CHAPTER XIV VERRUCA (WART), CALLOSITY, HELOMA (CORN OR CLAVUS) DISEASES OF THE NAILS--INGROWN NAIL VERRUCA OR WART

Definition. A verruca is a circumscribed overgrowth of all the layers of the skin, varying in size from a pin’s head to a small nut. These growths may be single or multiple, and may come and go without any special reason. Verruca plantaris, or plantar wart, is observed on the sole of the foot; it may be single or multiple. It is very painful; it may be the size of a pea and is often mistaken for a callosity, from which it may be distinguished by the pain on pressure, and the tendency to bleed when the horny layer is removed.

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

Treatment. Certain chemical substances (see “escharotics”) destroy tissue and can be employed with safety only after much experience. These drugs when allowed to spread on the normal skin often occasion painful and persistent lesions. They must therefore be applied directly and sparingly to the growth itself and not be left in contact too long.

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

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

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

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

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

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

CALLOSITY

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

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

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

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

The palliative cure rests for its efficacy on the removal of the horny tissue down to, but not into, the papillary layer.

HELOMA

(Corn or Clavus)

Definition. A heavy thickening of the cuticle, usually caused by pressure, and producing pain by its own pressure on the tissues beneath.

Though the term heloma is rarely used outside of text books, there are very few who have not had an unpleasant acquaintance with this cutaneous affection, under the name of “corns.” Heloma is undoubtedly the most frequent of all skin diseases.

Cause. The exciting cause of helomata is intermittent pressure combined with friction; while among the predisposing causes it is only necessary to mention the slavish adherence to fashion which lends all of us to wear stiff leather shoes, the contour of which bears little or no relation to the natural shape of the anterior portion of the foot. The pressure of the ill-fitting boot upon the toes, or, more strictly speaking, the pressure of the toes against the unyielding leather, in walking, soon occasions hypertrophy of the horny layer at the point of irritation, and in time a dense, conical, pea-sized or larger mass is formed. The apex of the cone presses downward on the sensitive papillae and causes the painful sensation which suggests a visit to the chiropodist.

Helomata are named according to characteristics which mark them. When the growth is indurated it is called heloma durum; when soft, heloma molle; when of the millet seed variety, heloma miliare; when blood vessels are numerous, heloma vasculare. Each of these varieties requires a different method of treatment.

Helomata are most frequently found on the outer surface of the little toes, but may occur upon the sole of the foot and even upon the palm, or plantar surface of the foot. Between the toes they often form from pressure of the opposing digits, caused by narrow shoes, and in this location they are softer and usually present a whitish, macerated surface.

The Prophylatic Treatment consists in wearing a broad-toed, though not necessarily a square-toed shoe.

If shoes were made fan-shaped, like the imprint of a bare-foot in the sand, instead of having the greatest width across the ball of the foot, they might look strange at first, but they would be comfortable for all time. Those then who care more for comfort than for style, as most of us falsely profess to do, would have both cornless and comely feet.

The Palliative Treatment of helomata consists of first softening the dense, hard, horny tissue, when it will exfoliate spontaneously, or be readily scraped away. This projecting callous portion of the heloma may be removed by cutting or scraping till, as nearly as may be, the surface is level with the plane of the adjacent skin.

In the soft variety found between the toes, or in the vascular ones, located in the arch on the inner border of the foot, where the skin is thin, no thick covering will be encountered.

A line or groove will be observed marking the circumference of any variety of heloma, and it is in this line that the operative attack must be made.

Helomata of the miliary variety, usually appear on the sole of the foot and are, as a rule, as numerous as they are small. The preferable treatment is to use a sharp, pointed knife in removing each one of the “seeds” separately.

A well pointed, narrow blade introduced here will find a plane of cleavage between the growth and the surrounding tissue, through which it is possible to dissect quite deeply without encountering blood. When the dissection reaches the papillary layer in the skin, as evidenced by the red color, further operative steps should cease.

In the treatment of soft and vascular growths it may frequently be preferable to employ disintegrating solutions from the beginning.

Repetition of the treatment, as described in verruca, every second or third day, will result in the gradual disintegration of the growth to its extreme depth, and prove more satisfactory than the radical operation.

Healing is rapid and with the use of properly shaped, and roomy foot-gear, recurrence should not take place.

It is evident from the nature of helomata, that any “cure,” rubbed or painted upon the affected surface, can only cause the softening of a certain thickness of skin, and that no hope for cure is justified unless the careful and complete removal of the growth is accomplished and followed by the use of roomy foot-gear.

Radical Cure. The total excision of corns, while disabling the patient more or less for a few days, is in many instances justifiable. There is little probability of recurrence if proper foot-gear is worn, and the results are especially good if the skin graft operation as devised by Dr. Robert T. Morris is employed, which is described in the next paragraph.

After the excision of the growth, a small piece of skin is removed from the leg and sewn to the denuded area. This prevents a tough cicatrix forming and assures a normal skin covering to the area previously occupied by the corn.

The Text Book of Practical Chiropody, now in course of preparation, will contain lengthy and explicit articles on the subjects of verruca and heloma. The purpose here has been largely to present the subject from a broad surgical viewpoint. The strictly chiropodial features will be thoroughly outline in the Text Book of Practical Chiropody after a manner never before attempted and will include all details of the chisel methods, the dissecting methods and the shaving operations.

DISEASES OF THE NAILS

INGROWN NAIL

Although chronic inflammatory affections of the neighboring skin often produce changes in the form, color and thickness of the nails, these so rarely call for surgical interference that only those conditions leading up to the development of ingrown nail will receive consideration in the following.

Ingrown nail may be due to either a lateral hypertrophy of the nail itself cutting into the soft parts, or to the primary hypertrophy of the soft parts themselves, thus producing the same picture. An accurate determination of which condition represents the original etiologic element is important in deciding upon a course of treatment directed to the radical cure of ingrown nail.

The term “radical cure” does not necessarily indicate the performance of the so-called radical operation, but may result from proper treatment of a down-curved nail edge, or of a diseased nail fold, together with such prophylaxis in foot-gear as is indicated. With sufficient room in the shoe and the removal of offending granulations or cutting nail edge, a radical cure can frequently be effected.

Any inflammatory condition, either of the nail or its matrix, or the tissues contiguous to the nail, may result in the train of symptoms which are indicative of ingrown nail. When, however, any of these conditions has existed sufficiently long to cause ingrown nail to be present, it ceases to be of the first importance; it then becomes necessary to treat the buried nail edge, or the overgrown soft tissues themselves.

The Choice of Method between radical and palliative operations will depend entirely upon the degree of infection present, and the facility with which it can be reached. Thus, in the event of the entire toe being red and swollen and much purulent discharge being present, there will in all probability also exist much inflammatory tissue and a deep burying of the nail edge.

With a tolerant patient it might be possible to scrape away with a sharp spoon the granulation tissue, and remove the offending nail edge; the gradual improvement sought in ordinary cases cannot be thought of in these cases. It is urgent to relieve the pain and throbbing and to circumvent the dangers of a spreading infection. The sensations of a cutting nail edge have been lost in the more severe development. Should the patient be tolerant of pain, exposure, disinfection and drainage of the infected area is possible, but in most instances the contrary will obtain, and the radical operation with local anesthesia will be indicated.

The possibility of doing an efficient operation will ordinarily determine the method to be employed.

On the other hand there are a large number of cases in which palliative treatment is not only effective but emphatically the method of choice. One might see a degree of burying of nail edge quite as extensive as in the foregoing, with however, only a slight degree of infection. The nail fold may be much hypertrophied and granulation tissue may be abundant. The tenderness and inflammatory condition, however, is not so great as to interfere with the ordinary procedure. There is no danger of a rapidly ascending infection, the nail groove showing no inordinate amount of discharge. It is in these cases that a permanent cure frequently results from the mere removal of the irritating nail edge followed by the disinfection of the nail groove.

It is held by many that all cases of ingrown nail, except those due to a true hypertrophy of the nail, would remain permanently cured were it not for short or badly shaped shoes.

The Palliative Treatment of Ingrown Nail must necessarily depend upon its original cause. Should it be due to the wearing of improper foot-gear, nothing primarily pathologic in the tissues themselves being present, treatment will be effective only when correct shoes are worn thereafter.

Eczematous skin surrounding a nail or infection of a nail groove or matrix, should be treated as such before sufficient hypertrophy takes place to bury the nail edge. The disinfection and drainage of the groove can usually be accomplished with iodin on a thin wire or wooden applicator inserted to the extreme depth of the groove, followed by the insertion of a narrow strip of gauze. Frequent changes of dressings and extreme cleanliness will cause the early subsidence of these infections. It, however, is to be deplored that in the early stages these cases so rarely obtain treatment.

Elevation of the nail edge is often practiced quite successfully, but in general, this method of treatment is not applicable to the acute stages of the disease on account of the concomitant pain. Either the nail is too thick to be elevated by the insertion of cotton under its free edge, or the soft tissues are too sensitive to admit of the pressure.

The real skill of the chiropodist is called into practice in the treatment of ingrown nail by palliative methods, and he may safely be judged by his results in this class of cases.

It requires discrimination whether to attack the exuberant granulation tissue or the cutting nail edge, and in many instances it will be found that both are necessary.

Much skill is required in removing that part of the nail which is buried without causing pain or bleeding; this is the first necessity for relieving pain and can only be accomplished by a technic acquired through practice, and often redounding more to the credit of the operator than the successful performance of a major operation. A sharp instrument, usually a chisel, is placed against the free edge of the nail so as to cut only through the nail itself and not into the nail bed, with the purpose in mind of removing a wedge-shaped piece of nail of just the size necessary to relieve irritation, and permit of proper drainage and dressing.

Exuberant granulations are best treated either with nitrate of silver applications (50 per cent.) or with tight packing, or both. Disinfection and wick drainage of the entire tract is of the utmost importance.

The Radical Treatment of Ingrown Toe Nail. The operations, as in the palliative treatment, naturally fall into two classes depending on (1) whether the nail originally was at fault, or (2) whether the soft tissues, by inflammatory processes, have hypertrophied and overgrown.

Operations depending on such diseases or malformations of the nail, causing it to grow down into the tissues, should be directed to the removal of the nail, or the offending part of it with its matrix. (See “Hypertrophy”).

In conditions manifestly due to disease and hypertrophy of the soft tissues, palliative treatment frequently fails, and it becomes necessary to curet the granulating nail fold or to erode it with chemicals.

The best and easiest operation to effect a permanent cure, where this condition obtains, is known as Weber’s operation. This operation consists of the excision of an elliptical section of tissue just alongside of the offending nail border, without interfering with the diseased tissues themselves, and suturing the cut edges together in the long direction of the wound. The incisions are made to extend a little further back than the nail and as far forward as possible. They are about a quarter of an inch apart at the centre and meet at these two points. The depth of the section of tissue removed, if sufficiently great, leaves a diamond shaped cavity. When the edges of the wound are brought together the overgrown edge is pulled away from the nail and the further cicatrization of the wound contracting the soft tissues, assures an excellent result.

HYPERTROPHY

Hypertrophy can result only from hyperplasia of the papillae of the matrix, the thickening of the nail occurring at the base, front, lateral edges, or over its whole extent, according to the parts diseased. The nail may be evenly thickened or variously curved or twisted, while its structure becomes brittle, opaque and discolored.

Removal of the most projecting portions of the nail will reveal the papillae elevated far above the normal level of the matrix.

The change is slow and progressive, and when pronounced is usually permanent. The causes are not well understood; pressure, however, seems to be an exciting cause, this being more causative in the nails of the toes, especially those of the great and the little toe.

The old, whose epithelial structures tend to overgrowth, are more liable to hypertrophy of the nails than the young.

When attacking the fingers, beyond the blunting of the tactile sensibility and the deformity, no special trouble arises, unless painful cracks form from the splitting of the brittle nails. When affecting the nails of the feet, however, it is difficult for the patient to wear shoes, the pressure leading to inflammation of the adjacent soft parts and eventually causing typical ingrown nail.

Back pressure upon the matrix from a short shoe upon a thick unresisting nail, is frequently the cause of onychia.

Palliative Treatment of Hypertrophy. When the deformity seriously interferes with the wearing of shoes, or shows a tendency to cut into the lateral fold, it becomes necessary to establish normal dimensions either with the knife or drill.

The total removal of the nail; including the matrix, is the only permanent cure. Excision of the cutting edge of the nail, as in radical operation of ingrown nail, eliminates only that element of discomfort.

The thinning of the nail, by scraping or with the drill, can also be accomplished with sodium sulphide. A sufficient quantity of the sulphide is added to starch paste to make it swell; this, when applied (use a wooden applicator) to the thickened nail, will cause the nail to disintegrate. By touching the surface with the applicator, one can determine the depth of nail destroyed before washing off the excess sulphide.

Radical Treatment of Hypertrophy. When the thick nail has cut into the lateral fold and actual ulceration has occurred, it becomes necessary to remove the down-curved edge.

Under local anesthesia, an incision is made through the nail, a little to the side of the inflamed area, and is carried well back through the matrix. A curved incision, outside of the infected fold, meets the first incision in front and back of the nail. All the tissue between is removed in one piece, including the offending portion of nail with its matrix and the nail fold with all granulation tissue.

This wound may be brought together by catgut sutures, or may be allowed to heal by granulation.

This operation suffices to prevent further trouble at the nail edge, but does not prevent the discomforts due to a long, distorted, horny nail. Total removal of the nail with its matrix is the only radical cure. (See “Local Anesthesia”).

Inflammation of the Matrix (Onychia). As a result oftraumatism in unhealthy individuals, inflammation and suppuration sometimes occur at the root of a nail and in the contiguous portion of matrix (“run-around”), and often stubbornly continue unless the loosened, sharp edge of the buried nail be carefully trimmed away from time to time, and a little iodoform gauze be employed to press back the inflamed tissues.

From lateral hypertrophy of a toe-nail the sharp lateral edge becomes imbedded in the lateral fold, or from improper lateral compression of the toes, the same portion of soft tissues is forced up against the margin of the nail. In either case, inflammation, suppuration, and ulceration ensue, resulting in the formation of red, exuberant, excessively painful granulations, constituting the condition called ingrowing toe-nail, though more correctly it should be termed “up-growing pulp.” Sometimes both edges, or even the whole matrix, become involved, producing pain on any movement of the member.

When inflammation and ulceration of the whole matrix occur, especially where a finger is involved, the condition is termed onychia maligna, which attacks only those in depressed health.

Treatment. The palliative treatment suggested for ingrown nail is indicated for all inflammations of the matrix, as far as the disinfection or removal of the portion of nail producing irritation is concerned, but in onychia maligna the whole nail usually requires removal under local anesthesia, with destruction of the matrix by caustics, or by curetment

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