li class="indx">Zinc stearate, <a href="#Page_313">313</a></li>
+
+  <li class="indx">Zinc sulphate, <a href="#Page_320">320</a></li>
+</ul>
+</nav>
+<hr class="chap x-ebookmaker-drop" aria-hidden="true">
+<div class="chapter">
+<div class="title">
+<p class="center"><span class="smcap">Practical Podiatry</span></p>
+
+<p class="center">is the second volume of a series of books known
+as a complete System of Podiatry.</p>
+
+<p class="center">The first volume</p>
+
+<p class="center"><span class="smcap">Surgery<br>
+with<br>
+Special Reference to Podiatry</span></p>
+
+<p class="center">has proven of worth and will be found in the
+libraries of all advanced podiatrists and of
+many progressive physicians.</p>
+
+<p class="center"><span class="smcap">Podiatry Orthopedics</span></p>
+
+<p class="center">will be the next volume of the System to be
+published and will be followed by other books
+along special lines bearing upon a knowledge
+of foot lesions and their care.</p>
+</div></div>
+
+
+<hr class="chap x-ebookmaker-drop">
+<div class="chapter transnote">
+<p class="center"> Transcriber’s Notes.</p>
+
+<p>
+Evident typographical and punctuation errors have been corrected silently.  Inconsistent spelling/hyphenation has been normalised.
+</p>
+
+<p> A half-title page has been discarded, and a publishers blurb for a companion volume moved to the end of the book.
+</p>
+
+<p>
+End of page footnotes have been sequentially numbered and relocated to the end of the text.
+</p>
+
+
+<p>
+To improve text flow, illustrations have been relocated between paragraphs.
+</p>
+
+
+<p> Cover art created for this eBook is granted to the public domain.
+</p>
+
+</div>
+
+
+</main>
+<div style='text-align:center'>*** END OF THE PROJECT GUTENBERG EBOOK 79224 ***</div>
+</body>
+</html>
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diff --git a/LICENSE.txt b/LICENSE.txt
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+++ b/LICENSE.txt
@@ -0,0 +1,11 @@
+This book, including all associated images, markup, improvements,
+metadata, and any other content or labor, has been confirmed to be
+in the PUBLIC DOMAIN IN THE UNITED STATES.
+
+Procedures for determining public domain status are described in
+the "Copyright How-To" at https://www.gutenberg.org.
+
+No investigation has been made concerning possible copyrights in
+jurisdictions other than the United States. Anyone seeking to utilize
+this eBook outside of the United States should confirm copyright
+status under the laws that apply to them.
diff --git a/README.md b/README.md
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+++ b/README.md
@@ -0,0 +1 @@
+[Project Gutenberg](https://www.gutenberg.org) public repository for eBook [#79224](https://www.gutenberg.org/ebooks/79224)