SCIATICA
Etiology.—What has been said of lumbago applies to a great extent also to sciatica. There are a number of different affections which have come to be grouped under the term sciatica. Here, much more frequently than in the lumbar region, the cause of the pain is a true neuritis. This may be of many forms. Occasionally it is syphilitic in origin; whenever the sciatica is double it commonly develops on a basis of diabetes, while in many cases it is of an infectious nature. There is no special reason to think that there is a rheumatic infection of the nerve, though inasmuch as rheumatic arthritis is probably due to infections by many different kinds of microbes, it may well be that some of these play a role in sciatica. There is no good reason, however, why the word rheumatism or the term chronic rheumatism should be applied either to lumbago or to sciatica. Certainly there is no reason in any definitely known etiology of the affections. Each individual case must be studied carefully. Always these are local and not constitutional conditions, and usually something in the patient's occupation, or in his habits of life, helps us to understand the development of sciatica or lumbago and gives the most valuable hints for treatment.
Men who shovel much and who bend one knee as they stoop in shoveling will often suffer, though more frequently in the leg which they do not bend than in the other. The same thing is true for men who use one foot to run a lathe or a small printing press, or anything of that kind. They must be taught to alternate in the use of their limbs.
Pressure.—Occasionally direct pressure upon the nerve is the cause of the disturbance. I once was asked to see in consultation an elderly lady who had complained very much, first of discomfort and then numbness in her legs, until finally she lost all power in them below the knees. The affection was considered to be some sort of creeping paralysis. I found that her favorite chair, an old-fashioned cushioned easy chair, allowed her to sink down so that the edge of the wood seat frame pressed upon her just where the sciatic nerve comes closest to the surface. As soon as the habit of sitting on this chair was changed her numbness and inability to use her limbs began to disappear.
Alcoholic Neuritis.—In both lumbago and sciatica one underlying factor is often present. This is the consumption of undiluted whiskey in considerable quantities. Outdoor workers are prone to take an occasional glass of whiskey, especially in the winter time, and a copious quantity of malt liquors in the summer. Both of these predispose to the development of a low-grade [{405}] neuritis in susceptible individuals. Alcohol is said to have an idiosyncrasy for the anterior tibial nerves. That only means, as a rule, however, that these nerves are more frequently affected by alcoholic neuritis than others in the body. The reason for this special location of the affection is that in people who stand and walk much, this constituting their main form of exercise, these nerves are much used. They are probably in such people (that is, if the intensity of impulses that pass through them be taken into account) the most used nerves in the body. It is this that makes them most susceptible to alcohol. In people who stoop much or who have to work hard in stooping postures, the nerves in the lumbar region and those that make up the sciatic trunk are over-used. This makes them more susceptible to pathological influences than others, hence the tendency for neuritis to develop in them.
Intrapelvic Causes.—Sciatica may be due to various pathological conditions within the pelvis. Women with fibroid tumors are particularly likely to suffer from it. Their removal by operation does not always assure against the occurrence of sciatic troubles. I once saw an obstinate case of sciatica in which there was a story of a fibroid having been removed years before and, though there were no signs of any recurrence of the growth of another, there were some adhesions in the region, and there was an obstinate constipation particularly likely to have as one symptom an accumulation of fecal material in the rectum until it was very hard. The keeping of the bowels open meant more than anything else for the relief of the sciatica. This patient subsequently died from what was diagnosed by a well-known French surgeon as rupture of the bowels. This was probably due to the adhesions that occurred after the old operation, done without any regard to the possible development of such a sequela, some twenty years ago. The sciatica was undoubtedly connected with the group of disturbed conditions within the pelvis.
Position at Work.—In this case, as in others that I have seen, the position assumed while at work seemed to have been an appreciable factor in the production of the pain in the limb. The lady made her living by writing and often wrote on a board resting on her knee—a feminine, not a masculine habit. This brought pressure to bear upon the right limb a little more than the other and then, when she crossed her knees in order to put the writing board on top of the knee, this side seemed to be used more than the other.
This question of the position in occupation, even though sedentary, is very important. I have seen a strikingly typical case of the so-called neuralgia paresthetica, the achy condition of the outside of the thigh with some anesthesia and paresthesia, occur in an old lady who still retained the girlish habit of sitting on her foot while she did crocheting. I have often seen achiness of muscles of the trunk develop in persons who read much in a cramped position because of the reading light being too low or otherwise wrongly placed for group reading. Whenever a patient has to stand much on one foot while doing something, it is important to remember that there should be alternation in the use of the limbs; otherwise sciatica and lumbar pains will often develop, usually on the side corresponding to the limb that is kept rigid.
Treatment.—Mental Persuasion.—The patient must be made to realize that his affection is not rheumatism, but is due to local conditions. Just as soon as a patient's mind is relieved by being made to appreciate that certain habits in his occupation, or certain local conditions that can be corrected, [{406}] are responsible for much of his discomfort, then that discomfort is much easier to bear. Even in cases where actual neuritis has developed, or where there have been changes in the intermuscular planes bringing considerable disability, the aches caused by these will be much more bearable if the patient's mind is set at rest as to the real significance of the condition. No condition should be called rheumatic unless at some time in the history of it there was an acute inflammatory condition with Galen's classical symptoms—tumor, color, rubor and dolor. Pain alone is never sufficient to justify the diagnosis. Painful disability is usually due to local causes.
Treatment of Acute Symptoms.—For acute symptoms, the coal tar products may be used and usually afford distinct relief. They include all the old-fashioned salicylates as well as certain more recent compounds, such as aspirin. Phenacetin, however, though usually not thought of in this connection, is an excellent remedy for the discomfort. These drugs should be used freely so as to give relief from the painful condition. The fact that they afford relief, however, should not be taken as an argument that the condition is rheumatic. Rheumatism, as we know it, is an acute infectious disease and there is no reason in the world for saying that the salicylates or cognate drugs are specifics in this affection. They relieve the pain, but just in the same way they would relieve the pain of toothache or of any other painful condition. After the acute symptoms are removed, the condition that remains may be treated in various ways, by massage, by local applications, and by such manipulations as will restore the normal circulation of the part. Care must be taken, however, to distract the patient's mind from the local condition after a time, or mental influence, by interfering with the capillary circulation, may inveterate the symptoms. It is not good to keep patients at rest, though rest, of course, is always indicated if there is much discomfort. Sometimes, however, the discomfort is really due to the fact that muscles have not been used for some time and so are easily fatigued and may ache even under ordinary use. In this case, a gradual restoration of the muscles to normal strength by progressively increased exercise is important.
Counter-Irritation and Its Suggestive Value.—Personally, I have found the use of turpentine particularly efficacious in connection with suggestion. The old-fashioned system of ironing seems to do more good than any ordinary application of turpentine. For this a piece of flannel wrung out in warm water has some turpentine scattered over it and then is placed on the affected loins or back of the thigh and covered by another piece of flannel, and a hot flat-iron is rubbed over it. The physical effect is a considerable hyperemia, but the effect upon the patient's mind is especially interesting, the unusualness of the mode of application adding decidedly to the effect. It must not be forgotten, however, that there are some people who are over-susceptible to the influence of turpentine, and its use is followed by a rash.
Lumbar and Sciatic Psychoneuroses.—Many cases of lumbago and sciatica are really psychoneuroses. They develop exactly as psychoneurotic conditions do in the abdomen or in joints. Not infrequently there is some accident or injury, some sprain or strain, or exposure to dampness or draft, that serves as the occasion. The Germans group all these occasions together under the word "insult." The "insult" produces little physical effect but after some days or sometimes weeks, the slight discomfort present secures the center of [{407}] attention and then the patient suffers from what seems to be severe pain and often inability to move or use muscles. Even when there is true sciatica or lumbago, that is, a genuine low-grade neuritis of the lumbar or sciatic nerves, most of the symptoms may come from the associated psychoneurosis. This is proved to be so by the fact that such patients are often cured, for the time being at least, by some shock or fright or sudden excitement, that makes them move, forgetful of the pain and inability from which they suffered just before. Besides, such cases are often cured by inert remedies of many kinds, by local applications that have no specific effect, and by various methods of treatment which cannot be responsible for the recovery. The amelioration of the condition is due to the mental influence accompanying the methods of treatment and the reassurance of the patient's mind.
Diversion of Attention.—Almost anything that produces a continuous succession of sensations on the surface of the affected area that attract and hold the attention of the patient may prove a valuable therapeutic suggestion and even eventual relief from symptoms that have proved obstinate to more rational treatment. Liebault, the well-known founder of the Nancy school of hypnotic therapeutics, tells in his "Thérapeutique Suggestive," that he has frequently cured lumbago by the simple recommendation of a rather stiff piece of paper to be applied over the patient's loins. The rationale of this treatment seems to be that the patient's attention is attracted to the skin surface by the sensations constantly produced by it and attention is distracted from other feelings deeper in the muscles. It often happens that after an acute lumbago has run its course, there is left a chronic achiness only partly physical and largely psychoneurotic. Some of it is undoubtedly due to the habit, formed during the acute period, of keeping the muscles quiet, in order to avoid the spasmodic pain that occurs on movement. Patients cannot, as it were, let go of their muscles, and their discomfort is largely due to holding them in a cramped position. The sensation produced by the paper on the cutaneous nerves distracts the attention and brings about relaxation of the muscles with decrease of discomfort and gradual relief of all symptoms.
The paper acts as a constant source of suggestion for the cure of the psychoneuroses when the affection is purely psychoneurotic. The mind has become concentrated on the idea of pain and discomfort in this region and needs another thought to occupy itself with so as to neutralize this. Wearing the paper with the assurance, for instance, that because of its impermeability to air it keeps the part more thoroughly protected from variations of temperature and from such possibilities of transudation as have before been possible, serves to lift patients out of themselves and affords relief. Whenever the sensation produced by the paper is noted, there is a renewal of the suggestion and its curative effects. There are many plasters that have obtained the reputation for curing lumbago. It is doubtful whether any of these have sufficient medicaments on them to be of any serious pharmaceutic significance. They are mostly rubber plaster. The presence of this and the consciousness of the sensation produced by it acts as favorably as does Liebault's sheet of paper.
Mechanical Agents.—It must not be forgotten, however, that a large sheet of adhesive plaster firmly applied may act as a mechanical therapeutic agent, somewhat in the same way that strips of adhesive plaster relieve the pain of pleurisy, or are helpful in a sprained ankle or a knee. The muscles may be [{408}] held rather firmly together and so there is no necessity for constant attention to prevent spasmodic pain. Undoubtedly some of the newer large-sized adhesive plasters produce an excellent effect in this way. If, besides, the patient has the feeling that they must be doing him good because of materials in their composition, the psychoneurotic elements are more readily relieved. The old idea was that such plasters drew out the pathological elements to the surface whence they were dissipated. There is no truth underlying this thought.
In the old days blisters were applied rather freely to these regions and the actual cautery was often employed. Both of these therapeutic processes are likely to do good in chronic cases, but much more from their psychic than their physical effects. The actual cautery is not used nearly so much as it ought to be in chronic muscular and neurotic conditions, for the mental effect of its application and the distraction of attention to the skin surface while the cauterized areas are healing are excellent remedies.
There are other counter-irritant procedures of the same kind that have been used with reported successes in many cases. Hot needles, for instance, if pushed deeply into the muscles, often have an excellent effect. Some years ago a distinguished surgeon insisted that both lumbago and sciatica might be cured in many cases by the insertion of needles deeply into the muscles. He argued that what happened was that these needles brought about an equilibrium of electricity in the muscular structures which had somehow been disturbed. Deep injections of water into the muscles also do good. Stretching of nerves has been applied with reported success. After a time all of these measures fail, however, because somehow after the novelty of the treatment wears off for the physician, the patient's mind is not sufficiently impressed and then the former results are not secured. Where there are actual neuritic processes present they will almost surely fail. So many of these cases are almost pure psychoneuroses, however, that it is little wonder that anything which produces a strong impression on the mind and leaves after it some condition that attracts attention and so furnishes favorable suggestion will almost surely cure even chronic conditions for which all sorts of physical remedies, employed on rational grounds, have failed.
Anything that modifies the circulation, even to a slight degree, or by causing a reaction in the local vaso-motor state, alters previous conditions, tends to enable the patient to control the affected part. These psychoneurotic conditions in large muscles help us to understand what happens in organic diseases. There is a physical element that must be modified, but unless a strong influence is brought to bear upon the mind so as to arouse all its capacity for control, the cure will not come. Anyone of a dozen things, however, may be used in this way and often when one fails another will succeed. In obstinate cases of lumbago and sciatica if necessary a number of these forms of treatment should be used successively.
Hypnotism.—How much pure psychotherapy may mean for many of these obstinate cases of lumbago and sciatica can be appreciated from the many reports of cures by hypnotism or by suggestion in a light hypnoidal state, or occasionally, under favorable circumstances, even in the waking state. One of these cases, indeed, is responsible to some extent for the French interest in hypnotism which attracted so much attention in the last quarter of the [{409}] nineteenth century. Prof. Bernheim of the University of Nancy had seen a case of sciatica in which every therapeutic means at his command had failed. As the result of disuse the leg was emaciated and possessed little muscular power. It looked as though the man would never be able to regain the use of it properly. Dr. Liebault succeeded in curing the patient by light hypnotic sleep, in which the suggestion that he would be better was given while the physician stroked the limb. After the first seance the patient was able to use the leg better and the discomfort was greatly decreased. Further seances with Dr. Liebault brought further improvement until finally the condition was cured. Prof. Bernheim, who knew how intractable these cases are, had the case called particularly to his attention and naturally wanted to learn more about the method by which it had been brought about. Liebault's methods had been quite contemned by the regular faculty before. After a series of experiences under Dr. Liebault's direction Prof. Bernheim became enthusiastic over the use of hypnotism as a curative agent and this led to the publication of his well-known work "De la Suggestion et ses Applications dans la Thérapeutique." [Footnote 34] It was the interest aroused at Nancy that led Charcot to take up hypnotism, and while he came to very different conclusions, there is no doubt that the work at Nancy meant much for our knowledge of suggestion in both waking and hypnotic state in therapeutics.
[Footnote 34: On Suggestion and its Applications in Therapeutics.]
CHAPTER VII
PAINFUL KNEE CONDITIONS
Most of the painful knee conditions of which patients complain are not directly due to true pathological conditions either of the knee joint itself or of its neighboring structures, but rather to affections of other portions of the leg that set a special strain upon the knee and, above all, to various kinds of foot disturbances. The erect position is maintained principally by a nice balance of nervous and muscular energy in the knee joint and its surrounding structures. Any irregular sensory or motor impulses to the knee-joint or to the muscles of the thigh will disturb the absolute equilibrium of the flexors and extensors and will make standing painful or even impossible. Whenever a morbid condition requires a different use of the muscles and tendons around the knee from that to which they are accustomed, fatigue readily ensues, and aches and even tenderness in muscles and tendons develop as the result of the over-exertion. These collateral conditions must not be overlooked in the diagnosis and treatment of painful knee conditions.
Etiological Factors.—Even a slight sore on one foot will give rise to considerable achy fatigue of the knee of the opposite leg, because, consciously or unconsciously, we stand much more on that leg, use it more in walking, and spare the other because of the pain induced by use of the foot. Above all, throwing more weight on the other leg causes us to use muscles a little abnormally with consequent soreness. This painful fatigue is most likely to be felt around the knee, though it may extend to the hip and even the lumbar [{410}] region of the well side if the foot continues to be spared for a number of days. Particularly will this be true if there is anything the matter with the big toe, on which so much of the use of the foot depends. An ingrowing toenail will not infrequently give so much discomfort to the well knee and hip as to make the patient sure that there must be some rheumatic or other condition at work in these joints. The serious affection of the joint which the patient apprehends is found to be no more than a sympathetic fatigue induced by having to use his feet, or one of them, a little differently from usual, perhaps because of some condition that leads him to spare them. To call the patient's attention to this is of itself therapeutic.
Inequality of Legs.—The effort required for standing and the accurate balance of the muscles involved in it is such that any mechanical disturbance of the feet or legs or even a trivial pathological condition causes painful fatigue. It must not be forgotten, for instance, that the presumption that human limbs are of exactly the same length is not confirmed by accurate measurements. There is an average difference of probably half an inch in length between the limbs of normal persons, and there may be even a difference of more than an inch before deformity is said to be present. The longer limbs are likely to do more work and are, therefore, more subject to fatigue and consequent complaint. One of the reasons why we can distinguish persons by their gait even at a distance is that the difference in the length of their limbs makes noteworthy characteristics in their walk.
High Heels.—People who are used to walking in a natural manner and who don a pair of high-heeled shoes for the first time are sure to complain of pain in the calf and knee, because the high heels require them to hold the knee more rigid and in a somewhat different position from that required when the persons stand under ordinary circumstances. It is the unusual in muscular effort that gives rise to the extreme fatigue which becomes positive pain if it is allowed to continue. It is curious how small a raising of the heel will cause discomfort. Over and over again I have known the careless putting on of rubber heels to be responsible for pains around the knee, which in damp weather were the source of so much discomfort that it was hard to persuade the patient that he was not suffering from rheumatism or some serious incipient pathological condition.
Unusual Occupations.—Joint pains often develop after the patient has been doing something quite unusual and putting an unaccustomed strain upon his muscles. I have often seen dispensary patients whose knee pains began after there had been a family moving. In the course of the removal of household goods, both men and women are likely to help in hanging pictures, in taking them down, in moving heavy furniture and other occupations of this kind which make them extremely tired. If there is any tendency to relaxation of joint structures the tiredness may manifest itself as a sense of painful discomfort. The knees are particularly likely to suffer if there is a relaxed condition anywhere in the leg. It must be remembered that the laxity of tissue which predisposes a patient to weak or flat feet will have a tendency to produce some looseness of fiber, at least, also in the tissues around the knee. The patient may not have a wabbling knee, nor may he be able to overextend the limb, but still there will usually be some noticeable relaxation of the tissues which will help in the production of the painful condition by [{411}] making exaggerated calls upon the muscles in order to keep the joint in proper position in spite of the over motion in it.
The disturbance is most frequent in waiters, store clerks, tailors' cutters and fitters, bench men in the trades, and in all those who have to spend much time on their feet. I have seen many such ready to give up their occupations, though they had no other resource and the future looked very blank, indeed, away from their work. It was difficult at first to persuade them that a slight yielding of the arch had so changed mechanical conditions in the use of the muscles of the leg as to produce such pains. But as soon as they were put in a condition where their arch was not allowed to sink, they were at once relieved of their discomfort to a great extent. The question of treatment is discussed more fully in the chapter which follows on [Foot Troubles].
An interesting set of painful conditions around the knee develops in a class of people in whom it might least be suspected of being due to over-exertion connected with their occupations. These are lecturers, clergymen, teachers, and others who, for several hours each day, are on their feet in a position from which, as a rule, they do not move, but stand almost perfectly quiet. A distinguished laryngologist has pointed out that not infrequently men who come to be treated for the chronic laryngitis, which is known as clergymen's sore throat, but which is seen so frequently in those who have to talk in the open air, auctioneers, cart-tail orators about election time, and in lecturers to large audiences who do not know how to use the voice, also complain of grievous discomfort from painful knee conditions which often makes the ascent or descent of stairs a painful task. He attributes the simultaneous occurrence of these conditions to some blood dyscrasia, uric acid, or the like, affecting the two most used sets of muscles and organs, the legs and the vocal cords. Whenever I have seen this condition—and circumstances have brought me into intimate personal relations with many clergymen and lecturers—the trouble at the knee has been due to some yielding of the plantar arch, while the laryngeal condition, if present, was due to an erroneous mode of using the voice consequent upon lack of proper training.
Sufferers of this kind must be warned not to stand absolutely immovable while addressing an audience. Some men stand without moving during a whole hour's lecture. This is unfortunate, for it obstructs the return circulation through the tense muscles, for the venous circulation was intended to be helped by muscular contraction. Many a man finds, as he comes down from pulpit or platform, that his knees are stiff and sore, though a moment before he knew nothing about it. The failure to notice any discomfort before is of itself an example of the influence of the mind over the body for the relief of pain.
Associated Lumbar Discomfort.—The painful condition around the knee which develops when high heels are worn is almost sure to be accompanied by pains, or at least a tired feeling, in the back. If we convince the patient that the trouble is due merely to a derangement of the mechanism involved in maintaining the erect posture we shall have scant need of medicine or even of local treatment. But as the pain is much worse on rainy days, owing to the relaxation of the muscles, we must be careful to remove the patient's suspicion that the pain must have a rheumatic origin. The restoration of normal mechanical conditions with the removal of the cause will prevent the [{412}] recurrence of the affection, and if some discomfort remains, the patient will not worry, and the muscles will gradually grow accustomed to the strain upon them. Of course, these conditions of discomfort are more common in those who are not naturally strong, who are run down, who are under-weight, or whose neurotic tendency will make any irritation seem worse than it is.
Heavy and Light Patients.—Two classes are likely to suffer more than others from these conditions. They are the people who are overweight and the people who are underweight. Those who are overweight exert much more effort to maintain the erect posture than ordinary people, and, besides, in most adipose persons the distribution of weight is such that a disproportionate amount of it is carried forward of the normal center of gravity. High heels cause a further tilting forward that has to be counter-balanced, and that, at least at the beginning, gives rise to muscular discomfort. In people who are underweight the nutrition of the muscles has suffered, and, as a consequence, they are not able to support the frame as well as before. In them the additional effort necessitated by the tilting tendency of high heels is particularly felt because such people are nearly always among the neurotically inclined.
Muscle Disuse.—Sometimes treatment of these conditions seems to lead up to the disuse of certain muscles and the over-use of others. I followed for several years an interesting case of this kind in which the course of the affection was so typical as to deserve to be recalled. A fuller account of the case occurs in my paper on "Rheumatism versus Muscular and Joint Pains" in The American Journal of the Medical Sciences, August, 1903.
In that case the joint symptoms caused by the pinching of a loose cartilage within the joint occurred suddenly on two or three occasions, so that a surgeon deemed it wise to put the knee in plaster. As a consequence, some atrophy of the muscles of the leg occurred, and a halt became habitual in the gait. Through this halting gait, the muscles of the back on the same side were also spared and thus became somewhat atrophied. Painful conditions developed in the muscles of the other side of the back from the over-use necessary to compensate for the condition on the less-used side. All of the muscles on the affected side became painful, apparently because of the atrophic condition to which they were reduced.
The young man, though with the best of good will, was utterly unable to conquer the tendency to halt in his gait, and so the muscles remained under-exercised and were used at a mechanical disadvantage, with the usual painful result. He went to at least two prominent orthopedic surgeons, who assured him that all he needed was confidence in himself to walk straight, and that then the normal condition of the muscles and absence of pain would result. But their directions were absolutely without result. He went through the hands of masseurs, of osteopaths, of rubbing quacks of all kinds, and suffered at least two attacks of artificial eczema as a consequence of the use of turpentine liniments, but he remained after it all in what he considered to be an intensely miserable condition. These cases are practically always cured by definite exercise of the muscles of the affected limb so as to bring them back to their normal tone. It requires special attention for this purpose, however, and the patient's mind must be brought to understand that at first the unaccustomed use of muscles will cause discomfort, but that this will disappear after a time. These patients are persuaded that they must be "cured" to get well.
CHAPTER VIII
FOOT TROUBLES
The more physicians see of affections of the feet and of painful conditions of the legs due to foot troubles the more they realize that the human faculty of the erect position becomes the source of many discomforts unless care is taken of the muscular apparatus of the legs. There are few people engaged in standing occupations who do not suffer from their feet. These achy sensations are especially bothersome if the patient is run down in health, or is in the midst of worry or irritation from physical or mental stress. Even under favorable conditions there are few who reach old age without serious foot troubles or without, at least, some deformity of the feet, which, by preventing or limiting exercise, have an important influence upon the general health. Careful analysis of the conditions that develop will convince an observer that yielding of the joints of the foot has much to do with the deformities and that the wearing of unsuitable shoes rather than any internal pathological condition is responsible for the foot troubles that are so common.
Foot Deformities in All Classes.—An Englishman who visited this country, and who had ample opportunity to observe our people, declared after seeing the bathers at Newport, that there were two interesting peculiarities of American masculine anatomy—the deformity in their feet and the appearance of having swallowed a watermelon whole and retained it within them. The latter condition has doubtless much to do with the causation of the former. Inactive lives, overeating, and the overweighting of flaccid limbs that are not capable of bearing even their normal burden, complicated by tight and ill-fitting shoes, give rise to the deformities of the toes that are so common—hammer toes, over-riding toes, bunched toes, twisted toes, bent toes. Examples of most of these are sure to be seen wherever we observe our men and women bathing. The Englishman's observation was of our so-called better class—at least, our leisure class. Ordinarily, it is assumed that clerks, waiters, and others, who have to stand upon their feet are the principal sufferers from foot deformities. They are, but they are not alone, and a goodly proportion of the population suffers in this way.
Mechanical Factors.—The most important deformity in these cases is a yielding of the arch of the foot with consequent flattening of the instep and lengthening of the foot. This overstretches especially the flexer tendons which run underneath the arch, produces bunions, and gives occasion for the development of corns. The pull upon the flexor longus hallucis which runs along the inside border of the foot, gives rise to the bunion by pulling the big toe outward—in the direction of least resistance. The pressure upon the tendons of the flexor longus digitorum pedis causes the smaller toes to bend somewhat, and this gives rise to projecting angular points on which corns readily form. Besides, the imperfect action of the muscles of the foot consequent upon the fall of the arch gives rise to plantar corns and callouses that are often painful. The living cushion of muscle which is the best protection against injury, while walking or running, has its vitality interfered with by [{414}] the fall of the arch and the consequent blocking of the return circulation through the thin walled veins. This gives rise to cold feet and, in those who stand much, to the tender feet that are now so much complained of and for which so many foot powders and appliances are advertised.
Confusion of Rheumatism and Foot Troubles.—Most foot troubles are reflected up the leg because muscles have to be overused or used at a serious mechanical disadvantage. This combined discomfort of foot and leg is readily referred to rheumatism. Some of the pains produced by yielding of the arch are in the ankle, some are in the calf, some in the tissues around the knee, and some even in the muscles and tendons above the knee. It is much easier to say "rheumatism" than to investigate carefully and differentiate the conditions that may be present. Out of forty successive patients who came to the dispensary of the Polyclinic Hospital of New York complaining of rheumatism, eighteen were suffering from flatfoot. Out of twenty-four who thought they had rheumatism in the feet or legs eighteen proved to be cases of flatfoot. Of the others, one was suffering from that rare disease meralgia paresthetica, two were suffering from sciatic neuritis, one was suffering with sub-acute joint trouble consequent upon pinching of a cartilage within the knee joint, and one had a painful condition consequent upon an old dislocation of the ankle due to a fall, accompanied by considerable laceration of the soft tissues. Analyses of the cases left no room for the so-called chronic rheumatism which had so easily covered all the cases at the beginning.
It was not unusual to see patients who had consulted many physicians and taken all sorts of internal and external remedies for the rheumatism that they supposed was causing their discomfort, yet who had nothing more than flatfoot. Their condition had become so bad that some of them had actually given up occupations that required them to stand. Merely following the advice to wear flatfoot braces in their shoes relieved these patients almost as if by magic. There was no need to measure them particularly; all they needed was an ordinary set of flatfoot braces. Some of them needed only a pair of good shoes, but the metal braces were advised to make sure that there would be a firm support for the arch of the foot. No wonder the "magic shoe-maker" had such success in New York a few years ago.
Nearly always the shoes worn by dispensary patients are of the worst kind, considering the condition. The patients' feet are often cold, and they think this is nature's demand for heavy shoes, so they buy heavy shoes and large sizes so as to be sure they will not hurt their feet. This clumsy footgear allows the arch to drop still further because no proper support is furnished, and the foot-trouble becomes more poignant. Then working people nearly always wear older shoes on rainy days, and this makes two elements for discomfort instead of one. The yielding arch is already a source of discomfort which is more noticeable in rainy weather because any affection around a joint is more bothersome at such times. The support that a new pair of shoes affords to the arch is lacking when what are so aptly termed "sloppy weather shoes" are worn, and the consequence is that the patient is particularly miserable in damp weather.
Unfavorable Disease Suggestions.—Of the cases in my experience of so-called rheumatism in the legs, over one-half are due either to flatfoot or to the incipient yielding of the arch which is called weak foot. Rheumatism is [{415}] most commonly held accountable for the condition, though gout comes in for its share of blame with quite as little justification. Occasionally some even more serious pathological condition is appealed to. I have seen the tendency to passive congestion in the feet with slight swelling around the ankle consequent upon the yielding of the arch called kidney trouble in spite of the fact that there was nothing in the urine to justify any such diagnosis. I have even known the coldness of the feet, which is likely to be a symptom of the disturbed circulation consequent upon the yielding of the arch, attributed to heart disease. As we shall see, most of the curious deformities of the old that make locomotion so difficult and so painful are due to a breaking down of the arch just after middle life and then to a progressive deformity of the foot. The mechanics of the support of the body are sadly interfered with when the arch yields, for bones are pushed out of place and ligaments and tendons are lengthened in order that the foot may accommodate itself to the new conditions. In nearly all these cases the patients are prone to say that they are sufferers from rheumatism. This diffuses and inveterates the notion which is a source of many unfavorable suggestions, that rheumatism is a curious progressive crippling disease which begins insidiously but advances remorselessly and eventually leaves its victim a prey to deformity.
Gout and Flatfoot.—Bunions consist originally of an enlargement of a bursa over the proximal end and the inner side of the big toe in order to protect the bone and joint from friction. If the irritation is continued, the proximal end of the first phalanx may enlarge, though usually this is preceded by a series of attacks of more or less acute inflammation of the bursa, when the bunion is said to "become sensitive." I have seen these attacks called gout so often that I feel sure that much of the gout reported in this country is nothing more than bunions. There is true gout, and it is probably almost as frequent with us as it is in England, but many of the so-called cases are really flatfoot associated with development of the bunion that so commonly occurs as the arch yields.
I was once asked to see a physician's wife who was thought to be a sufferer from gout. Long ago Oliver Wendell Holmes said that, as the shoemaker's children are likely to wear the worst shoes of the village, so the doctor's family is likely to take the least medicine, that is, be subjected to the least formal medication. The physician had seen the more or less acutely swollen and red enlargement of the base of the big toe, and heard his wife complain of the severe pain associated with it, and had suggested the possibility of gout. After rest in bed and the administration of salicylates and colchicum, the pain subsided and the redness and much of the swelling disappeared. This was a typical illustration of one event following another without causal relation. The succession of events was taken as a therapeutic test of the diagnosis of gout, and the patient was advised to regulate her diet so as to prevent the further accumulation of urates or uric acid in her blood. She was warned about eating red meat, about taking acid fruits, and about the acid fermentation of starchy vegetables. The main result of eating only white meat is apt to be simply a limitation in the amount of meat eaten, because white meat is less savory and after a time palls on the appetite. In the same way fruit was largely eliminated and sweets were taken out of the diet and vegetables were limited.
As she did not escape recurrent attacks of soreness in her bunion, while at the same time there were achy feelings in her foot, she took up the careful study of the dietary for gouty patients which she found in the books in her husband's library. So many things have seemed possibly deleterious for gouty people that it is not surprising that after a time nearly everything worth eating except a few cereals and milk and eggs had to be eliminated and she began to suffer from inanition. Then, after a time, came constipation, due to the insufficient amount of residue in her intestines, and this, partly by physical action but largely by mental suggestion, still further diminished the appetite for food, and a loss of over twenty pounds in weight was the result. The weakening of the general muscular system consequent upon this loss emphasized the trouble with the foot and the painful condition at the base of the big toe became more marked.
The supposed necessity for more exercise in the open air led her to walk long distances and in order to prevent her feet from hurting her, as she thought, she wore roomy shoes, distinctly too large. This is one of the common mistakes of people whose feet bother them, and it is just the wrong thing to do, since a snug, well-fitting shoe provides both support and protection. It is not surprising that the attacks of sub-acute bursitis became more frequent and more painful.
It was then that I saw her, and, as I feared to disturb the family harmony by suggesting that the whole trouble was a bunion and flatfoot, I compromised by saying that, while there might be some gout, there was undoubtedly flatfoot, and if she would wear the proper sort of shoe and stop limiting her diet so strenuously, and cease suggesting to herself that she had a progressive gouty affection that would lead to deformity and decrepitude, she would soon be much better.
It required tact to make her look favorably on this advice, after all that she had gone through during months of limited diet and enforced exercise. Though not quite convinced, she was ready to try the new method. She began to be better as soon as she was fitted with a pair of shoes that supported her arch and as soon as her increased nutrition began to make itself felt. At the end of two weeks she was able to give up the remedies for constipation that she had been using for nearly a year, while at the end of four weeks she had regained ten pounds of weight and felt much better.
Several years have passed since I saw her professionally and occasionally I hear from her only to be told what a great measure of relief it afforded her and how much better she has been as a consequence of a few simple directions with regard to her feet. I have seen at least a dozen of cases of so-called gout in educated people which followed almost exactly the same course and yielded promptly to the same treatment. The hardest symptom about these cases to cure is the cherished mental conviction that they are the victims of constitutional disease, either gout or rheumatism, to which all their symptoms are attributed. They are cases for psychotherapy more than any other form of therapeutics and need for a considerable period to have repeated assurances of the entirely local character of their affection.
Bunions and Flatfoot.—The etiology and preventive treatment of a bunion has always seemed to me to bear a closer relation to a flat foot than to anything else. The flatfooted man has nearly always a tendency to bunions. The [{417}] explanation of this is not difficult if one traces the relation between the tendons that run around the arch to the big toe. The usual etiological explanation, however, is that in youth short shoes were worn which initiated a tendency to divert the big toe inward toward the other toes. But there are many reasons against this explanation. Anyone who tries will find that it is practically impossible to wear shoes that are so short that the big toe is crowded back. Women are more apt to shorten their shoes than men, yet women suffer both from flat feet and from bunions much less than men. The reason for this seems to be that the forward position with the elevation of the heel of the shoe supports the arch and gives the shoe a shape more fitted to the normal foot than is found in the masculine flat-heeled shoe. Besides, this form of shoe maintains its shape better, and then, too, women are not so prone to wear old so-called comfortable shoes as are men.
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 [{418}] 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 [{419}] 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. [Footnote 35]
[Footnote 35: How much deterioration of the tissues of the foot may be brought about by improper footwear and, above all, by sedentary life and the substitution of the trolley car for the exercise of walking, is well illustrated by the functions that are lost. The child can use its adductor and abductor muscles for the toes quite as well as for the fingers. Those who go barefooted retain those muscular powers. Some time we will be able to influence young folks' minds enough to keep them from sacrificing all the more delicate muscular powers of their feet to the fashion of small or curiously shaped shoes. Armless men learn to use their feet almost as hands, they write, pick up small articles, oven play musical instruments.
Some people have special muscular faculties, as, for instance, the power to displace certain tendons and bring them back with a snap which makes a distinct sound. The Fox sisters, to whom we owe the origin of modern spiritism, confessed that this was the way they produced their spirit rapping. Some mediums can, it is said, dislocate the tendon of the flexor longus hallucis onto the edge of its grove and then bring it back with a snap. Others can produce partial toe dislocations which by muscular power are suddenly reduced with a dull noise like the sound of a gloved hand rapping beneath the table.]
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 [{420}] 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 [{421}] 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 [{422}] 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.