Kitabı oku: «Psychotherapy», sayfa 53

The mechanism of the formation of the bunion in many cases seems to be, that the large toe, instead of lying straight along the inner edge of the foot, is pushed or pulled toward the other toes. If this process began from the wearing of pointed shoes, especially if such shoes did not have a straight line on the inside, conditions within the foot would soon tend to emphasize it. If the adductor hallicis once gets the habit of contracting rather strongly, as it is likely to do through the irritation set up by the yielding of the arch, it will be hard for its opposing muscles to counteract it. More important than this, however, is the fact that the tendon of the flexor longus hallucis runs along the inner border of the foot and is particularly affected by the yielding of the arch. For it works at a decided mechanical disadvantage under the new conditions and is stretched in such a way as to pull forcibly and constantly upon the big toe, necessarily turning it more and more outward as the arch continues to yield. The dropping of the arch makes the distance from the heel to the toe longer than before and the tendon pulls the toe as far outward as possible to compensate for this, as the distance to its insertion is thus made somewhat shorter.

The yielding of the arch lengthens the foot and puts the tendons of all the flexors on the stretch. All of them have a tendency to bend the toes, and as this action is constant, gradually the tendons of the extensors become over-stretched and these muscles are not capable of exerting their full force in overcoming the action of the flexors. The flexor longus digitorum has a tendency to cause a bending of the small toes, and as it also runs across the foot it pulls the toes somewhat inward, that is, toward the big toe. This crowding leads to hammer toes and over-riding. The big toe, however, is maintained in a state of extension by its firm, full contact with the sole of the shoe and with the floor when walking barefoot. The one direction in which it can yield rather readily is outward toward the other toes because this shortens the distance between the end of the toe and the heel. The pressure put upon the flexor longus hallucis will have a tendency to cause this, for it is over-stretched by the yielding of the arch and keeps constantly pulling on the big toe until that member has a distinct flexion outwards.

This makes the metacarpo-phalangeal joint prominent and then nature proceeds to protect it by a water cushion, a special bursa due to the formation between layers of connective tissue of a pocket in which some serum is constantly present. One can scarcely admire enough this provision of nature by which she protects prominent bony points whenever they are subject to much irritation or to such use as would cause injury to important structures below. If continued pressure continues to be irritating, however, the water cushion proves unavailing and an inflammation of the overlying skin occurs with occasionally a spreading of infectious agents from the surface into the serum pocket below. This serum is such a good culture medium that an acute abscess is likely to form—the acute bursitis of the surgeons.

Rarer Foot Troubles.—Besides bunions, a number of other deformities of the feet occur as a consequence of the yielding of the arch. All the toes are likely to bend rather acutely, and the points of them are pressed against the shoe, while the knuckles, so to speak, are made prominent and are more likely to be subject to corns than would otherwise be the case. Besides, the displacement of the big toe toward the little toes leads to a crowding of the toes together, and this gives rise to soft interdigital corns and to a lowered resistive vitality which may be the predisposing factor to slight infections of various kinds that will make the patients miserable. Such affections may appear negligible, a matter for the chiropodist, and not deserving the physician's attention; but they mean so much for the comfort of the patient and the prevention of exercise through sore feet reacts so deleteriously on the general health that these minor ailments become important and merit careful attention. Dr. Emmet tells the story of the old family servant, always grumpy and complaining, who, when he had the many blessings of life pointed out to him, confessed that the Lord had been very good to him, but said, "The Lord knows He takes it out of me in soft corns."

Hammer Toes—Clam Toes .—Nature has provided a wonderful mechanism in the arch of the foot and the anatomical relations of the toes to support the weight of the body firmly, gracefully, and comfortably; yet any yielding of any part of it leads to a disturbance of its delicate mechanical relations and, consequently, to ever-increasing deformity. Hammer toes are typical examples of what such a disturbance may lead to. One of the toes becomes pressed downward between two others. This over-stretches the extensor muscles and tempts the unbalanced flexors to contract. As the extensor muscles become, after a time, unable to work in the constantly bent toes, they atrophy to some extent and then the flexor muscles pull the toe farther and farther down until there is no possibility of its being straightened at all. Now, if the flexor tendons are cut and the toe straightened the atrophic extensor muscles will not hold it in that position, and when the flexors grow together the old condition will reassert itself. In the meantime, muscle changes in the neighboring toes have also taken place. With no resistance on one side of them, they become bent sidewise over the hammer toe, and so their muscles on one side are overstretched and on the other side become contracted. After a time it is impossible to correct this series of deformities which are being constantly increased and emphasized by the weight of the body above.

Present-day Shoes.—In recent years we have heard much more than heretofore about foot troubles. As the old-fashioned shoes were carefully made by skilled shoemakers to fit the feet of one individual and not to conform to some supposed ideal pedal extremity, they supported the feet much better than do the modern cheap machine-made shoes. These custom shoes lasted a long time, and, after they were once molded to the foot, the wearer was not disturbed for many months by the process of having to become accustomed to another shoe. The many advertisements in quite recent times of foot powders and other artificial relief for the foot show that people are suffering much more than before, or, at least, are less able to bear the discomfort. These powders, however, are not likely to do good in the long run, since they tempt the wearers to stand the discomfort against which they do furnish a certain amount of soothing. It is much better, however, for the sufferer to find the cause of the discomfort and to remove it if possible, for otherwise it will lead to constantly growing displacement of bones and muscles and may eventually even bring on actual and ever-increasing deformity.³⁴

Prophylaxis.—The most important means of prophylaxis in these cases is to have patients who must assume the standing position for some hours each day, exercise their legs rather vigorously. If teachers, lecturers, and the like, have to stand for a long time, it is important that on the way to and from their occupations they should not have to stand up in cars nor assume cramped and uncomfortable positions. It would be better for them to walk rapidly for several miles rather than ride in a standing or a constrained position. If they are convinced of the necessity for exercise, there is much less likelihood of the development of the severer discomfort that is sometimes very discouraging. It is particularly difficult to make women understand this; yet, once they have found how much relief is afforded by vigorous exercise, they are likely to overdo it and thus run the risk of incurring ills quite as serious as those consequent upon not taking enough. In nervous people the nagging discomfort of a yielding arch will sometimes (just as eye strain does) produce reflex headaches, constipation, lack of appetite, and apparently predispose to the frequent recurrence of migrainous headaches. I have, in not a few cases, seen these conditions relieved by rational treatment of the foot condition.

Circulatory Disturbances Due to Flatfoot.—An interesting direct consequence of flatfoot is the disturbance of the venous circulation, which is likely to bring about some swelling of the feet and nearly always considerable coldness and numbness, particularly in the winter and, above all, on damp days during cold weather. The swelling of the feet makes the patient think—sometimes at the suggestion of his physician—of kidney trouble or heart trouble, and sometimes it is hard to persuade him that there is nothing serious the matter with these important organs. The disturbance of the circulation further leads to numbness, to some anesthesia, and to paresthesia. Corns and especially callouses grow more readily between the toes, and patients who are prone to read about such ailments may conclude that they are suffering from hypesthesia and hyperesthesia due to some serious progressive organic nervous disease. I once had a woman patient discourse learnedly to me about these things who was sure that she had the beginning of some incurable spinal disease. Locomotor ataxia was the least she might expect from her description of her feelings. What I found was flatfoot. Raising her arch cured her.

The cold feet and the numbness, to call them by simple Saxon names which will not disturb patients, may sometimes keep them awake. In the chapter on Insomnia we suggest that the best thing for this is to secure a return of the circulation either by exercises, or by wearing a flatfoot brace during the day, or by putting the feet in water as hot as can be comfortably borne and keeping them there for a quarter of an hour. Of these means exercise is the best. Raising up on the toes after the shoes are off and coming down on the outside of the foot strengthens the muscles, pulls the bones of the arch firmly together and encourages the circulation. For beginning flatfoot this is a curative measure and it is the natural mode of treatment for the coldness and numbness of the feet. Rubbing, also, is good for the feet in order to restore the circulation, but patients are inclined to rub downwards while they should rub upwards in order to help the hampered venous circulation. The thin-walled veins are more likely to be compressed by any disturbance of tissues than are the firm-walled arteries, and it is to help the veins that our remedial measures must be directed.

Secondary Consequences.—The secondary consequences of flatfoot are interesting. It is surprising how many people who frequently suffer from sprains of the ankle have some yielding of the arch as a predisposing factor to that condition. Two classes seem to suffer frequently from sprained ankle—those with yielding arches and those with high insteps. Apparently there is weakness in the excess in both directions. Very flatfooted people apparently do not suffer so frequently from sprained ankles as those in whom there is only an incipient yielding of the arch. They seem to have learned to walk more circumspectly. Perhaps, too, their well-known tendency to toe outward lessens their liability to turning on their ankle. The effects of sprains of the ankle in people with weak foot last, as a rule, longer and leave more weakness after them than they do in ordinary cases. This, of course, might be expected, but it is surprising how often the significance of beginning flatfoot fails to be noticed even by the physician. I have seen rather frequently cases of so-called chronic rheumatism in which there is a series of stories of sprained ankle because of the assumed weakness of the ankle from supposed rheumatism, when the whole case can be summed up in a yielding arch.

Exercises.—If the arch has not yielded much, it is often unnecessary to prescribe flatfoot braces or arch supports of any kind, unless perhaps at first. After the first soreness has passed off, exercises may be employed to strengthen the muscles. As we have said, the patient should rise on his toes and then come down slowly on the outside of his feet. He may be instructed to sit with his feet—not his legs—crossed, the feet resting on their outer edges. He may be shown how even various slight movements of his toes, almost without moving his shoes at all, will strengthen the muscles that pass around the arch, which, thus strengthened, will hold the bones of the arch firmly together and prevent further yielding. There is, at the present day, a tendency to recommend too freely the wearing of flatfoot braces or arches. After all, these are only crutches and should not be worn unless absolutely necessary. If the arch can be strengthened—as it can be in many cases—so as to bear the body weight without discomfort, then this is much the better treatment. If the arch is restored the feet are in a more natural condition, while artificial support leaves the muscles without that exercise which will preserve their functions. Flatfoot braces may be necessary, but only if absolutely necessary should they be advised, and palliative measures, such as exercise, manipulations, and rubbings, should be given a fair trial after the unfavorable suggestions as to his foot condition have been removed from the patient's mind.

Significance of Foot Troubles.—We have devoted much space to foot troubles—more, perhaps, than will seem justified to the minds of many physicians. We have done so, however, because of the firm conviction that the feet are the source of more discouragement and depression of mind than any other part of the body. Life very often takes on another aspect when foot troubles are relieved. In the old, progressive deformities of the feet consequent upon mechanical disturbance are probably the source of more discomfort, and by their interference with exercise and outing, the cause of more ill-feeling and even disturbance of health than any other single factor. Even life may be shortened by the confinement or limitation of movement consequent upon bad feet. Above all, the idea that any constitutional trouble, or hereditary disease, is at the bottom of their affliction must be removed, and then these patients are encouraged to live their lives more fully and with more happiness for themselves and others. Hence this long chapter.

CHAPTER IX
ARTHRITIS DEFORMANS

Arthritis deformans has unfortunately been called by several names besides the descriptive term which, in the present state of our knowledge, is the most suitable for it. We do not know its cause. We do not well understand even the predisposing factors in its causation. Hence, the term arthritis deformans, which declares simply that it is an inflammatory condition of the joints producing deformities, exactly fits it. It has often been spoken of by such names as "rheumatic arthritis," or "rheumatoid arthritis," and, above all, by the unfortunate term "rheumatic gout." Many of the worst suggestions that attach to the word rheumatism are founded on these ill-chosen designations. Arthritis deformans was supposed to be connected with rheumatism or with gout, or perhaps to be due to a combination of the two. In a majority of the cases there is no history of either true gout or rheumatism to be obtained from the patient, and where a rheumatic or gouty history does occur, it is either quite indefinite or it is clear that arthritis deformans developed in a gouty or rheumatic subject, that is, following genuine gout or rheumatism, just as it might develop in any other individual without any causal connection between it and the other affections.

Supposed under the old theory to be a constitutional, probably a blood disease, patients who saw the ugly, crippling deformities produced by it and then heard the word rheumatism used in connection with it were prone to think of this as the terminal stage of all the severe rheumatic conditions. As a matter of fact no evidence that we have shows that the disease has any connection with chemical modifications of nutrition or metabolism; nor, above all, has the so-called uric acid diathesis or any other superacidity of the blood any etiological connection with it. It has always seemed to me to be clearly a nervous arthropathy, as the lesions are almost without exception more or less symmetrically distributed. The joints that suffer are commonly the smaller ones in corresponding positions on opposite sides of the body, and they run a definite atrophic course sometimes with the preceding phase of hypertrophy that is so characteristic of the trophic lesions of an affection produced by a disease or defect of the nervous system. This symmetrical distribution constitutes the best possible evidence that arthritis deformans is not a nutritional disease and, above all, is not due to chemical changes in the blood.

The affection exists in at least three forms and there is a growing persuasion that there are even more varieties of it that will have to be separated by clinical observation.

There is a good study of the three types of the disease in Guy's Hospital Reports, Vols. 56-57, London, 1902. The article is entitled "Acute Rheumatoid Arthritis," but there seems no reason for applying the word rheumatoid to the group, especially since there is no proved connection with rheumatism and no similarity, except in the case of acute deforming arthritis in which at the beginning it may be difficult to differentiate the two affections.

HEBERDEN'S NODES

The most familiar form is named Heberden's nodes, from the great English physician who first made a special study of it. The affection is characterized by an enlargement of the sides of the distal phalanges with small, hard nodules, "little hard knobs", as Heberden called them, developing at these points. They are more frequent in women than in men. Evidently neither hard work nor exposure nor excesses in eating or drinking occasions them. They occur in all classes, the poor and rich, manual workers as well as professionals. It is rare to find them on one hand alone, though it is not at all rare to find them affecting solely the little fingers of each hand. I have seen several cases where surgical intervention had been attempted on one little finger because of the deformity produced when the node originally appeared. When I asked if there was not some trace of a similar condition on the other hand I was told there was not, yet I have been able to show that the first signs, at least, of a corresponding growth already existed on the little finger of the other hand. In the two cases in which my attention was called to a slight enlargement on one side before anything developed on the other, my tentative prophecy that corresponding nodosities would grow on the other side was fulfilled during the following years.

While this form of the disease is a true arthritis deformans it seems to be entirely separate from the progressive forms which we shall speak of later. The nodes increase in size and occasionally develop on all of the fingers, but usually never spread beyond the phalangeal joints. There is a tradition in the medical profession of England, where this affection has been observed with care for some two hundred years, that sufferers from these nodes commonly live to long life. This is not founded on any theory, but is an actual observation. There is also a tradition, though I cannot vouch for its truth, that the people who are thus affected have some sort of immunity to tuberculosis, or at least good resistive vitality against a rapidly running tuberculous process.

I have had at least a score of Heberden's nodes cases under observation for more than ten years and some of them for nearly twenty years, and have been surprised at the slowness with which the process develops. A year often makes no change in the size of the nodes, and I have seen cases where after five years the photograph showed no difference. The lesions are often exquisitely symmetrical so that the question of the origin of the affection in the spinal cord constantly crops up, for that is the symmetrical influence in the body. There are, however, no other symptoms that point to involvement of the cord in any way. Most of these patients have suffered more from worry about it than from their affection. It is another case of "having many troubles most of which never happen."

Some of my patients are physicians, and all of them have consulted other, some many other, physicians. As a consequence, many of them have taken to various diets, especially eliminating certain foods and liquids with the idea that this might stop the progress of the disease. I have never known any change of diet or any abstinence from liquids or solids that seemed to make the slightest difference, though I have seen a number of cases that were considerably worse than they would have been if the diet had not been tinkered with to such an extent as seriously to disturb nutrition.

The main disturbing feature of the affection is the dread of the development of serious crippling conditions in the hands or in the large joints.

As a rule, after a time the nodes cease to grow, and then a period of remission sets in that lasts for many years and there may be no recrudescence of the affection. This remission is delayed if the patients allow themselves to run down in general health. It is apparently hastened by getting the patients up to normal weight and removing any factors that disturb their general health. If the patients' minds are properly disposed, the neurotic symptoms that sometimes develop as the result of over-solicitude about their condition are done away with, the patients are more comfortable, and even the progress of the disease is inhibited.