Medical Matters: She hobbled into the surgery and winced as she sat down. "You're supposed to be good with feet so you are, well I'd like you to do something with mine," she said rather truculently.
I am forced to be good with feet or at least to have an interest in them. Medical school seems to skip anything below the knee except for things like poor circulation, gout and athlete's foot.
Gout was described by Thomas Sydenham who died in 1689. "The victim goes to bed and sleeps in good health. About two o'clock in the morning he is awakened by a severe pain in the great toe. The part affected cannot bear the weight of the bed clothes, nor the jar of a person walking in the room. The night is spent in torture."
Of course it was then seen as a rich man's disease but is now common in all social groups probably because we are all better fed.
Bunions, chilblains, calluses, corns and even ingrowing toe nails are sniffed at by doctors and public alike. "I hate feet" is a common refrain. Lots of doctors will tell of a patient presenting with a foot ailment and of wanting to compare it with the other foot only to experience reluctance from the patient. "I only washed the sore one as I didn't think you'd want to see the good foot."
We have an odd relationship with feet us humans. The Pope shows his humility by washing them in public and in Iraq the biggest insult you can throw at anyone is to hit them with a shoe. Artists avoid painting them or just add simple foot coverings.
Ancient sculptors on the other hand were good with feet as a splayed foot helps to demonstrate vigorous action.
There is no doubt that the advent of washing machines has made the practice of medicine more bearable, especially in general practice. A small consulting room can get very fetid after seeing 20 patients.
Student doctors get off to a bad start with feet. In the final exam many are guaranteed to be asked to find the foot pulses which can be difficult to feel. You can see them working out something must be wrong them but what is it.
Good foot pulses are important as they are an indication of a good supply of healthy blood to the feet. They can become blocked or narrowed in diabetes or vascular disease leading to poor circulation. The feet become bluish, legs lose hair and toenails become unhealthy with fungal material.
The feet may also lose their feeling of discomfort and the patient may not notice that the shoes are too tight or a knock against a chair leg. What started out as bad circulation may end with a serious foot infection. So we are not being fussy by insisting our students know about foot pulses.
But these are the big things that affect feet. Pain in the foot is a common problem presenting to general practice. It can be caused by arthritis, foot strain, flat feet, warts, corns, calluses and ingrowing toe nail problems. Then there are bunions, hammer toes and gout. Ankle injuries are common in all ages including children.
You seldom hear about chiropodists in healthcare but they have a devoted following of grateful patients who get enormous relief from their expertise. They are now seen as important players in keeping the elderly mobile for longer and essential in the management of the so-called diabetic foot.
Now you don't need six hundred points in the Leaving Cert to make sense of these foot conditions, but they do need careful diagnosis and management if the patient is to be able to get about free from pain. So no more looking down on feet.
Tom O'Dowd is professor of general practice at Trinity College Dublin and a practising GP.