Surgery, with Special Reference to Podiatry

by Maximilian Stern; Edward Adams

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.