RD78f SohG Columbia ©ntoetsitp mtljfCitpofltagork Collese of ^fjpaiciang anb burgeons; Hibxaxv Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/humanfootanatomyOOscho THE HUMAN FOOT ANATOMY, DEFORMITIES AND TREATMENT A VOLUME CONTAINING A COMPLETE AND COMPREHENSIVE DESCRIPTION OF THE ANATOMY OF THE FOOT. NORMAL AND ABNORMAL CONDITIONS, DEFORMITIES OF THE FOOT, THEIR CAUSE AND MECHANICAL TREAT- MENT. SPECIAL CHAPTERS ON SHOE FITTING AND ITS ALLIED BRANCHES, INCLUDING HISTORICAL FOOTWEAR. A TEXT BOOK FOR THE STUDENT AND PRACTITIONER BY DR. WILLIAM M. SCHOLL 4~ PUBLISHED BY THE FOOT SPECIALIST PUBLISHING CO. CHICAGO, U. S. A. Copyright 1915 BY DR. WILLIAM M. SCHOLL CONTENTS Preface 7 Introduction 9 CHAPTER I The Bones 11 Bones of the Human Body — Bones of the Foot. CHAPTER II The Tarsus 18 The Os Calcis or Heel Bone — The Astragalus Bone — The Scaphoid Bone — The Cuboid Bone — Internal Cuneiform Bone — Middle Cuneiform Bone — External Cuneiform Bone. CHAPTER III The Metatarsals and the Phalanges 21 First Metatarsal Bone — Second Metatarsal Bone — Third Metatarsal Bone — Fourth Metatarsal Bone — Fifth Meta- tarsal Bone — The Phalanges or Bones of the Toes — The Tibia — The Fibula. CHAPTER IV Arches of the Foot 25 Inner Longitudinal Arch — Outer Longitudinal Arch — Transverse or Anterior Arch. CHAPTER V Soft Structures of the Foot 29 Ligaments — Tendons — Muscles — Arteries — Veins — Nerves. CHAPTER VI The Ligaments 33 Tibio-Fibular Ligaments — The Inferior Tibio-Fibular Liga- ments — Ligaments of the Ankle Joint — Ligaments of the Tarsus — Metatarso-Phalangeal Ligaments. CHAPTER VII Muscles and Tendons of the Leg 43 Extensor Muscles of the Leg — Anterior Group — Posterior Group — Fibular Group. 3 4 THE HUMAN FOOT CHAPTER VIII Muscles and Tendons of the Foot 54 Dorsal Region — Plantar Region. CHAPTER IX The Arteries of the Foot 66 The Dorsalis Pedis Artery — The Posterior Tibial Artery — The Internal Plantar Artery — The External Plantar Artery. CHAPTER X The Veins of the Leg and Foot 77 CHAPTER XI The Nerves of the Leg and Foot 81 CHAPTER XII The Skin and Nails . '. . . 88 Appendages of the Skin — General Review. CHAPTER XIII Comparative Anatomy 91 CHAPTER XIV Physiology 97 The Functions of the Foot — Movements. CHAPTER XV Mechanical Consideration of the Human Foot 102 CHAPTER XVI Examinations 108 Examination of the Foot — Palpation — Pain. CHAPTER XVII Weakened Foot 117 Weak Flexible Foot — Acute Weakened Foot. CHAPTER XVIII Fiat-Foot— Broken-Do wn Arch 125 Acquired Fiat-Foot — Diagnosis — Causes — Congenital Fiat- Foot — Traumatic Fiat-Foot. CHAPTER XIX Treatment of Flat- Foot 142 CHAPTER XX Metatarsalgia — Morton's Toe 153 CHAPTER XXI Method of Fitting Arch Supports 168 How to Make Secondary Adjustment — Crystallization of Metals from which Arch Supports are Made. CONTENTS 5 CHAPTER XXII Hallux Valgus and Bunion 188 Felt Padding — Treatment of Bunion. CHAPTER XXIII Hallux Rigidus or Painful Great Toe — Hallux Varus or Pigeon Toe 201 CHAPTER XXIV Painful Heel 204 CHAPTER XXV Hammer Toe 208 Overlapping Toes. CHAPTER XXVI Weak Ankle — Sprained Ankle — Tubercular Ankle 212 CHAPTER XXVII Talipes or Club-Foot 215 Talipes Equinus — Talipes Varus — Talipes Valgus — Talipes Calcaneus. CHAPTER XXVIII Pes Cavus — Hump-Foot — Hollow Claw-Foot 224 CHAPTER XXIX Knock- Knee — Bow-Legs — Deformities of the Knee 227 Accidents to the Patella and its Ligaments. CHAPTER XXX Rheumatism — Gout — Other Joint Affections 235 Joint Affections Simulating Rheumatism — Gonorrheal In- fection of the Foot. CHAPTER XXXI Diseases Affecting the Feet 240 Myasthenia (Intermittent Limping) — Syphilis — Raynaud's Disease — Rickets — Varicose Veins — Ankylosis. CHAPTER XXXII Diseases of the Feet 245 Verruca or Wart — Supernumerary Toes (Polydactylism) — Webbed Fingers and Toes — Perforating Ulcer of the Foot — Chilblains (Pernio) — Frost Bite — Hyperidrosis or Exces- sive Perspiration — Anhidrosis or Scanty Perspiration — Bromidrosis or Fetid Perspiration — Eczema — Syphilis — Plantar Neuralgia — Osteoma — Blister. CHAPTER XXXIII Fractures Affecting the Feet 253 6 THE HUMAN FOOT CHAPTER XXXIV Dislocations Affecting the Feet 264 Anatomy — Sub-Astragaloid Dislocations — Dislocations of the Tarsal and Metatarsal Bones — Dislocations of the Metatarsal Bones from the Tarsus and from One Another — Dislocations of the Toes. CHAPTER XXXV Corns (Cornu, Horn) 274 Hard Corns — Soft Corns — Suppurated Corns — Nervo-Vas- cular Corns — Vascular Corns. CHAPTER XXXVI Callosities — Callous 285 CHAPTER XXXVII Ingrowing Toe-Nail 289 Other Abnormal Nail Conditions. CHAPTER XXXVIII Skiagraphy '. 293 CHAPTER XXXIX History of Footwear 297 Footwear of the Ancients B. C. 53-A. D. 450 — Footwear of the Greeks and Romans — Footwear of Anglo-Saxons — Anglo-Norman Footwear 1060-1200 A. D. — Shoes Worn in the Thirteenth Century — Shoes Worn in the Fourteenth Century — Shoes Worn in the Fifteenth Century — Tudor Period, Sixteenth Century — Stuart Period of the Seven- teenth Century. CHAPTER XL Footwear and Fitting of Shoes 318 Method of Measuring the Foot for Fitting Ready-to-Wear Shoes — Summary. CHAPTER XLI Hosiery 334 CHAPTER XLTI Care of the Feet 341 CHAPTER XLIII Method of Making Plaster of Paris Cast of the Foot 343 To Take Plantar Impression — To Take a Plaster Cast of the Entire Foot Above the Ankle — Method of Taking Cast of Bunion or Enlarged Toe Joint. Index to Illustrations 359 Index to Subjects 367 PREFACE IN presenting this volume, probably the first of its kind ever pub- lished, I do so only after numerous requests from the students and profession desiring- to become more efficient in the care and covering of the human foot. Great care and every consideration have been taken, with a purpose to convey the fundamentals in a language thoroughly understood by the layman as well as the practitioner. The anatomy of the foot, a knowledge of which I consider a valuable asset to those interested in these branches, is written in an elementary manner, and profuse with illustrations that it may be readily understood by all. I have embodied considerable informa- tion of the utmost value to the shoe man, chiropodist, orthopedist and the general practitioner of medicine. Cognizant of the many discomforts, pains and improper shapes, fitting and styles of shoe, I feel assured that a work of this kind in the possession of the shoe man will render him more proficient in his calling. To be familiar with the structure of the human foot and its de- formities, with the serious consequences of the improper fitting of sizes and shapes of shoes, is a step toward the abolition of many foot ailments. Thus, a careful study of the subjects contained in this volume will enable the shoe fitter to not only apply correct remedial measure, but to remove the cause giving rise to these de- formed conditions. The fitting of proper shoes and hosiery, and perhaps a modified simple appliance will render much foot comfort and shoe satisfaction. Considerable good can be accomplished by the profession in prescribing proper corrective appliances and foot gear. In the preparation of this volume reference has been made to the works of Gray, Cunningham, Bradford, Lovett, Stimson and others for which acknowledgment is made. PREFACE Before concluding, I wish to state that the illustrations, etc., shown in this book are gathered from my experience in the mechanical treatment of weakened and deformed conditions of the foot, with that of my contemporary colleagues, extending over a period of fifteen years. DR. WM. M. SCHOLL. INTRODUCTION IN the study of anatomy — the foundation of medical science — we shall confine ourselves more particularly to a general and detailed consideration of the study of the human foot. A volume might be written upon anatomy alone, but it is only necessary here to deal with those points absolutely essential to the student and also with the structures of the foot, viz : Bones, muscles, nerves, etc., and this course has been followed throughout. The mechanical consideration of the foot, its abnormal condition, causes and mechanical treatment, will then be discussed. Believing that mechanical treatment affords the most satisfactory and gratify- ing results, I have included various chapters describing the same that the student may familiarize himself with the proper remedial appliances and their mode of application. In my description of the deformed conditions of the foot I dis- cuss the various joint diseases and deformities that the student may be better enabled to recognize those cases which require the attention of a skilled surgeon, and to advise the patient to this effect that the case may be correctly diagnosed and treated. Before fitting a pair of arch supports it is advisable to determine if the deformity is not of systemic origin ; if the latter the patient should be referred to a physician at once. The shoe being an important adjunct of the foot and the prime causative agent of deformities it will be discussed at length, reverting to the origin of shoes and footwear and continuing with a chronological history of shoes worn to the present period. Suggestions on shoe fitting, construction, last measurements and information in general pertaining to this subject will be discussed in the following chapters. CHAPTER I THE BONES In order to thoroughly comprehend the bony structure of the foot, it is advisable to give a description of the framework of the body. TAH5U5 tlCJATARSUS PHAUM6CS Chart No. Al Skeleton of the Human Body. Bone is one of the hardest structures of the body, consisting of a dense, compact texture, and is covered by a fibrous membrane called Periosteum from which the bone derives its nourishment. 12 THE HUMAN FOOT Bones form the framework over which the structures are built and when covered with muscles and flesh make the contour perfect. BONES OF THE HUMAN BODY The human body has as its foundation a framework of approxi- mately two hundred bones, and of this number there are twenty-six bones in each foot, and as this concerns the student most, the upper extremity will be entirely omitted. The bones of the lower extremities consist of the thigh, leg and foot. The Pelvis is most massively constructed, a heavy, bony ring inter- posed between the end of the spine which it supports, and the lower extremities upon which it rests. Next to the Pelvis comes the Thigh. The Thigh is that portion which is situated between the Pelvis (beginning at the hip) and the Knee. It consists in the skeleton of a single bone, the Femur (thigh- bone), which is the longest, strongest and largest bone in the skeleton. The skeleton or bones of the leg consist of the Tibia and Fibula, and the Patella or Knee Cap. The Tibia is situated at the front and inner side of the leg and, excepting the Femur, is the largest and longest bone in the skeleton. It articulates with the knee-joint above and with the Astragalus or key-bone of the arch below. The Fibula is situated at the outer side of the leg. It is the smaller of the two bones and, in proportion to its length, the most slender of all the long bones. The Fibula acts as a balance to the Tibia, and in case of fractures they are both usually broken. (See Chart No. 1.) As the foot receives the entire weight of the body, is it not natural to assume that this part of the body is most likely to become dis- torted, as is the fact? For example, we will take a person weighing two hundred pounds. Just think of the pressure exerted upon the weak framework of the foot. In such individuals we find flat-foot to be a general affliction. That the various resulting deformities may be thoroughly understood, it is necessary to be familiar with the different bones which make up the framework of a foot. Thus, BONES OF THE FOOT 13 referring you to Chart No. 3, I have divided the foot into three principal parts for the convenience of the student. 1. Phalanges or Toes. 2. The Metatarsus. 3. Tarsus or Heel and Ankle Joint. Chart No. 1 Bones of Leg and Foot. Now let us take up each one separately. You will notice by Chart No. 2 that each toe has three bones, called Phalanges, except the large toe, that only having two bones. The Metatarsus has five bones, called Metatarsal bones. Notice that the Metatarsus has as many bones as there are toes on a foot, and each corresponds to the 14 1st DISTAL PH THE HUMAN FOOT 2 nd DISTAL PHALANX 2 nd MEDIAL PHALANX 2 nd PROXIMAL » 3 BD DISTAL " 3 rd MEDIAL " 3 RD .PR0XIMAL •' 4 th DISTAL " 4.™ MEDIAL »» 4 T , H PROXIMAL PHALANX 5T" DISTAL »• 5 th MEDIAL »» 5 TH PR0XIMAL '• 1st METATARSAL 2ND fl 3RD II 4-TH II 5 th •• INTERNAL CUNEIFORM MIDDLE »' EXTERNAL » SCAPHOID CUBOID ASTRAGALUS OSCALSIS Chart No. 2 Bones of the Foot, Dorsal or Top View. BONES OF THE FOOT 15 1st Distal Phalanx. 1st Proximal Phalanx. Sesamoid. Sesamoid. 1st Metatarsal. Internal Cuneiform. Middle Cuneiform. External Cuneiform. Scaphoid. Cuboid. Astragalus. Sustentaculum Tali. Os Calcis. Chart No. A3>< .. Bones of the Foot, Plantar or Bottom View. 16 THE HUMAN FOOT respective toe. Next is the Tarsus, which also includes the Ankle Joint. This has seven bones, as follows : Three Cuneiform, Scaphoid, Cuboid, Astragalus and Os Calcis. It is a very easy matter to remember the number of bones in the foot. If you will remember, each toe has three bones, except the large toe, it having one less. Everybody knows there are five toes on every foot, so consequently there are fourteen bones in the five toes on each foot. The Metatarsus has one bone for each toe, consequently the Metatarsus contains five bones, making nineteen bones for toes and' Metatarsus together. Now, if there are twenty-six bones in all PHALANGES Chart No. 3 Dividing the Foot into the Three Groups of Bones. in the foot, there remain but seven bones for the Heel and Ankle Joint. Again, each bone forms a joint with the succeeding bone, so in the toes we have several joints. Any one of these bones may be distorted, forming a malformation of the foot. The bones of the Arch and Ankle have several joints which may in turn be distorted and produce a malformation. It is very plain from the foregoing that the knowledge of the different bones of the foot is of the utmost importance to a foot specialist. Let us now continue to explain the relation of the muscles, ligaments, arteries and nerves of the foot to the bones before we take up the study of each individual bone. Each bone in the foot is sup- plied with arteries, nerves and a number of muscles and ligaments. Later on we shall consider the minute details of every artery, nerve, BONES OF THE FOOT 17 muscle and ligament, but at this moment it will serve our purpose to refer to the same in a general way. Take, for instance, the muscles and ligaments which are attached to the toes and arch of the foot, which are constantly stretched when a person walks. Should the pressure be too great, these muscles and ligaments become weakened, and the bones of the foot do not have their support, the result being a displacement of that bone whose muscles and ligaments have been weakened. Let us now consider why these conditions would be painful. The distorted bone or malformation may press against a nerve, producing pain, or it may press against an artery, which would in- terfere with the natural circulation of the blood supply in the foot. Before continuing with the next chapter, I recommend the re-reading of Chapter I, as it should be thoroughly comprehended in order to master the description of each bone of the foot. CHAPTER II THE TARSUS Referring you again to Chart No. 2, you will find each bone of the foot represented by its respective name. In the previous chapter I called your attention to the fact that the foot had twenty-six bones and that the heel and ankle joint contained seven bones. I will here describe each bone separately. For our convenience we will commence with the heel. I now refer you to Chart No. 3, where you will again find the foot divided into three different parts, but each part is named respectively: The Tarsus, which is the back part of the foot, includes the heel and ankle joint. The Metatarsus or the middle part of the foot has the appearance of an arched bridge. The Phalanges or the front part of the foot includes all the bones of the toe. 1. The Os Calcis or Heel Bone is the largest and strongest bone of the foot, and is situated at the back of the foot in front of which are the Astragalus and Cuboid bones. Referring to Chart No. 3 you will see that this bone forms the heel and is irregular and cuboidal in shape. The chief facts about this bone to be remembered are that it transmits the weight of the body to the ground and that it articulates with the next two bones, the Astragalus and Cuboid. It is held in its position by strong ligaments. The muscles of the calf of the leg and Achillis tendon are also attached to this bone. The importance of this bone is readily observed in deformities of the foot. 2. The Astragalus Bone. — As you will notice in Chart No. 2, the next bone to the Os Calcis is the Astragalus. It is also the next largest bone of the Tarsus, and is situated in front of the Os Calcis and is the middle bone of the Tarsus, being supported underneath 18 THE TARSUS 19 by a part of the Os Calcis and articulates in front with the Scaphoid bone. The upper surface of the Astragalus is so shaped as to receive the bone of the leg. This bone is called the Tibia, and as the weight of the entire body is transmitted through the leg and is received at the upper part of the Astragalus, it can be clearly understood that this bone is the most important one of the lower appendages, and liable to succumb under the great weight borne, producing the deformity known as flat-foot. This bone has strong ligament and muscle attachments, which are frequently stretched by the constant strain placed upon them, causing the Astragalus to be displaced. 3. The Scaphoid Bone. — This is the bone which I described as being immediately in front of the Astragalus. On the chart you will readily notice that this bone is situated on the inner side of the Tarsus, and articulates with the Astragalus behind and with the three Cuneiform bones in front. From its posi- tion in the Tarsus, it is evident that the Scaphoid bone also plays an important part in flat-foot cases, as it is also in the center of the foot and can be readily felt in such deformities. 4. The Cuboid Bone. — This is the bone which is situated on the outer side of the Tarsus, immediately in front of that part of the Os Calcis which does not articulate with the Astragalus. You will notice by the chart that the Cuboid bone fills up that space between the outer side of the Os Calcis and the fourth and fifth Metatarsal bones. The Cuboid also articulates with the External Cuneiform bone. There is no doubt that this bone is usually involved in condi- tions of flat-foot. 5. Internal Cuneiform Bone. — There are three Cuneiform bones, namely, the Internal, Middle and External. They are thus named according to their location, as, for instance, the Internal Cuneiform which we are about to describe is situated on the internal surface of the Tarsus. It is located immediately in front of the Scaphoid bone and articulates with the Scaphoid behind, the first Metatarsal bone in front, and on the side with the Middle Cuneiform and part of the second Metatarsal bone. The relation of this bone shows 20 THE HUMAN FOOT plainly that it is very often distorted as are the other bones of the Tarsus. 6. Middle Cuneiform Bone. — This bone is so named because it is situated, between the Internal and External Cuneiform bones. It is the smallest of the three Cuneiform bones and articulates with the Scaphoid behind and the second Metatarsal bone in front, with the Internal Cuneiform on the inner side and the External Cunei- form on the outer side. The relative position of this bone is identical with that of the other Cuneiform bones, which are invariably affected by any displacement of the bones of the Tarsus. 7. External Cuneiform Bone. — This is the last bone of the Tarsus to be described. It is situated in the middle of the foot, and for this reason receives a considerable degree of pressure. It articulates with the Scaphoid behind, the third Metatarsal bone in front and the Cuboid and part of the fourth Metatarsal bone on the outer side, and also with the middle Cuneiform on the inner side. We have now considered all seven bones of the Tarsus; thus you will notice that the last six bones go to make up part of the arch of the foot which is so important in flat-foot subjects. In the next chapter we will describe the five Metatarsal bones which make up the other part of the arch. CHAPTER III THE METATARSUS AND THE PHALANGES THE METATARSUS The Metatarsus consists of the five Metatarsal bones, numbered one to five, number one commencing at the great toe. 1. First Metatarsal Bone. — This is the shortest but thickest bone of the Metatarsals. It articulates with the Internal Cuneiform bone behind and with the first Phalanx of the large toe in front. 2. Second Metatarsal Bone. — This is the longest of the Metatarsal bones. It is situated between the first and third Metatarsal bones and articulates with the Middle Cuneiform bone and part of the Internal and External Cuneiform bones behind and laterally with the third Metatarsal bone. 3. Third Metatarsal Bone. — There is nothing particular to re- member about this bone, except that it articulates with the External Cuneiform bone behind and laterally with the second Metatarsal bone on the inner side and the fourth Metatarsal bone on the external side. 4. Fourth Metatarsal Bone.— In describing this bone all one has to remember is that it articulates with the Cuboid bone and External Cuneiform bone behind, the third Metatarsal bone internally and the fifth Metatarsal bone externally. 5. Fifth Metatarsal Bone. — It is the smallest of the Metatarsal bones and is situated on the outer side of the foot. It articulates with the Cuboid behind and laterally with the fourth Metatarsal bone. This concludes the description of all the bones of the arch of the foot. In the previous chapters I called your attention to the fact that all these bones had muscles and ligaments attached to them. They play an important part in malformations of the foot, and you must always bear in mind, when we find a malformation, that these muscles and ligaments are generally affected. 21 22 THE HUMAN FOOT THE PHALANGES OR BONES OF THE TOES Each toe, as you remember, has three Phalanges, except the large toe, which has only two. The Phalanges which articulate with their respective Metatarsal bones are called the first Phalanx of each toe, consequently the next Phalanx in each toe is called the second or Medial Phalanx, and the last Phalanx is called the third or Distal Phalanx. Of course there is not a third Phalanx in the large toe, as that toe only has two Phalanges. In order to understand with what bones they articulate I refer you to Chart No. 2, and there you will notice that the first Phalanges articulate with their respective Metatarsal bones behind and with the second Phalanx of each toe in front. The second Phalanx in each toe articulates with the first Phalanx behind and the third Phalanx in front. Again the exception is the large toe, as previously stated; it has only two Phalanges. That leaves the four Distal or third Phalanges to be described. They articulate with the second Phalanx of each toe behind and are flattened in front so as to receive the nail of the toes. The Phalanges play an important part in malformation of the feet as they are often distorted, due to ill-fitting shoes, such as high heels and narrow-pointed lasts. Very often one toe overlaps the other. We also find many ingrown toe nails, etc. These conditions will all be described as we advance. Before we proceed I must call your attention to two other bones, namely, those two bones which are in the lower limb, for they are the bones which are received by the Astragalus and are part of the ankle joint. The large shin bone is called the Tibia ; the smaller bone, which is located on the outer side of the large bone, is called the Fibula. I believe a de- scription of these bones would enable you to more thoroughly under- stand the ankle joint. THE TIBIA Is the largest of the two bones in the lower part of the leg. It is situated in front and the inner side of the leg, and is otherwise called the shin bone. The upper part of the bone is called the head THE METATARSUS AND THE PHALANGES 23 of the Tibia. It is very much enlarged at the head and articulates with the Femur (which is the thigh bone) to form the knee joint. It then tapers gradually until it reaches the lower part of the bone, that part between the head of the Tibia and lower extremity being called Arf/cu/aA wit/Jin TIBIA- FIBULA WITH ASTRAGALUS' Chart No. 7 Bones of the Right I,eg Posterior Surface. the shaft of the bone. The lower extremity is smaller than the upper one and it articulates with the Astragalus. You can readily see the importance of this bone in considering the ankle joint. The lower part of the bone internally forms the Internal Malleolus. The Mai- 24 THE HUMAN FOOT leolus is that part of the ankle joint which is most prominent on the internal side of the ankle. Many muscles are attached to this bone, which also are attached to the bones of the foot. The outer side of the head of the Tibia articulates with the Fibula, which is the second bone of the lower leg. The outer side of the lower extremity of the Tibia also articulates with the Fibula. I refer you to Chart No. 7, which will explain fully the relation of these bones to each other. THE FIBULA The small bone of the lower part of the leg is situated on the outer side of the Tibia which we have just described. It is much thinner and articulates above with the outer side of the Tibia, running parallel with the same, and being situated directly in back of it at the lower extremity, it inclines a little forward and projects a little below the Tibia, forming the outer prominence of the ankle joint or External Malleolus. This bone as well as the preceding one has many muscles and ligaments attached to it, which also are attached to the bones of the foot. The function of this bone is to act as a balance to the Tibia in transmitting the weight into the foot. It is important for the student to master each bone of the foot and leg thoroughly, making it unnecessary to consult the charts every time you read about them. For this reason I emphasize the necessity of studying the different charts and the description of each bone. In the next chapter we will consider the arches of the foot. As you have made yourself familiar with the names of the bones and have a mind picture of their shapes and sizes, it will not be difficult for you to now thoroughly understand the anatomical descriptions. The arches are very important in foot trouble cases. CHAPTER IV ARCHES OF THE FOOT The bones of the foot are arranged to adapt themselves best for their work, and are so joined to form two distinct arches — the Longitudinal Arch and the Transverse Arch. Some writers mention that there are three by taking in the Outer Longitudinal x\rch, and others say there are four by taking the Trans- verse Arch and the Anterior Metatarsal Arch as separate arches, but we will describe the Longitudinal Arches, both inner and outer, and the Anterior Transverse Arch. (See Chart No. 4.) TIBIA INTERNAL I CUNEIFORM I ASTRAGALUS | METATARSALS SCAPHOID OSCALSIS sesamoid LONGITUDINAL ARCH Chart No. 4 Bones of Foot Showing Inner Longitudinal Arch. INNER LONGITUDINAL ARCH The inner Longitudinal Arch carries most of the weight. It is composed of the Os Calcis from behind as furnishing the main sup- port and the head of the first Metatarsal furnishing the forward support. It extends from the inner side of the Os Calcis and is composed of the Os Calcis, the Astragalus, the Scaphoid, the Internal Cuneiform and the first Metatarsal. 25 26 THE HUMAN FOOT OUTER LONGITUDINAL ARCH The outer Longitudinal Arch extends from the outer side of the bottom of the Os Calcis to the head of the fifth Metatarsal, and is composed of the Os Calcis, Cuboid and fifth Metatarsal, this being the shorter arch and not frequently disturbed in ordinary cases. The two arches to bear in mind are the inner Longitudinal Arch and the Anterior or Transverse Arch. (See Chart No. 5.) These arches are supported mainly by ligaments, and the Longi- tudinal Arch is weakest between the Astragalus and the Cuneiform where it is very liable to yield, giving cause to flat-foot. OUTSIDE VIEW Chart No. 5 Showing Outer Longitudinal Arch. THE TRANSVERSE OR ANTERIOR ARCH This arch extends across the ball of the foot from the outside of the head of the first Metatarsal to the outside of the fifth Metatarsal. It is composed of the second, third and fourth Metatarsal in addition to the first and fifth. This arch plays an important part in the mechanics of the foot, as it provides for the elasticity as well as the strength of the foot and permits of space for the muscles, nerves and blood vessels of the sole of the foot to protect them from pressure. The Metatarsal heads which go to make up the Anterior Transverse Arch are very fre- quently subjected to displacement, creating much disturbance to the foot. (See Chart No. A6.) ITS STRUCTURE 27 ANTERIOR TRANSVERSE ARCH TRANSVERSE ARCH > PHALANGES 1 st METATARSAL 3RD ft 4.TH ,i 5 th " INTERNAL CUNEIFORM MIDDLE " EXTERNAL " SCAPHOID CUBOID ASTRAGALUS OSCALSIS Chart No. 6 Showing Transverse and Anterior Transverse (or Metatarsal) Arch. 28 THE HUMAN FOOT We have considered the entire bony structure of the foot and ankle joint, and it would now be advisable to explain to you in a general way, first, what keeps these bones in their respective posi- Chart No. A6 Arrows Point to Line of Dome Forming the Transverse Arch. tions. The best way to understand this is by considering each struc- ture, such as ligaments, muscles, tendons, arteries, veins and nerves separately, then later describe their location, etc. CHAPTER V SOFT STRUCTURES OF THE FOOT In order that we may clearly understand each one of these various structures, we must know of what they consist and their action. Thus, let us study that first. LIGAMENTS Each bone of the skeleton joins another bone, this producing a joint of the two respective bones, which are held together by liga- ments consisting of tough fibrous bands of tissues. We can thus define a ligament as follows : A strong fibrous band of tissue, whose function is to hold the bony joints in their respective places ; com- posed of waving bands of white fibrous tissue held together by a semi-fluid substance, pliant and flexible, to allow freedom of move- ment but inextensible so as not to readily yield under pressure. In ligaments and tendons these bundles run parellel with each other. They are exceedingly strong so that upon the application of external violence the bone with which it is connected will fracture before the fibrous tissue would be ruptured. Continuous strain may cause liga- ments to lose their normal tone and toughness. Whereas the tendons are composed of the same tissue as ligaments, we will consider them next. TENDONS Tendons are white fibrous cords varying in length and thick- ness. Sometimes they have a round, sometimes a flattened appear- ance ; very strong in texture, but having no elasticity. These fibers run 29 30 THE HUMAN FOOT parallel with each other as in the ligaments, and are composed of the same kind of fibrous tissue. The tendons serve to connect the muscles to the bony structures, and in many instances appear almost like a continuation of a muscle. You will notice I am taking- the structures of the foot from the innermost part, outward. First we considered the bony structure in full ; then I gave you a description of the liga- ments which are the structures next to the bones and serve to hold them in their respective positions. Then the tendons, which form the link between the muscles and the bones and serve as levers, and trans- mit the action from the muscles to the different bones when movement of a joint is required. MUSCLES Now we are to consider the muscle tissue and its function in general. Muscles are defined as follows : A muscle is a bundle of fibers intermingled with arteries, veins and nerves varying in the arrangement according to their attachment as, for instance, where muscles are attached to bony structure they terminate in blunt ex- tremities upon the covering of the bone. Should they be attached to tendons their fibers gradually taper into a small bundle of fibers and are connected with fibrous tissue to the tendons. We have different shapes of muscles such as long, broad, short, etc. These terms will be used later when we describe each individual muscle. For instance, we find long muscles in the leg and short muscles in the foot. The upper part of a muscle is generally termed the origin of a muscle, the middle part the belly and the lower the extremity or insertion end of the muscle. I could expatiate upon the above descrip- tion of ligaments, tendons and muscles, but I believe the foregoing will suffice to give you a general idea of these structures. Next in order come the arteries, veins and nerves. The arteries are very important structures, as they convey the blood which nourishes the different tissues of the body to all parts of the human anatomy. SOFT STRUCTURES OF THE FOOT 31 ARTERIES They are cylindrical tubular vessels which are made up of three coats of tissues. The inner coat consists of a layer of cells called epithelium, the middle coat consists of elastic and muscular fibers of tissue arranged in a circular manner, and the external or third coat mostly of elastic and connective tissues. Let me call your attention to the circulation of the blood in those arteries, etc. The blood is expelled from the heart through the large arteries of the body. These large arteries branch of! into smaller arteries called branches, and they again are subdivided into smaller vessels called capillaries. You may liken the arterial system to a tree. The tree has branches and these branches again give off smaller branches. So we find that the blood is distributed all over the body through these different arteries, branches and capillaries. Again the blood is returned to the heart through a system of veins which we are about to consider. VEINS The veins, like the arteries, are composed of three coats, namely, the internal, middle and external coat. These coats are, with the necessary modifications, analogous to the coats of the arteries, the in- ternal being made up of an epithelial layer of cells, the middle of mus- cular fibers, and the external of connective tissue. The main difference you will notice between the coats of the arteries and those of the veins is in the middle coat, which in the veins is composed of muscular tissue only, consequently making it a much stronger structure. Most of the veins are provided with valves which serve to prevent the reflux of the blood. These valves are formed by reduplications of the inner coats of the veins strengthened by connective tissue and elastic fibers, and are semilunar in form. There remain only the nerves to be described in a general way, and then we have considered all the soft tissues which we find in the study of the leg and foot, and that which pertains to their general characteristics. 32 THE HUMAN FOOT NERVES Under this heading I could include the minute description of every nerve tissue in the body, but as it would burden you with unnecessary material requiring considerable time and study I have decided to discuss only that which would be of value in your work. You may liken the nervous system to the telephone system. In the latter we have a central office from which wires radiate in all directions and messages are received from the outside to the central station. So we have the same conditions existing in the nervous system, namely, the brain of a person is called the central nervous system, and from this center the spinal nerves and other branches originate, consequently any stimulus from without or within would send a message to the brain or central nervou's system to act For instance, when a person sees something falling and wishes to pick it up, the central nerves send messages to the nerves in the muscles of the arm to act, I believe this a comprehensive illustration. We will now continue with a description of the tissues which make up a nerve. Xerve tissue is composed of two substances, namely, gray matter and white or fibrous matter. The gray matter is 'mostly found in the brain, spinal cord and some of the nerves of special sense, which is intermingled with a fibrous nervous substance. We then must consider the nerves, as they are really what we have to deal with. We find nerve cells called neurons distributed throughout the nervous system; then we have nerve fibers, some being enclosed in a sheath while others are not. They generally run in bundles from the different nerve centers enclosed in a sheath to all parts • ' the body, as I ex- plained above. So we find branches of nerves in all parts of the body, the foot also having its share. Should there be any displacement of bones they in turn would press on a nerve filament and produce ex- cruciating pain. This concludes the description of the soft parts of the foot in a general way. We will now consider each ligament, tendon, muscle, artery, vein and nerve separately. CHAPTER VI THE LIGAMENTS Under this heading we are obliged to consider all ligaments which may have all or partial influence on the movements of the ankle joint and foot, and for this reason it is best to start with those ligaments that connect the two bones in the lower limb, namely, the Tibia and Fibula. TIBIO-FIBULAR LIGAMENTS The Fibula is connected with the Tibia by an interosseous mem- brane in the middle, and at the upper and lower ends by ligaments. The ligaments of these two bones are divided into three sets. 1. The Superior or Upper Tibio-Fibular ligaments. 2. The Middle Tibio-Fibular or Interosseous membrane. 3. The Inferior Tibio-Fibular ligaments. 1. The Superior or Upper Ligaments are two in number, called the Anterior and Posterior Tibio-Fibular ligaments. 2. The Middle Tibio-Fibular Ligament is a membrane extending from the margin of the Fibula and Tibia. It is continuous below with the Inferior Interosseous ligament. 3. The Inferior Tibio-Fibular Ligaments are of more importance for our study than the foregoing two sets of ligaments, as the inferior are directly connected with the ankle joint, and for this reason will give a more elabor .e description of these. THE INFERIOR TIBIO-FIBULAR LIGAMENTS Are four in number, namely : 1. Anterior Inferior Tibio-Fibular. 2. Posterior Inferior Tibio-Fibular. 3. Transverse. 4. Inferior Interosseous. 33 34 THE HUMAN FOOT Referring to Chart No. 8 you will notice their relations to the bones. 1. The Anterior Inferior Tibio-Fibular Ligament is a flat triangu- lar band of fibers broader below than above and is situated in front between the Fibula and Tibia, extending from the margin of one bone to the margin of the other, at the lower end of the bones just above the ankle joint and comes in contact with the Astragalus INTEROSSEOUS Tibuip} lNF£RIOri TlBlD-f/BVIfiJi .jnamaa us. Chart No. 8 Ligaments of Ankle Joint. (Right Foot, Outside View) 2. The Posterior Inferior Tibio-Fibular Ligament is of the same kind of tissue, but is smaller than the anterior; in fact the description of the posterior is the same except that this ligament is located pos- teriorly at the same position as is the anterior ligament. (See Chart No. 8.) 3. The Transverse Ligament is a long, narrow band continuous with the posterior ligament passing transversely across the back of the joint from the external Malleolus to almost the internal Malleolus, and THE LIGAMENTS 35 projects a little below the joint to form part of the articulating surface of the Astragalus. 4. The Inferior Interosseous Ligament consists of numerous short, strong fibrous bands which pass between the contiguous rough sur- faces of the Tibia and Fibula and constitute the chief bond of union between the two bones. It is difficult to show these bands on a chart, but I feel certain from the description you can readily understand their location and action. (See Chart No. 8.) LIGAMENTS OF THE ANKLE JOINT Next we are to consider the ligaments of the ankle joint. They are four in number, namely : 1. Anterior. 2. Posterior. 3. Internal Lateral. 4. External Lateral. 1. The Anterior, or Otherwise Called Anterior Tibio-Tarsal Liga- ment, with reference to its location, is a broad, thin membranous layer attached above to the anterior margin of the articular surface of the Tibia and below to the margin of the Astragalus. (See Chart No. 9.) 2. The Posterior, or Otherwise Called Posterior Tibio-Tarsal Ligament, is also very thin and is attached to the posterior margin of the Tibia and posterior margin of Astragalus. (See Chart No. 8.) 3. The Internal Lateral Ligament, or Otherwise Called Deltoid Ligament, consists of two layers of fibers, namely, the superficial and deep layers. The superficial layer is a strong, flat triangular band at- tached above to the anterior and posterior borders of the Internal Malleolus. You will notice by referring to Chart No. 9 that the an- terior fibers pass forward to be inserted into the Scaphoid and Inferior Calcaneo-Scaphoid ligament, the middle fibers descend perpendicu- larly to be inserted into the Os Calcis, the posterior fibers pass back- ward and outward, to be attached to the inner side of the Astragalus. The deep layer is a short, thick and strong bundle of fibers and passes from the Malleolus to the inner surface of the Astragalus. 36 THE HUMAN FOOT 4. The External Lateral Ligament consists of three bundles of fibers, taking different directions, and are distinctly separated. They are named after their location, namely, the Anterior Fasciculus, the Posterior and Middle Fasciculus. A Fasciculus is a bundle of fibers drawn together. a. The Anterior Fasciculus is the shortest of the three and passes from the anterior margin of the External Malleolus downward and forward to the front of the Astragalus. —TIBIA Chart No. 9 Ligaments of Ankle Joint. (Right Foot, Inside View) b. The Posterior Fasciculus is the most deeply seated and passes from the posterior surface of the External Malleolus to the posterior surface of the Astragalus. c. The Middle Fasciculus is the longest of the three and appears like a narrow rounded cord passing from the External Malleolus down- ward and backward to the middle of the outer side of the Os Calcis. (The above is very well illustrated in Chart Xo. 8.) Referring back to the ligaments of the ankle which we just de- THE LIGAMENTS 37 scribed, it is at once evident that the Internal Lateral or Deltoid ligament is of very great power, and that the Middle Fasciculus of the External Lateral ligament binds the bones of the leg firmly to the foot and resists displacement in every direction. The remaining ligaments of the ankle also resist displacement of the bones, and are attached to them, but not to so great a degree. THE LIGAMENTS OF THE TARSUS In order that you may understand the arrangement of this group of ligaments, it is necessary that we refer back to the bones of the Tarsus. (See Chart No. 3.) The bones are arranged in almost two separate rows. In the first row we will consider the Ds Calcis and the Astragalus, and in the second row the Scaphoid, Cuboid and three Cuneiform bones. Therefore, in studying the ligaments which connect these bones, we will for simplicity divide them also into two respective rows, with an additional row which connects the Os Calcis to the Cuboid and the Scaphoid bones separately. The first row has three ligaments, namely: 1. External Calcaneo-Astragaloid. 2. Posterior Calcaneo-Astragaloid. 3. Interosseous. 1. The External Calcaneo-Astragaloid Ligament is a short, strong Fasciculus passing from the outer side of the Astragalus to the outer surface of the Os Calcis. (See Chart No. 8.) 2. The Posterior Calcaneo-Astragaloid Ligament, as its name implies, is situated between the two bones. (See Chart No. 9.) It is the chief bond of union between the Astragalus and Os Calcis and unites these bones firmly together. The second row has three liga- ments, namely : 1. Dorsal (or top part of the foot). 2. Plantar (or sole of foot). 3. Interosseous. 1. The Dorsal Ligaments are so called because they are located on the Dorsal surface of the foot. They are small bands of parallel 38 THE HUMAN FOOT fibers, which pass from each bone of the Tarsus to the neighboring bone with which it articulates. 2. The Plantar Ligaments have the same arrangements as the Dorsal ligaments, only they are situated on the Plantar surface of the foot. 3. The Interosseous Ligaments of the Tarsus are four in number, one between the sides of the Scaphoid and Cuboid, a second between the Internal and Middle Cuneiform bones, a third between the Middle and External Cuneiform bones, and a fourth between the External ■JJ5TRAGAVJ5 OS CALCJ5 Chart No. 10 Cut Section of the Bones of the Foot Showing Interosseous Ligaments. Cuneiform and Cuboid bones. The third row has six ligaments, four ligaments connecting the Os Calcis and Cuboid together, and two ligaments connecting the Os Calcis and Scaphoid, namely: 1. Superior Calcaneo-Cuboid (on Dorsal Surface). 2. Internal Calcaneo-Cuboid (on Dorsal Surface). 3. Long Calcaneo-Cuboid (on Plantar Surface). 4. Short Calcaneo Cuboid (on Plantar Surface). 5. Superior Calcaneo-Scaphoid. 6. Inferior Calcaneo-Scaphoid. 1. The Superior Calcaneo-Cuboid Ligament, as the name implies, is a thin Fasciculus passing between the contiguous surfaces of the THE LIGAMENTS 39 (See Os Calcis and Cuboid bone on the Dorsal surface of the foot. Chart No. 8.) 2. The Internal Calcaneo-Cuboid Ligament is a short, thick and strong band of fibers and forms one of the chief bonds of union between 05CALC15 SHORT ) CAL-CU5. > LIGAMENT) INF.CALCANEO} -SCAPHOID LI& SCAPHOID INTERNAL CUNEIFORM LONGCALCANEO CUBOID L1G. TEND, or PERONE.US L0N6U5. Chart No. 11 Ligaments of the Sole of Right Foot. the first and second rows of the Tarsus. It is situated between the Os Calcis and the Cuboid internally. (See Chart No. 8.) 3. The Long Calcaneo-Cuboid Ligament is the longest of all ligaments in the Tarsus and is very superficial. (See Chart No. 11.) 40 THE HUMAN FOOT It is attached to the under surface of the Os Calcis and its fibers pass forward to be attached to the under surface of the Cuboid bone, and some fibers to the second, third and fourth Metatarsal bones. This ligament is also called the long Plantar ligament. 4. The Short Calcaneo-Cuboid Ligament is short, being only one inch long, and very broad. It connects the fore part of the under sur- face of the Os Calcis to the inferior surface of the Cuboid bone. This ligament is also known as the short Plantar ligament. (See Chart Xo. 11.) 5. The Superior Calcaneo-Scaphoid Ligament passes forward from the inner side of the anterior extremity of the Os Calcis to the outer side of the Scaphoid bone. (See Chart Xo. 8.) It is located on the Dorsal surface of the foot. 6. The Inferior Calcaneo-Scaphoid Ligament is situated on the Plantar surface of the foot. (See Chart No. 11.) It is larger and stronger than the foregoing ligaments, and passes from the interior and inner extremity of the Os Calcis to the under surface of the Scaphoid bone. This concludes the ligaments of the Tarsus proper, and next in order are the ligaments which connect the Tarsal bones with the Metatarsal bones, called Tarso-Metatarsal ligaments. TARSO-METATARSAL LIGAMENTS There are three in number, namely : 1. Dorsal. 2. Plantar. 3. Interosseous. 1. The Dorsal Ligaments consist of flat fibrous bands which con- nect the Tarsal with the Metatarsal bones, and are situated on the Dorsal surface of the foot. The first Metatarsal bone is connected to the Internal Cuneiform by a single broad, thin fibrous band; the second Metatarsal bone has three Dorsal ligaments, one from each Cuneiform ; the third Metatarsal has one from the external Cunei- form ; and the fourth and fifth Metatarsal bones have one each from the Cuboid bone. THE LIGAMENTS 41 2. The Plantar Ligaments consist of longitudinal and oblique bands connecting the Tarsal with the Metatarsal bones on the Plantar surface of the foot. The first and second Metatarsals are more promi- nent, the second and third Metatarsals have strong fibers passing over the Internal Cuneiform, and the fourth and fifth Metatarsal bones have only a few fibers. 3. The Interosseous Ligaments are three in number, namely, the Internal, Middle and External. The internal one passes from the outer extremity of the Internal Cuneiform to the second Metatarsal. The middle one connects the External Cuneiform with the second Metatarsal. The external one connects the External Cuneiform with the third Metatarsal bone. Besides the above ligaments of the Tarso- Metatarsal articulations, there are Dorsal, Plantar and Interosseous ligaments of the Metatarsal bones proper. The Dorsal and Plantar ligaments pass from one Metatarsal bone to the other. (See Chart No. 8.) The Interosseous ligaments lie deeply between the lateral surfaces of the Metatarsal bones. The digital extremities of the Meta- tarsal bones are united by the Transverse Metatarsal ligament. This ligament also connects the great toe with all the Metatarsal bones. The ligaments to be considered next are those which connect the Metatarsal bones with the phalanges of the toes. METATARSO-PHALANGEAL LIGAMENTS There are three ligaments to each joint, one Plantar and two Lateral ligaments. Chart No. A12 Lateral Ligaments, Metatarsophalangeal Joint 1. The Plantar Ligaments are thick fibrous structures placed on the Plantar surface of the joints in the intervals between the lateral 42 THE HUMAN FOOT ligaments, to which they are connected. They are attached to the Metatarsal bones and the first phalanges. 2. The Lateral Ligaments are strong rounded cords placed on each side of the joint, each being attached by one extremity to the Metatar- sal bones and by the other to the first phalanges. The last of the ligaments of the foot to be described are those of the phalanges. There are three ligaments for each pair of phalanges, one Plantar and two Lateral ligaments. The arrangements of these ligaments are similar to those of the Metatarso-Phalangeal ligaments which were described above. This concludes this chapter, and we will next consider the chief muscles and tendons of the foot. CHAPTER VII MUSCLES AND TENDONS OF THE LEG The tendons are generally described in conjunction with the muscles, as most of them are contiguous with the muscles. Tendons are white fibrous cords varying in length and thickness, of considerable strength and devoid of elasticity, and have hardly any blood vessels. The fibers run parallel with each other and are firmly united together, having the appearance of a white, glistening cord. The muscles are connected with the bones, ligaments and skin directly or through the intervention of fibrous structure called tendons. Where the muscles are attached to the bone the fibers terminate in blunt extremities upon the covering of the bone called Periosteum. Where the muscles are connected with the skin they either lie as a flattened layer beneath the skin or connected with connective tissue. The muscles vary extremely in their form ; they may be long, short, broad, flat, round, etc. The arrangement of the fibers varies greatly in different muscles. The muscles of the leg are completely invested by the Deep Fascia, which is a fibrous structure investing the whole of this region of the limb, excluding the inner surface of the Tibia. It is thick and dense in the upper exterior part of the leg, and gives attachment to some of the muscles of the leg, which we will consider later when we describe each muscle separately. Some tendons of the muscles of the leg are attached to the ankle and foot, hence we must consider these muscles first before we take up the muscles of the foot. For convenience I have divided the muscles of the leg into three groups, namely, the Anterior, Posterior and Fibular groups. 43 44 THE HUMAN FOOT EXTENSOR MUSCLES OF THE LEG Anterior Group This consists of four muscles : 1. Tibialis Anticus. 2. Extensor Proprius Pollicis. 3. Extensor Longus Digitorum. 4. Peroneus Tertius. These muscles are located on the anterior part of the leg. All anterior muscles are extensors of the leg and foot ; in other words, they extend the foot, while those on the posterior surface are Flexor muscles and, consequently, flex the foot. AVe will now de- scribe the above named four muscles : 1. The Tibialis Anticus, as the name implies, is situated on the anterior and outer side of the Tibia. It arises from the outer and upper two-thirds of the shaft of the Tibia, and from the Deep Fascia the fibers pass downward and terminate in a tendon which is ap- parent on the anterior surface of the muscle at the lower third of the leg. It is inserted into the inner and under surfaces of the Internal Cuneiform bone and the base of the Metatarsal bone of the large or great toe. (See Chart No. 12.) 2. The Extensor Proprius Pollicis. — This is the extensor muscle of the large toe proper, as the name implies. It is a thin, elongated and flattened muscle situated between the Tibialis Anticus and the Extensor Longus Digitorum, the next muscle which we are to con- sider. (See Chart No. 12.) It arises from the anterior surface of the Fibula, about the middle two-fourths of its length. The fibers pass downward and terminate in a tendon which occupies the anterior border of the muscle, crosses the bend of the ankle and is inserted into the base of the last phalanx of the great toe. 3. The Extensor Longus Digitorum. — This is the extensor muscle of the other four toes, as you will notice by the following description. It is an elongated, flattened muscle situated the most externally of all the muscles on the fore part of the leg. (See Chart 12.) It arises from the upper part of the Tibia and the upper three-fourths of the MUSCLES AND TENDONS 45 * I i a dirt- 1 "'" 6 * 31 W bone V* Chart No. 12 Anterior Group of Muscles of Leg. 46 THE HUMAN FOOT anterior surface of the shaft of the Fibula, also from the Deep Fascia and the next muscles, called the Peroneus Longus and Peroneus Brevis. The fibers pass downward and terminate in a tendon which again divides into four slips, which run across the dorsum of the foot, and are inserted into the second and third phalanges of the four lesser toes. 4. The Peroneus Tertius. — This muscle is a small bundle of fibers and is claimed by some authorities to be part of the Extensor Longus Digitorum, and may be described as a fifth tendon of this muscle. The fibers arise from the lower fourth of the anterior surface of the Fibula. The tendon is inserted into the dorsal surface of the base of the Metatarsal bone of the little toe on the inner side. POSTERIOR GROUP The muscles of this group are subdivided into two layers, super- ficial and deep. The superficial layer constitutes a powerful muscu- lar mass forming the calf of the leg. Superficial Layer This consists of three muscles : 1. Gastrocnemius. 2. Soleus. 3. Plantaris. 1. The Gastrocnemius. — The Gastrocnemius is the most super- ficial muscle, and forms the greater part of the calf. It arises by two heads, which are connected to the condyles of the Femur by two strong flat tendons. The inner head arises from the inner condyle, or inner side of the leg, while the external head arises from the ex- ternal condyle, or the outer side of the leg. This muscle is tendinous along the middle, and each tendon expands into an aponeurosis which covers the posterior surface of that part of the muscle. From the anterior surface of these tendinous expansions muscular fibers are given off. The fibers continue downward and terminate with the fibers of the next muscle to be described, the Soleus, forming a MUSCLES AND TENDONS 47 HEADS OF GASTROC NEM1US GASTROCNEMIUS PERONEUS LONGUE PERONEUS BREY1S FLEXOR LONGUS DIGITORUM TENDO ACHILU5 Chart No. 13 Posterior Group of Muscles of Leg, Superficial Layer. 48 THE HUMAN FOOT common tendon of the two muscles called the' Tendo-Achillis. This tendon being of vast importance, it will be described separately. (See Chart No. 13.) OUTER HEAD Chart No. 14 Posterior Group of Muscles of the Leg, Superficial L,ayer. 2. The Soleus is a broad flat muscle situated beneath the preced- ing muscle. It arises by tendinous fibers from the back part of the head of the Fibula, and from the upper third of the posterior surface MUSCLES AND TENDONS 49 of its shaft and the middle third of the internal border of the Tibia. The fibers pass backward to an aponeurosis which covers the muscle, and this gradually becomes thicker and narrower and joins with the tendon of the Gastrocnemius to form the Tendo-Achillis. (See Chart No. 13.) The Tendo-Achillis is the thickest and strongest tendon in the body. It is about six inches in length, and commences about the middle of the back of the leg, being the common tendon of the two large muscles of the leg, namely, the Gastrocnemius and Soleus, and is inserted into the lower part of the posterior surface of the Os Calcis. (See Chart No. 13.) The tendon spreads out somewhat at its lower end. This tendon can be readily observed when standing on tip toes. 3. The Plantaris is an extremely diminutive muscle, placed be- tween the foregoing two muscles, the Gastrocnemius and Soleus, and has a long and delicate tendon. It arises from a ridge on the Femur and the posterior ligament of the knee joint, the fibers form a small fusiform belly, about three or four inches in length, terminating in a long slender tendon which crosses obliquely the two muscles of the calf and running along the inner border of the Tendo-Achillis, and is inserted with it into the posterior part of the Os Calcis. (See Chart No. 13.) The muscles of the calf possess great power, and are con- stantly called into use in standing, walking, dancing and leaping, thus the large size they usually present when active. Deep Layer This consists of four muscles : 1. Popliteus. 2. Flexor Longus Pollicis. 3. Flexor Longus Digitorum. 4. Tibialis Posticus. Before describing the above muscles, we must consider the Deep Transverse Fascia of :he leg. This is a broad transverse inter- muscular Septum interposed between the superficial and deep muscles of the posterior group. On each side it is attached to the margins of the Tibia and Fibula. This Fascia is thickened above and below, 50 THE HUMAN FOOT Popliteus Soteus Tibial Origin. Tibialis Posticus Flexor Lona us Diqitorum TTexorLoncfi/s PoJlicis Soleus ■Rbuhv OrLain. Chart No. 15 Deep Layer of Muscles of Back of Leg. MUSCLES AND TENDONS 51 but in the middle it is thin. It continues onward internally between the ankle and the heel. 1. The Popliteus Muscle is a thin, flat triangular muscle. It arises by a strong flat tendon, about an inch in length, on the outer side of the external condyle of the Femur, and is inserted into the posterior surface of the shaft of the Tibia. Notice the triangular shape of the muscle in the back part of the knee joint in Chart No. 15. 2. The Flexor Longus Pollicis is situated on the Fibular side of the leg, and is the most superficial and largest of the next three muscles of the leg. It arises from the lower two-thirds of the pos- terior surface of the shaft of the Fibula and from the Fascia. The fibers pass obliquely downward and backward and terminate in a round tendon which passes through a groove on the posterior surface of the Tibia, then through another groove on the posterior surface of the Astragalus, and along a third groove of the Os Calcis into the sole of the foot, where it runs forward and is inserted into the base of the last phalanx of the great toe. You can readily see that the action of this muscle is to flex the great toe. (See Charts Nos. 15 and 17.) 3. The Flexor Longus Digitorum is situated on the Tibial side of the leg. It arises from the posterior surface of the shaft of the Tibia and from the Transverse Fascia, the fibers terminating in a tendon. This tendon passes behind the Malleolus through a groove, and passes obliquely forward and outward beneath the arch of the Os Calcis into the sole of the foot, and finally divides into four separate tendons, which are inserted into the bases of the last phalanges of the four lesser toes. Its action is, as the description would imply, to flex the second, third, fourth and fifth toes. (See Charts Nos. 15 and 17.) 4. The Tibialis Posticus lies between the two preceding muscles, and is the most deeply seated of all the muscles of the leg. It com- mences by two pointed processes and arises from the interosseous membrane from the posterior surface of the shaft of the Tibia, and from the upper two-thirds of the internal surface of the Fibula. The fibers pass downward and terminate in a tendon which passes through 52 THE HUMAN FOOT a groove behind the inner Malleolus, thence beneath the Inferior Calcaneo-Scaphoid ligament, and is inserted into the Scaphoid and internal Cuneiform bones. It also gives off fibrous expansions, one of which passes backward to the Os Calcis, others outward to the Middle and External Cuneiform and Cuboid, and some forward to the bases of the second, third and fourth Metatarsal bones. (See Charts Nos. 15 and 18.) The action of this muscle is a direct extensor of the Tarsus upon the leg, and also turns the sole of the foot inward in conjunction with the Tibialis Anticus. FIBULAR GROUP This consists of two muscles : 1. Peroneus Longus. 2. Peroneus Brevis. 1. The Peroneus Longus is situated at the upper part of the outer side of the leg, and is the more superficial of the two muscles. It arises from the head and upper two-thirds of the outer surface of the shaft of the Fibula, from the Fascia and intermuscular septum. It terminates in a long tendon which passes behind the outer Malleolus in a groove. It is then reflected obliquely across the outer side of the Os Calcis ; then in another groove on the under surface of the Cuboid bone. It then crosses obliquely the sole of the foot, and is inserted into the outer side of the base of the Metatarsal bone of the great toe and the Internal Cuneiform bone. Occasionally it sends a slip to the base of the second Metatarsal bone. Its action is also to extend the foot upon the leg, just opposite to that of the Tibialis Anticus and the Peroneus Tertius, which are flexors of the foot. (See Charts Nos. 15 and A16.) 2. Peroneus Brevis lies beneath the Peroneus Longus and is shorter and smaller. It arises from the lower two-thirds of the ex- ternal surface of the shaft of the Fibula, and from the intermuscular septum. The fibers pass vertically downward and terminate in a tendon which runs in front of that of the preceding muscle through MUSCLES AND TENDONS 53 the same groove, behind the External Malleolus ; it then passes to the outer side of the Os Calcis and is finally inserted into the dorsal surface of the base of the Metatarsal bone of the little toe on the outer side. Gastrocnemius, Soleus. Peroneus Longus. Peroneus Brevis. Annular Ligament, Tibialis Anticus. External Annular Ligament. Tendon Peroneus Longus. Tendon Peroneus Brevis. Chart No. A16 External View of Right Leg, Showing the Peroneus Longus and Brevis. From the above it can be seen that the Peroneus Longus and Brevis muscles serve to steady the leg upon the foot in standing upon one foot. (See Charts Nos. 15 and A16.) CHAPTER VIII MUSCLES AND TENDONS OF THE FOOT Under this chapter we are to consider the muscles and tendons of the foot, and in this connection I must call your attention to four structures which we find in the foot and which are closely related to the muscles and tendons and will be described separately. They are the 1. Anterior Annular ligament. 2. Internal Annular ligament. 3. External Annular ligament. 4. Plantar Fascia. 1. The Anterior Annular Ligament consists of a superior or ver- tical portion which binds down the extensor tendons as they descend on the front of the Tibia and Fibula, and an inferior or horizontal portion which retains the tendons in connection with the Tarsus. The vertical portion is attached externally to the lower end of the Fibula, internally to the Tibia and above is continuous with the fascia of the leg. The horizontal portion is attached externally to the upper surface of the Os Calcis. It passes upward and inward as a double layer, one layer passing in front and the other behind the Peroneus Tertius and Extensor Longus Digitorum. Later the two layers join together, forming a sort of a loop in which the tendons are enclosed. From the inner extremity of this loop two bands of fibers are given off, one passing upward and inward to be attached to the Internal Malleolus, the other passing downward and inward to be attached to the Plantar Fascia. This ligament is a very important structure of the ankle joint, as you will notice by referring to Chart No. 12 and Chart No. A16. 2. The Internal Annular Ligament is a strong fibrous band which extends from the inner Malleolus above to the inner margin of the Os 54 MUSCLES AND TEXDOXS 55 Calcis below, converting a series of grooves in this situation into canals for the passage of the tendons of the flexor muscles into the sole of the foot. It is continuous above with the Deep Fascia of the leg and by its lower border with the Plantar Fascia. 3. The External Annular Ligament extends from the outer Mal- leolus to the outer surface of the Os Calcis and is a shorter fibrous Branches of Internal Plantar Nerve. Inner Portion of Plantar Fascia. — ts=?S* Thick Central Portion of Plantar Fascia. Inner Portion of Plantar Fascia. Connective Tissue and Fat wr~in the Web of the Toes. uperficial Transverse Metatarsal Ligament. Branches of External Plantar Xerve. Outer Portion of Plantar Fascia. Branches of External Plantar Xerve. Outer Portion of Plantar Fascia. Calcaneo-Metatarsal Ligament. Chart Xo. B16 The Plantar Fascia and Plantar Cutaneous Xerves. structure which binds down the tendons of Peronei muscles. (See Chart Xo. A16.) 4. The Plantar Fascia is the densest of all the fibrous membranes. It is of great strength and consists of dense pearly-white fibers disposed for the most part longitudinally. It is divided into a central and two lateral portions, namely, the outer and inner portions. The central portion is the thickest, is narrow behind and attached to the 56 THE HUMAN FOOT inner tubercle of the Os Calcis, becomes broader and thinner in front and divides near the heads of the Metatarsal bones into five processes, one for each toe. Each of these processes again subdivides into two, opposite the Metatarso-Phalangeal joints, a superficial and a deep. The superficial one is inserted into the skin. The deep divides into two slips which embrace the sides of the flexor tendons of the toes and laterally with the Transverse Metatarsal ligaments, thus form- ing a series of arches through which the tendons of the short and long flexor muscles pass to the toes. The Central Portion of this Fascia is continuous with the lateral portion on each side and sends off several septums upward into the foot. The Outer Portion covers the under surface of the Abductor Minimi Digiti muscle, which will be described later. It is thick be- hind and thin in front, and extends from the Os Calcis forward to the base of the fifth Metatarsal bone where it is attached to its outer side. It is continuous internally with the middle portion of the Plantar Fascia and externally with the Dorsal Fascia. The Inner Portion is very thin and covers the Abductor Pollicis muscle, another muscle which will be described later. It is attached behind to the Internal Annular ligament and is continuous around the side of the foot with the Dorsal Fascia and externally with the middle portion of the Plantar Fascia. We will now describe the muscles of the foot, and for your con- venience I have divided these muscles into two main groups, namely: 1. The muscles of the Dorsum of the foot. 2. The muscles of the Plantar surface of the foot. DORSAL REGION 1. The Dorsal Region has one muscle, namely: The Extensor Brevis Digitorum. — It is -a broad, thin muscle which arises from the outer side of the Os Calcis from the External Calcaneo- Astragaloid ligament and from the horizontal portion of the Anterior Annular ligament. It passes obliquely across the Dorsum of the foot MUSCLES AXD TEXDOXS 57 and terminates in four tendons. The innermost, which is the largest of the four tendons, is inserted into the first phalanx of the great toe; the other three are inserted into the outer sides of the long extensor tendons of the second, third and fourth toes. (See Charts Nos. 12 and C16.) INTERNAL BRANCH OF ANT.TIBIAL NERVE fEXTENSOR {BREVIS [digitorum THE 4 DORSAL INTEROSSEI MUSCLES Chart No. CI 6 Showing the Extensor Brevis Digitorum and Its Insertion. PLANTAR REGION 2. The Plantar Region is divided into four layers, and each layer consists of several muscles. We will therefore describe these muscles under their respective layers. FIRST LAYER This consists of three muscles, namely : 1. Abductor Pollicis. 2. Flexor Brevis Digitorum. 3. Abductor Minimi Dio-iti. 58 THE HUMAN FOOT 1. The Abductor Pollicis lies along the inner border of the foot. It arises from the under surface of the Os Calcis from the Internal Annular ligament, from the Plantar Fascia and from the Intermuscu- lar Septum. The fibers terminate in a tendon and are inserted together Os Calcis FLEXOR BREVIS DiGlTORUf> Chart No. 16 Muscles of the Sole of the Foot, First Layer. with the innermost tendon of the Flexor Brevis Pollicis into the inner side of the base of the first phalanx of the great toe. (See Chart No. 16.) 2. The Flexor Brevis Digitorum lies in the middle of the sole of the foot, immediately beneath the Plantar Fascia with which it is MUSCLES AND TENDONS 59 firmly united. It arises from the under surface of the Os Calcis, from the central part of the Plantar Fascia and from the Intermuscular Septum ; it then passes forward and is divided into four tendons, which are inserted into the four lesser toes. Opposite the middle of the first Phalanx of each toe the tendon presents a longitudinal slit to allow the passage of the corresponding tendon of the Flexor Longus Digitorum ; the tendon of the Flexor Brevis Digitorum then reunites and again divides into two processes, which are inserted into the sides of the second Phalanges of the four lesser toes. (See Chart No. 16.) 3. The Abductor Minimi Digiti lies along the outer border of the foot. It arises by a very broad origin from the under surface of the Os Calcis, from the Plantar Fascia and from the Intermuscular Septum, and terminates in a tendon which is inserted, together with the tendon of the Flexor Brevis Digitorum of the little toe, into the outer side of the base of the first Phalanx of the little toe. (See Chart No. 16.) SECOND LAYER This layer has five muscles, namely: 1. Flexor Accessorius. 2. Lumbricales (four in number). 1. The Flexor Accessorius arises by two heads, the inner or larger head being attached to the inner surface of the Os Calcis and to the Calcaneo-Scaphoid ligament. The outer head is flat and tendinous and is attached to the under surface of the Os Calcis and to the long Plantar ligament. The two heads join at an acute angle and are inserted into the outer margin and the upper and under sur- faces of the tendon of the Flexor Longus Digitorum. (See Chart No. 17.) 2. The Lumbricales are four small muscles, accessory to the ten- dons of the Flexor Longus Digitorum. They arise from the tendons of the long Flexor as far back as their angle of division, each arising from two tendons of the long Flexor, except the internal one. Each 60 THE HUMAN FOOT muscle terminates in a tendon which passes forward on the inner side of each of the lesser toes and is inserted into the long Extensor and base of the first Phalanx of the corresponding toe. Chart No. 17 Muscles of the Sole of the Foot, Second Layer. THIRD LAYER This layer has four muscles, namely: 1. Flexor Brevis Pollicis. 2. Adductor Pollicis. 3. Flexor Brevis Minimi Digiti. 4. Transversus Pedis. MUSCLES AND TENDONS 61 1. The Flexor Brevis Pollicis arises by a pointed tendinous process from the inner border of the Cuboid bone, from the External Cuneiform bone and from the prolongation of the tendon of the Tibialis Posticus. The muscle divides into two portions which are inserted as follows : Chart No. 18 Muscles of Sole of the Foot, Third Layer. One on the inner side of the base of the first phalanx of the great toes, blended together with the Abductor Pollicis; the other portion is inserted into the outer side of the first Phalanx of the great toe 62 THE HUMAN FOOT and blended together with the Adductor Pollicis and the tendon of the Flexor Longus Pollicis. (See Chart Xo. 18.) 2. The Adductor Pollicis is a large, thick, fleshy muscle passing obliquely across the foot and occupying the hollow space between the four inner Metatarsal bones. It arises from the Tarsal extremities of the second, third and fourth Metatarsal bones and from the tendon of the Peroneus Longus and is inserted, together with outer portion of the Flexor Brevis Pollicis, into the outer side of the base of the first Phalanx of the great toe. (See Chart No. 18.) 3. The Flexor Brevis Minimi Digiti lies on the Metatarsal bone of the little toe and arises from the base of that bone and from the Peroneus Longus, and is inserted into the base of the first Phalanx of the little toe on its outer side. (See Chart Xo. 18.) 4. The Transversus Pedis is a narrow, flat muscular fasciculus stretched transversely across the heads of the Metatarsal bones. It arises from the under surface of the head of the fifth Metatarsal bone and from the Transverse ligament of the Metatarsus and is inserted on the outer side of the first Phalanx of the great toe. Its fibers blend with the tendon of the Adductor Pollicis. The action of the Trans- versus Pedis increases the arching of the foot and abducts the great toe. (See Chart Xo. 18.) FOURTH LAYER This layer consists of seven Interossei muscles. There are four in the Dorsum of the foot and three in the Plantar surface. The Dorsal Interossei are four in number and are situated between the Metatarsal bones. They arise by two heads from the adjacent sides of the Metatarsal bones ; their tendons are inserted into the bases of the first Phalanges of the middle three lesser toes and into the com- mon Extensor tendon. The first Dorsal Interosseous muscle is in- serted into the outer sides of the second toe ; the other three are inserted into the inner side of the second, third and fourth toes. (See Chart Xo. 19.) The Plantar Interossei, three in number, lie beneath the third, MUSCLES AND TENDONS 63 fourth and fifth Metatarsal bones. They are single muscles and arise from the base and the shaft of their respective Metatarsal bones, and are inserted into the inner sides of the bases of the first Phalanges of the same toes and into the common Extensor tendon. (See Chart No. 20.) All the muscles of the foot act upon the toes, and for the purpose of description as regards their action may be grouped as Abductors, Adductors, Flexors or Extensors. And, whereas the ■ith- DORSAL SA/ZCAOSSri Chart No. 19 The Dorsal Interossei Mus- cles (Left Foot), Fourth L,ayer. muscles of the foot are of prime importance in your work, it is well that I give you an idea of the function of each muscle. The Abductors are the Dorsal Interossei, the Abductor Pollicis and the Abductor Minimi Digiti. The first Dorsal Interosseous muscle draws the second toe inward toward the great toe; the second muscle draws the same toe outward. The third muscle draws the 64 THE HUMAN FOOT third toe and the fourth muscle draws the fourth toe in the same direction ; they also flex the proximal Phalanges and extend the two terminal Phalanges. The Abductor Pollicis abducts the great toe from the other toes and also flexes the proximal Phalanx of the great toe. The Abductor Minimi Digiti acts in the same manner on the little toe. The Adductors are the Plantar Interossei, the Adductor Pollicis J* PLANTAR JNTSROSSET 3 is Chart No. 20 The Plantar Interossei (Left Foot). and the Transversus Pedis. The Plantar Interosseous muscles draw the third, fourth and fifth toes toward the second toe, also flex the proximal Phalanges and extend the two terminal Phalanges. The Adductor Pollicis adducts the great toe toward the second toe and also assists in flexing this toe. The Transversus Pedis approximates all the toes and thus increases the curve of the Transverse Arch of the Metatarsus. MUSCLES AND TENDONS 65 The Flexors are the Flexor Brevis Digitorum, the Flexor Acces- sorius, the Flexor Brevis Pollicis, the Flexor Brevis Minimi Digiti and the Lumbricales. The Flexor Brevis Digitorum flexes the second Phalanges upon the first and brings the toes together. The Flexor Accessorius assists the long flexor of the toes and converts the oblique pull of the tendon of that muscle into a direct backward pull upon the toes. The Flexor Brevis Minimi Digiti flexes the little toe and draws its Metatarsal bone downward and inward. The Lumbricales assist in flexing the proximal Phalanges and, by their insertion into the long Extensor tendon, aid in straightening the two terminal Phalanges. The Extensors. — In this group there is only one, the Extensor Brevis Digitorum. It extends the first Phalanx of the great toe and assists the long Extensor in extending the next three toes ; it also gives to the toes an outward direction when extended. This con- cludes the description of the muscles and tendons of the leg, ankle and foot, and before giving you the arteries, veins and nerves it would be advisable to study these muscles again by comparing them with the charts given in this book and master them thoroughly, as they are of vital importance in malformations of the foot. CHAPTER IX THE ARTERIES OF THE FOOT Under Chapter Y I gave you a general description of the struc- ture of the arteries, also the mode of distributions, and now we are to describe each artery and branch of the leg and foot separately. Before we can comprehend the origin and division of these arteries, I must refer you back to Chapter V, in which you will find a descrip- tion of the circulation of the blood. The blood is forced through the large vessels by the heart, which acts as a pump. These vessels or arteries have branches and capillaries. It is not necessary to consider all the arteries of the body in this book, as we are only interested in those vessels which distribute the blood supply to the lower limb and foot. For this reason we will commence at the knee joint and go down. The first artery to be considered is the Popliteal artery, which is a continuation of the largest artery in the thigh, namely, the Femoral artery. The Popliteal Artery commences at the junction of the middle and lower third of the thigh, and passes obliquely downward and outward behind the knee joint to the lower border of the Popliteus muscle, where it divides into the Anterior and Posterior Tibial arteries. (See Charts Nos. 21 and 22.) This brings us down to the arteries of the leg proper. The arteries of the leg are divided into two main arteries and their branches, which will be described under their re- spective headings, namely, the Anterior Tibial artery and the Posterior Tibial artery. The Anterior Tibial Artery commences at the bifurcation of the Popliteal artery at the lower border of the Popliteus muscle, passes forward between the two heads of the Tibialis Posticus muscle and through an aperture left between the bones to the deep part of the front of the leg; it then descends on the anterior aspect of the Tibia 66 THE ARTERIES 67 POPLITEAL ARTERY GASTHDC N£N/i/J PIANT F0FL1IEU5 SOLEUS TIBIAL OKIGJN POSTERIOR TIBIAL ARTERY fWCQR IOMGUS DIG. Chart No. 21 The Popliteal, Posterior Tibial and Peroneal Arteries. 68 THE HUMAN FOOT to the bend of the ankle joint, where it lies more superficially and becomes the Dorsalis Pedis artery. (See Chart Xo. 22.) The Anterior Tibial artery is accompanied by two veins, called venae comites, which lie one on either side of the artery. The Anterior Tibial nerve lies at first to its outer side, and about the middle of the leg is placed superficially to it. At the lower part of the artery the nerve again is on the outer side. The Anterior Tibial artery is divided into four branches, namely: 1. Recurrent Tibial. 2. Muscular. 3. Internal Malleolar. 4. External Malleolar. 1. The Recurrent Tibial Branch arises from the Anterior Tibial artery as soon as that vessel has passed through the aperture about the knee joint. It ascends in the Tibialis Anticus muscle and ramifies on the front and sides of the knee joint, anastomosing with the articu- lar branches of the Popliteal and the Anastomotica Magna. (See Chart Xo. 22.) 2. The Muscular Branches are numerous. They are distributed to the muscles which lie on either side of the vessels, some piercing the Deep Fascia to supply the Integument, others passing through the Interosseous membrane and anastomosing with the branches of the Posterior Tibial and Peroneal arteries. The Malleolar arteries supply the ankle joint. 3. The Internal Malleolar Branch arises about two inches above the ankle joint and passes beneath the tendons of the Extensor Proprius Pollicis and Tibialis Anticus to the inner ankle, upon which it ramifies, anastomosing with branches of the Posterior Tibial and Internal Plantar arteries and with the Internal Calcanean branch of the Posterior Tibial artery. (See Chart No. 22.) 4. The External Malleolar Branch passes beneath the tendons of the Extensor Longus Digitorum and Peroneus Tertius and supplies the outer ankle, anastomosing with the Anterior Peroneal artery and with ascending branches from the Tarsal branch of the Dorsalis THE ARTERIES 69 Chart No. 22 The Anterior Tibial and Dorsalis Pedis Arteries. 70 THE HUMAN FOOT Pedis. (See Chart No. 22.) To facilitate the study of the arteries of the leg" and foot, it is necessary that I describe the Dorsalis Pedis artery and its branches before we take tip the Posterior Tibial artery and its branches, as the Dorsalis Pedis is a continuation of the An- terior Tibial artery which was just described. THE DORSALIS PEDIS ARTERY Commences at the bend of the ankle as a continuation of the Anterior Tibial artery and passes along the Tibial side of the foot to the back part of the first Interosseous space, where it divides into five branches, namely : (See Chart No. 22.) Branches of the Dcrsalis Pedis Artery 1. Tarsal. 2. Metatarsal. 3. Interosseous. 4. Dorsalis Pollicis. 5. Communicating. 1. The Tarsal Branch arises from the Dorsalis Pedis as that vessel crosses the Scaphoid bone. It passes outward, lying upon the Tarsal bones and is covered by the Extensor Brevis Digitorum. It supplies that muscle and the Tarsus and anastomoses with the branches of the Metatarsal, External Malleolar, Peroneal and External Plantar arteries. (See Charts Nos. 22 and A23.) 2. The Metatarsal Branch arises a little anterior to the preceding, and passes outward to the outer part of the foot over the bases of the Metatarsal bones beneath the tendon of the short Extensor. It anastomoses with the Tarsal and External Plantar arteries. It gives off three branches, the Interosseous. (See Charts Nos. 22 and A23.) 3. The Interosseous Branches are three in number, passing for- ward upon the three outer Dorsal Interossei muscles and between the toes and divides into two collateral Dorsal branches for the ad- joining toes. At the back part these vessels receive the Posterior Perforating branches from the Plantar arch and at the fore part they THE ARTERIES 71 Peroneus Brevis. Extensor Longus Digitorum. Anterior Peroneal Artery. External Malleolar Artery. Extensor Brevis Digitorum. Tarsal Artery Metatarsal Artery. Dorsal Interosseous Arteries. Anterior Tibial Artery. Extensor Eongus Hallucis. Tibialis Anticus. Internal Malleolar Artery. Dorsalis Pedis Artery. Dorsalis Pollicis Artery. Chart No. A23 The Dorsalis Pedis Artery and Its Branches. 72 THE HUMAN FOOT are joined by the Anterior Perforating branches from the Plantar arch, the outermost Interosseous artery sending- off an additional branch, which supplies the outer side of the little toe. (See Chart Xo. A23.) 4. The Dorsalis Pollicis runs along the outer border of the first Metatarsal bone and between the first and second toes and again divides into two branches, one of which passes inward beneath the tendon of the Extensor Proprius Pollicis and is distributed to the inner border of the great toe. The outer branch bifurcates to supply the adjoining sides of the great and second toes. (See Chart Xo. A23.) 5. The Communicating Branch dips down into the sole of the foot between the two heads of the first Dorsal Interosseous muscle and communicates with the termination of the External Plantar artery to complete the Plantar arch. It here gives off two digital branches : one runs along the inner side of the great toe on its Plantar surface, the other forward along the first Interosseous space and bifurcates for the supply of the adjacent sides of the great and second toes. (See Chart Xo. 22.) THE POSTERIOR TIBIAL ARTERY Is of large size, which extends obliquely downward from the lower border of the Popliteus muscle along the Tibial side of the leg to the Fossa between the inner ankle and the heel, where it divides into the Internal Plantar and External Plantar arteries. It lies upon the Tibialis Posticus and Flexor Digitorum muscles and on the Tibia and back part of the ankle, joint at its lower part, running parallel with the Tendo-Achillis. It is accompanied by two veins and the Posterior Tibial nerve. (See Chart Xo. 21.) The branches of the Posterior Tibial artery are divided as follows : 1. The Peroneal. 2. Anterior Peroneal. 3. Muscular. 4. Xutrient. 5. Communicating. 6. Internal Calcanean. THE ARTERIES 73 1. The Peroneal Artery lies deeply seated along the back part of the Fibular side of the leg. It arises from the Posterior Tibial artery an inch below the lower border of the Popliteus muscle, passes ob- liquely outward to the Fibula and then descends along the inner border of that bone through the fibers of the Flexor Longus Pollicis to the lower third of the leg, where it gives off the Anterior Peroneal branch. It then passes across the articulation between the Tibia and Fibula to the outer side of the Os Calcis, supplying the neighboring muscles and back of the ankle. It anastomoses with the External Malleolar, Tarsal and External Plantar arteries. The Peroneal artery in its course gives off branches to the Soleus, Tibialis Posticus, Flexor Longus Pollicis, Peronei muscles and a nutrient branch to the Fibula. (See Chart Xo. 21.) 2. The Anterior Peroneal Branch pierces the Interosseous mem- brane about two inches above the External Malleolus to reach the fore part of the leg, and passing down beneath the Peroneus Tertius to the outer ankle ramifies on the front and outer side of the Tarsus, anastomosing with the External Malleolar and Tarsal arteries. (See Chart No. 22.) 3. The Muscular Branches of the Posterior Tibial are distributed to the Soleus and deep muscles along the back of the leg. 4. The Nutrient Branch arises from the Posterior Tibial, near its origin, and after supplying a few muscular branches enters the nutrient canal of the Tibia which it traverses obliquely from above downward. This is the largest nutrient artery of bone in the body. 5. The Communicating Branch to the Peroneal runs transversely across the back of the Tibia about two inches above its lower end, passing beneath the Flexor Longus Pollicis. (See Chart No. 23.) 6. The Internal Calcanean are several large arteries which arise from the Posterior Tibial just before its division ; they are distributed to the fat and integument behind the Tendo-Achillis and about the heel, also to the muscles on the inner side of the sole, anastomosing with the Peroneal and Internal Malleolar arteries. (See Chart No. 21.) 74 THE HUMAN FOOT THE INTERNAL PLANTAR ARTERY Is the smaller of the two Plantar arteries and passes along- the inner side of the foot. It is first situated above the Abductor Pollicis and then between it and the Flexor Brevis Digitorum, both of which it supplies. At the base of the first Metatarsal bone it passes along the inner border of the great toe. (See Charts Xos. 23 and 24.) cotmvmcATM BRANCH OP D0XMISJ£D15\ Chart No. 23 The Plantar Arteries. (Deep View) THE EXTERNAL PLANTAR ARTERY Is much larger than the Internal, passes obliquely outward and forward to the base of the fifth Metatarsal bone ; it then turns inward between the bases of the first and second Metatarsal bones, where it anastomoses with the communicating branch of the Dorsalis Pedis artery, thus completing the Plantar arch at its commencement. It is THE ARTERIES 75 placed between the Os Calcis and Abductor Pollicis, then between the Flexor Brevis Digitorum and Flexor Accessorius; as it passes on to the little toe, it lies between the Flexor Brevis Digitorum and Abductor Minimi Digiti. The remainder of the artery extends from the base of the Metatarsal bone of the little toe to the back part of the first Interosseous space and forms the Plantar arch. The branches Chart No. 24 Showing Plantar Arteries. (Superficial View) of the Plantar arch, besides distributing numerous branches to the muscles and integument in the sole, are : (See Charts Nos. 23 and 24.) 1. The Posterior Perforating. 2. The Digital or Anterior Perforating. 1. The Posterior Perforating are three small branches which ascend through the back part of the three outer Interosseous spaces, 76 THE HUMAN FOOT and anastomose with the Interosseous branches from the Metatarsal artery. (See Chart Xo. 23.) 2. The Digital Branches are four in number and supply the three outer toes and half of the second toe. The first passes along the outer side of the little toe. The second, third and fourth run along the Interosseous spaces and divide into two collateral branches, which supply the adjacent sides of the three outer toes and the outer side of the second toe. Each Digital artery sends upward, through the fore part of the corresponding Metatarsal space, a small branch which communicates with the Interosseous branches of the Metatarsal artery and are called the Anterior Perforating branches. (See Charts Nos. 23 and 24.) This concludes the description of the arteries of the leg and foot, and from the arrangement of these arteries you can readily see the perfect system of blood supply to all the tissues which are found in these parts. Should any disturbance arise in the blood vessels of the foot, it is liable to cause a great many conditions, such as swelling, enlarged joints, etc. It is very important also to bear in mind the location and distribu- tion of these arteries when using mechanical appliances in correcting foot disturbances. CHAPTER X THE VEINS OF THE LEG AND FOOT In considering the veins it is only necessary to give here a general outline of their mode of distribution and to describe a few of the chief veins of the leg and foot in order to understand their relation to the arteries, etc. The veins are vessels which serve to return the blood from the capillaries of the different parts of the body to the heart. They consist of two distinct sets of vessels, the, Pulmonary and Systemic. Whereas we are only to describe the veins of the lower extremity, we will only take the Systemic veins into consideration. The veins, like the arteries, are found in nearly every tissue of the body. They commence by minute plexuses which receive the blood from the capillaries. The branches which have their commencement in these plexuses unite together into trunks, and these as they pass toward the heart increase in size. The veins are larger and altogether more numerous than the arteries, hence the entire capacity of the venous system is much greater than that of the arterial system. The veins communicate very freely with one another. The Systemic veins are divided into the superficial and deep veins. The superficial veins are placed beneath the integument between the Superficial Fascia ; they return the blood from these structures and communicate with the deep veins by perforating the Deep Fascia. The deep veins accompany the arteries and are usually enclosed in the same sheath with those vessels, and are called for that reason the Venae Comites of those vessels. Both sets of veins are provided with valves which are more numer- ous in the deep than in the superficial set. The superficial veins of 77 78 THE HUMAN FOOT SUPERFICIAL CIRCUMFLEX- ILIAC SUPERFICIAL -EPIGASTRIC SUPERFICIAL ■ EXTERNAL PIED/O INTERNAL f SAPHENOUS VEIN Chart No. 25 The Internal or Large Saphenous Vein and Its Branches. VEINS OF THE LEG AND FOOT 79 the lower extremity are two, the Internal or Long Saphenous, and the External or Short Saphenous veins. Before describing these two veins, we must describe the veins of the foot and so upward, as the blood returns from the most distant point and ascends toward the heart. IPOPLITEAL VEIN a EXTERNAL -SAPHENOUS VEIN Chart No. 26 External or Short Saphenous Vein. On the Dorsum of the foot there is a Venous arch situated in the superficial structures, over the anterior extremities of the Metatarsal bones, which terminates internally in the Long Saphenous vein and externally in the Short Saphenous vein. (See Chart No. 25.) The Internal or Long Saphenous Vein commences at the inner 80 THE HUMAN FOOT side of the Venous arch on the Dorsum of the foot. It ascends in front of the inner Malleolus and along the inner side of the leg; accompanied by the Internal Saphenous nerve, it continues to ascend until it terminates in the Femoral vein. It receives, in its course, cutaneous tributaries from the leg. It communicates in the foot with the Internal Plantar vein, in the leg with the Posterior Tibial veins, by branches which perforate the Soleus muscle, and also with the Anterior Tibial veins. (See Chart No. 25.) The External or Short Saphenous Vein commences at the outer side of the Venous arch on the Dorsum of the foot. It ascends behind the outer Malleolus and along the outer border of the Tendo-Achillis, across which it passes at an angle to reach the middle line of the posterior aspect of the leg. It ascends to terminate in the Popliteal vein, and is accompanied by the External Saphenous nerve. It receives numerous large tributaries from the back part of the leg and communicates with the deep veins on the Dorsum of the foot. It also gives off a communicating branch which passes upward and inward to join the Internal Saphenous vein. (See Chart No. 26.) The deep veins are situated too high up in the leg to be of any service in the consideration of the blood supply of the foot; therefore, this concludes the description of all of the veins which will be necessary for our purpose. CHAPTER XI THE NERVES OF THE LEG AND FOOT Under this heading we are to study just those nerves which are in direct relation to the structures of the lower limb alone. The minute description of the structure of a nerve was given under Chapter V. For our convenience we must commence with the upper- most nerve in the leg supplying nerve force to the lower limb and foot. The first one to be considered is the Great Sciatic nerve. It is not necessary to describe the Great Sciatic nerve minutely, as it will suffice to say that this nerve gives off two important branches which supply the muscles of the calf of the leg and foot, namely, the Internal Popliteal and External Popliteal nerves. (See Chart No. 27.) The Internal Popliteal Nerve. — The larger of the two terminal branches of the Great Sciatic nerve descends along the back part of the thigh to the lower part of the Popliteal muscle, where it becomes the Posterior Tibial nerve and lies in close relation with the blood vessels. This nerve has several branches, namely, the Articular, Muscular, Cutaneous and the External or Short Saphenous nerve. The Articular Branches, usually three in number, supply the knee joint. The Muscular Branches, four in number, supply the Gastrocne- mius, Plantaris, Soleus and Popliteus muscles. The Cutaneous supplies the integument. The External or Short Saphenous descends about the middle of the back of the leg and receives a communicating branch from the External Popliteal nerve. It then continues its course down the leg along the outer margin of the Tendo-Achillis, and is distributed to the integument of the outer side of the foot and little toe. (See Chart No. 28.) The Posterior Tibial Nerve commences at the lower border of the 6 81 82 THE HUMAN FOOT CJuf,. Medium Quelle 7lf.<0 O&XURATOn SnitsJJ Sciatic Gsca tSciaticNervl Extern al Saphenous fostertoir Tibial " Plantar Cutaneous Chart No. 27 Nerves of Leg and Foot. (Posterior View) THE NERVES 83 Popliteus muscle and passes along the back part of the leg with the Posterior Tibial vessels to the interval between the Inner Malleolus and the heel, where it divides into the External and Internal Plantar Chart No. 28 Cutaneous Nerves of the Lower Ex- tremity. (Posterior View) nerves. Besides these, it sends off three smaller branches, namely, the Muscular, Plantar-Cutaneous and Articular. (See Chart No. 27.) The Muscular branches arise from the upper part of the nerve and supply the Tibialis Posticus, Flexor Longus Digitorum and Flexor 84 THE HUMAN FOOT Longus Pollicis muscles. The Plantar-Cutaneous branch perforates the Internal Annular ligament and supplies the integument of the heel and inner side of the sole of the foot. The Articular branch sup- plies the ankle joint. IN7ZRNAL PLWTATi /zrx DIGIT £X2FIWAZ PZANTAR Chart No. 29 The Plantar Nerves. The Internal Plantar Nerve, the largest of the two terminal branches of the Posterior Tibial nerve, accompanies the Internal Plantar artery along the inner side of the foot. It commences at the ankle, passes forward, dividing at the bases of the Metatarsal bones into four digital branches, and communicates with the External Plan- THE NERVES 85 tar nerve. (See Chart No. 29.) This nerve gives off cutaneous branches which supply the integument of the sole of the foot; muscu- lar branches which supply the Abductor Pollicis and Flexor Brevis Digitorum muscles ; articular branches to the articulations of the Tarsus and Metatarsus, and four digital branches which pass between the toes and are distributed as follows : The first supplies the inner border of the great toe; the second bifurcates to supply the adjacent sides of the great and second toes; the third supplies the adjacent sides of the second and third toes, and the fourth supplies the cor- responding sides of the third and fourth toes. The External Plantar Nerve, the smaller of the two terminal branches of the Posterior Tibial nerve, completes the nervous supply to the structures of the foot, being distributed to the little toe and one- half of the fourth toe, as well as to most of the deep muscles. It passes obliquely outward to the outer side of the foot, lying between the Flexor Brevis Digitorum and Flexor Accessorius, and divides into a superficial and deep branch supplying the Flexor Accessorius and Abductor Minimi Digiti muscles. The Superficial Branch separates into two Digital nerves. One sup- plies the outer side of the little toe, the Flexor Brevis Minimi Digiti, and the two Interosseous muscles of the fourth Metatarsal space, the other digital branch supplying the adjoining sides of the fourth and fifth toes, and communicates with the Plantar nerve. The Deep or Muscular Branch accompanies the External Plantar artery into the deep part of the sole of the foot and supplies all the Interosseous muscles (except those in the fourth Metatarsal space), the two outer Lumbricales, the Adductor Pollicis and the Transversus Pedis. (See Chart No. 29.) The External Popliteal or Peroneal Nerve is situated about the Popliteal space in the back of the leg, descends to the Peroneus Longus muscle, where it divides into the Anterior Tibial and Musculo- cutaneous nerves. (See Chart No. 27.) The branches of the Ex- ternal Popliteal nerve before its division are the Articular and Cuta- neous branches, which supply the knee joint and the integument in that region. 86 THE HUMAN FOOT The Anterior Tibial Nerve commences at the bifurcation of the Peroneal nerve, passes forward and then descends to the front of the ankle joint, where it divides into an external and internal branch. Sartorius interior dural Middle. Cutaneous Mvsculo- Cutaneous interior Tibial Chart No. 30 Nerves of the Leg and Foot. (See Chart No. 30.) The branches of the Anterior Tibial, in its course through the leg, are the muscular nerves to the Tibialis Anticus, Extensor Longus Digitorum, Peroneus Tertius and Extensor Proprius Pollicis muscles, and an articular branch to the ankle joint. THE NERVES 87 The External or Tarsal Branch passes outward across the Tarsus and supplies the Extensor Brevis Digitorum and the articulations of the Tarsus and Metatarsus. The Internal Branch is a continuation of the Anterior Tibial nerve. It accompanies the Dorsalis Pedis artery along- the inner side of the Dorsum of the foot and, at the first Interosseous space, divides into two branches, which supply the adjacent sides of the great and second toes, communicating with the internal division of the Musculo-Cu- taneous nerve. The Musculo-Cutaneous Nerve supplies the muscles on the Fibular side of the leg and the integument of the Dorsum of the foot. It passes forward and at the lower third of the leg it divides into two branches. In its course it gives off muscular branches to the Peroneus Longus and Brevis and Cutaneous filaments to the integument of the lower part of the leg. (See Chart No. 30.) The Internal Branch passes in front of the ankle joint along the Dorsum of the foot, supplying the inner side of the great toe and the adjoining sides of the second and third toes, also supplying the integu- ment of the inner ankle, and inner side of the foot, communicating with the Internal Saphenous nerve, and joins with the Anterior Tibial nerve between the great and second toe. The External Branch passes along the outer side of the Dorsum of the foot, to be distributed to the adjoining sides of the third, fourth and fifth toes, also supplying the integument of the outer ankle and outer side of the foot, communicating with the Short Saphenous nerve. From the foregoing description of the nerves, it will be seen that every structure of the leg and foot is supplied with a number of nerves which are intimately related to these structures, and any malformation of the foot may cause pressure on these nerves, resulting in severe pain. Thus it is important that you have a knowledge of the nerves described in this chapter. CHAPTER XII THE SKIN AND NAILS Under this chapter we will consider the outermost structures of the foot, namely, the Skin and Xails, and also give a resume of the entire anatomy of the leg and foot in general. THE SKIN The skin may be regarded as a covering for the protection of the deeper tissues ; it is also an important excretory and absorbing organ. It is the principal seat of the sense of touch and the chief factor in the regulation of the body temperature. It consists principally of a layer of vascular tissue "named the Derma, or Corium (true skin), and an external covering of epithelial cells, termed the Epidermis or Cuticle. On the inner layer are found the Sweat Glands, Hair Follicles and Sebaceous Glands. (See Chart Xo. 31.) The Epidermis, or Cuticle, is an Epithelial structure forming the defensive covering to the true skin, and varies in thickness in different parts. In the soles of the feet it is thick, hard and horny in texture, as these parts are exposed to intermittent pressure, while on the Dorsum of the foot this layer is much thinner and exceedingly fine in. texture. The deep surface of the Epidermis is accurate^ molded upon the Derma. The superficial layer of cells of the Epidermis, called the horny layer (Stratum Corneum), is the layer most frequently involved in corns and callouses when subjected to pressure and friction. The Derma is a tough, flexible and highly elastic structure for the purpose of protecting the parts beneath from violence, and consists of fibrous connective tissues with a large admixture of elastic fibers, blood vessels and nerves. 88 THE SKIN AND NAILS 89 APPENDAGES OF THE SKIN The Hair. — Hair is found on every part of the surface of the body except the palms of the hands and the soles of the feet. A hair con- sists of a root, the part implanted in the skin; the shaft or stem, the portion projecting from the surface of the skin. The root at its extremity is bulbous and is lodged in an involution of epidermis called the hair follicle. Superficial Layers. §B Rete Mucosum. Papilla Corium. Fat Cells. ,< Fibrous Tissue. Sebaceous Glands.' 1 Hair Follicle g I Epidermis or S | Cuticle. erma or Cutis. Nutrient Artery, Chart No. 31 Sectional View of the Skin (Magnified). Sebaceous Glands are small sacculated glandular organs lodged in the substance of the Corium. They are found in most parts of the skin, but are wanting in the palms of the hands and the soles of the feet. The orifices of the ducts open most frequently into the hair follicles. The Sweat Glands or Sudoriferous Glands are the organs by which a large portion of the aqueous and gaseous materials is excreted by the skin. They are situated in the Corium and subcutaneous areolar 90 THE HUMAN FOOT tissue surrounded by adipose tissue. They are small, lobular, reddish bodies consisting of a single convoluted tube from which the efferent duct proceeds upward through the Corium and Cuticle, becomes dilated and opens on the surface of the Cuticle by an oblique valve- like aperture called a pore. The size of the glands varies and they are most numerous in the palms of the hands and the soles of the feet. THE NAILS The nails are flattened, horny structures placed upon the terminal phalanges of the toes. Each nail is implanted by a portion, called the Root, into a groove in the skin, the exposed portion being called the Body, and the anterior extremity the Free Edge. The nail has a firm adhesion to the cutis, being accurately molded upon its surface. The part of the cutis beneath the body and root of the nail is called the Matrix, because it is the part from which the nail is produced. The nails protect the terminal ends of the toes, and are subject to many malformations due to the pressure they receive from shoes, etc. GENERAL REVIEW This concludes the description of all the soft parts of the leg and foot. I will now give you a basis upon which you may distinguish and clearly understand how the various malformations occur. Let us now look over the foregoing pages and review in general the anatomy of the leg and foot. First the bones of the leg and foot were described as they make up the framework of these parts, then the ligaments were considered, being the structures which keep the bones in their position ; after that the muscles and tendons were fully described, as they are the structures which produce movement of the different bones. Then the blood vessels, such as arteries and veins, were described, as it is their function to supply these struc- tures with nourishment and, ultimately, the nerves and the outer covering of these parts; thus giving you a detailed description of the lea: and foot. CHAPTER XIII COMPARATIVE ANATOMY The purpose of this chapter is to compare the foot with the hand, the foot being the distal member of the lower extremity, while the hand is the distal member of the upper. By such a comparison we obtain the most valuable aid in the comprehension of its structure. It has been stated on several occasions that the foot is merely a hand altered by the functions of support and locomotion which it is obliged to perform. While it is generally true that the feet and hands are constructed Upon similar plans, it must be remembered that the differentiation evolves from the animal series. The similarity of the anterior and posterior extremities of a quadruped, such as the horse, for instance, disappears to a consid- erable extent when the anatomical structure is minutely examined. Also, in quadrupedal locomotion the posterior extremities are the ones most active in propelling the body, the anterior limbs being chiefly for support and equipoise. The impression of the fore feet of an unshod horse is different from that of the hind feet, due to the fact that, as the fore limbs come to be more used for the purpose of prehension and dexterity, the dif- ference in structure is more pronounced. The higher apes were improperly called quadrumana; for no animal, zoologically speaking, has four feet anatomically similar; nor has any animal four organs that can be called hands. The differ- ences are various according to the adaptation of the anterior and posterior members for the special activities of the animal. The bones of the Carpus are never found to be the same as those of the Tarsus, varying either in number or in the union of the various osseous elements. There is not, properly speaking, any 91 92 THE HUMAN FOOT Chimpanzee's Hand. Chimpanzee's Foot. Human Hand. Chart No. 33 Comparing the Human Hand and Foot with the Ch Human Foot. impanzee's. COMPARATIVE ANATOMY 93 opposability of the great toe in apes, as it cannot be carried around and placed at will against the various other toes;, but is set at a wider angle than the others in order that it may be used like the curve of a pincers, or of a cramp-iron, for grasping and climbing. The posterior extremities of apes are merely feet adapted for walk- ing upon trees, the resemblance of the foot or "hind-hand" to a true hand being only skin deep. There appears from the structure of the human foot no reason to doubt that it has been developed from an organ adapted for the same use. Strong evidence of this is found in the fetal condition of the foot, which approaches in many respects that of the Anthro- poid apes, there being less development of the heel, an arrange- ment of the joints which permits more inversion of the sole, and a difference in the .corresponding length of the first and second Metatarsal bones, indicating that the adult condition in which the great toe is as long or longer than the others has been gradually acquired. Chart No. 33 shows the hand and foot of the chimpanzee con- trasted with the same members in the adult man. In the gorilla the resemblance to the human hand and foot is still greater. The feet of a child that has never walked show decided dif- ferences in power of using the toes, there being considerable grasp and the same imperfect opposability of the great toe as is seen in the apes. The markings on the foot of a child that has never worn a shoe, nor stood alone upon its feet, resemble somewhat those of the palm of the hand, indicating considerable freedom of flexion and a certain amount of independent use of the great toe. They almost entirely disappear after the foot is used as a sup- port. The power of the great toe may, however, be kept up if the feet are not confined, and many savage tribes use the feet for grasping. Among Australian savages this grasping power is of great as- sistance in climbing trees, and they habitually pick up a spear or similar object with the foot. Nubian horsemen are said to use the 94 THE HUMAN FOOT reins, and Chinese boatmen to pull an oar, by means of the great toe. Occasionally persons may be found who are either born with- out hands, or losing them early in life, have acquired the habit of using the foot for various acts ordinarily performed by the hands, and can thread a needle fas the Hindoo tailors), use scissors, or even write with the toes. The fact that walking' in the erect position is learned only with difficulty shows that it is a late acquirement. The main characteristics of the human foot are. therefore, those which adapt it for support and locomotion. For this purpose a most beautiful structural arrangement has been effected, combining great strength with peculiar elasticity and lightness. The bones are set in the form of a vault, supported at the points connected by arches, two of these starting from the same point of the heel (the Tuberosity of the Os Calcis) and extending forward, one to the ball of the great toe (head of first Metatarsal), the other to a corresponding point on the little toe. These arches are known as the Inner and Outer Longitu- dinal. The third arch is transverse, connecting the anterior ends of the longitudinal ones. (See Charts of Arches in Chapter IV.) The Inner Longitudinal arch is formed by the Os Calcis behind the first, second and third Metatarsal bones, the Cuneiform and Scaphoid bones in front, with the Astragalus set at the vertex as a keystone. The Outer Longitudinal arch, which is nearly flat, is formed by the Os Calcis, Cuboid, and two outer Metatarsal bones, which articu- late with it. The transverse arch is formed behind by the three Cuneiform bones and the Cuboid, in front by the Metatarsal bones. It should be noted that the curvature of the arch diminishes as the toes are approached until it reaches the heads of the Metatarsal bones, the weight being fully upon them all. The imprint of a normal human foot shows this clearly. The height of the arches forms the instep, a feature peculiar to man, and which varies considerably in different races, being generally higher in the Indo-European than in others. Arabs are said to boast that their insteps are so high that water will run under them without COMPARATIVE ANATOMY 95 wetting the sole. The Andalusian instep is said to be famous. A popular saying has it that the foot of the negro is so flat that it makes a hole in the ground. A very amusing proof of this primitive condi- tion of the negro foot may be noticed in Southern cities where, during the heat of summer, it is customary to wet the pavements in the even- ing. It is not unusual to see barefooted negro boys whose feet are so flat that atmospheric pressure makes them adhere slightly when applied to the wet and smooth pavement, in the same way that a boy's leather sucker adheres to a smooth stone, and it is a favorite pastime with such gifted individuals to walk the streets producing a somewhat startling report every time the foot is withdrawn from the pavement. It is, perhaps, not without some reason that the height of the instep is considered a mark of aristocracy, as it appears to be one of the signs of complete adaptation to the erect posture and to locomo- tion in that position. Man is the only animal that has the feet placed at right angles to the axis of the body, most mammalia not touching the ground with the Os Calcis at all. The horse, for instance, literally walks upon the points of the toes, the hoof being comparable with the nails of the human foot, and the hock or "knee" being the tuberosity of the Os Calcis. There appears to be some relation between this ascension of the Os Calcis and the fleetness of the animal, as those who are the most rapid have the bones so arranged that they walk merely upon the tips. If support alone were needed there would be no necessity for the Metatarsal bones and toes, as may be seen in those who have had them amputated. The anterior part of the arch is therefore for pur- poses of locomotion, and it may be noted that in running the heel is raised off the ground and the anterior part only is used, the ana- tomical relation of the bones to the ground being similar to that which occurs ordinarily in the foot of the hoofed animals. The great swift- ness and lightness of motion of a dancer is owing to her ability to dispense entirely with the posterior portion of the arch. Owing to this difference of formation the anterior and posterior 96 THE HUMAN FOOT pillars of the longitudinal arches differ — the posterior, being - for sup- port, is short, thick and strong, being of but one bone ; the anterior, composed of several bones, is longer, so that the motion of raising the heel can be quickly performed. The apparent length of the heel in the African race is caused by the flattening of the arch rather than by a real projection. Long heels are characteristic among any sufferers of flat-foot or broken down arch when the posterior portion is mostly involved, the Os Calcis is forced downward and backward and unless the weakened condition is corrected. The number of bones in the anterior arch greatly aids in the dis- tribution of the force, as one may see who will take the trouble to note the difference "in shock" which occurs when alighting upon the heels rather than upon the balls of the toes. We will now proceed to consider the complete structure of the foot as a whole, including its physiology and mechanical principles. CHAPTER XIV PHYSIOLOGY The human body is composed of different parts which are called organs. Although each organ has its own special work to perform, it also acts in harmony with the other organs. Thus this relationship which exists between the organs enables us to group them into sepa- rate bodies, which are termed "systems," namely, the Circulatory system, including the heart, arteries, veins, etc., conveying the blood to different parts of the body; Respiratory system, including air passages, lungs, etc., which are concerned in the act of breathing; the Digestive system, which deals with the digestion of food; the Excretory system, which rids the body of its waste products; the Muscular system, with movement, and the Skeletal system, with the support of the softer parts ; the Nervous system, including the brain, spinal cord and nerves, is the greater master system of the body, which controls and regulates the functions of the other systems. THE FUNCTIONS OF THE FOOT In its natural state, the human foot presents an example of the most perfect mechanism connected with the human frame. The frame- work of the foot is composed of twenty-six bones: the seven bones in the Tarsus, and the five in the Metatarsus, which unite to form the arch and give elasticity by yielding to pressure, and the four- teen bones which form the toes or phalanges. All of the fundamental tissues of the body enter into its complex parts, such as the ligaments, composed of fibrous inelastic bands which unite the bones at the points of articulation; the strata of muscles arranged next to the bones which, by their contraction and relaxation, produce motion and locomotion, enabling the foot to bear the weight of the body; the nerves, extending in various branches from the t 97 98 THE HUMAN FOOT brain and spinal cord, through which messages are conveyed to the mind, knowledge of substances with which the foot comes in con- tact, and through which the power of the will is exercised upon the muscles, causing them to contract; the blood vessels which convey the blood to the different parts, nourishing and promoting their growth; the synovial membranes and bursae sac or capsules, which secrete a viscid liquid, lubricating the joints, preserving their normal state; the cellular and fatty tissues, which serve to cushion, giving the foot the perfect symmetry and artistic beauty with which all are familiar, and the skin and its appendages, which conform to, cover and protect the delicate structures beneath, and which contain nerves, veins, arteries, secretory and excretory glands, in direct relationship with all parts of the body system. When you realize the complexity of the structures, the complete- ness of every form of tissue involved in the physiological construction of the human foot, it is then clear what an important part of the body this is. MOVEMENTS The various kinds of movements which the foot is capable of per- forming are known as Flexion and Extension, Abduction and Adduc- tion, Inversion and Eversion : Abduction of the Foot. — Is the act of drawing the foot away from the center or median line, when acted upon by the abductor muscles. (Fig. 2, Chart No. 35.) Adduction of the Foot. — Is the drawing of the foot towards the center or median line of the body, when acted upon by the adductor muscles. (Fig. 1, Chart No. 35.) Flexion of the Foot. — Is the act of bending the joints when acted upon by the Flexor muscles. Extension of the Foot. — Is the stretching of the foot when acted upon by the Extensor muscles. Inversion of the Foot. — Is the inward turning of the foot. Eversion of the Foot. — Is the outward turning of the foot. The movements of Flexion and Extension are most marked at the PHYSIOLOGY 99 ankle joint, and are known as Plantar and Dorsal Flexion, respec- tively. With the foot upon the ground the leg- can be flexed on the foot until it forms an angle of approximately seventy to seventy-five degrees with the sole of the foot. When Dorsal Flexion is limited, as when the Tibia can be flexed only to a right angle, an abnormal condition exists, and the proper functioning of the foot is interrupted. \\ 'A „ >A- .Voluntary Adduction. Chart No. 34 Plantar Flexion of the foot is greater, extending to form an angle of about one hundred and fifty degrees with the leg, because of the con- vexity of the outer border of the pulley-like process, or Trochlear of the Astragalus. The interior portion of that bone is turned slightly inward when in full Plantar Flexion, and less markedly outward when in full Dorsal Flexion. This is clearly demonstrated by the outward 100 THE HUMAN FOOT thrust of the ankle when a person rises on tip-toes, the weight of the body preventing the toes being carried inward and, therefore, as Plantar Flexion progresses the ankle is forced outward. It can thus be seen by the above illustration that Plantar Flexion with Ad- duction and Dorsal Flexion with slight Abduction is normal at the Fig. 1. Involuntary Adduction. Chart Xo. 35 Fig. 2. Involuntary Abduction. ankle joint. Inversion and Eversion, in which the sole is drawn in- ward or towards the center and outward or away from the center, are the chief movements at the Sub-Astragaloid joint. With Eversion and Inversion there is also some Adduction and Abduction and rotation about a vertical axis. PHYSIOLOGY 101 The Astragalo-Scaphoid and the Calcaneo-Cuboid joints are usually spoken of as one, and called the Medio-Tarsal joint. The movement at this joint is about a vertical axis in the direction of Abduction and Adduction ; also rotation on an Anterio-Posterior axis, and movement on a Transverse axis, producing flexion and extension. The Arthrodial joints, which are anterior to the Medio-Tarsal joint, have only slight movements, but are necessary in the normal use of the foot. Any abnormality of the Metatarso-Phalangeal joints, espe- cially the first, may occasion serious loss of function of those joints. From the above the student will see that there are three principal axes of movement in the foot, namely, (a) Transverse, through the lower part of the Astragalus, in which the movements are chiefly extension and flexion; (b) Horizontal, extending anterio-posteriorly Chart No. 36 Manner of Walking — How Steps Are Made. through the. Sub-Astragaloid joint, where inversion and eversion are the most marked movements ; (c) Vertical, through the Medio-Tarsal joint, abduction and adduction of the fore foot being the movements most marked at this point. The advantage of the construction of the great toe is readily seen when it is learned that by its large size it forms a firm and solid base; and by its division into two phalanges, with two flexor muscles one to each, is effective in holding them down and keeping it straight in all its length. Motion in the first Metatarso-Phalangeal joint is chiefly in a plane downward and inward, away from the other toes and towards the middle line of the body. When at rest the great toe is drawn towards the other toes and slightly dorsal flexed ; in action it is never flexed or extended, is in a line with the foot, and abducted. Thus the space noticed between the great and second toes. CHAPTER XV MECHANICAL CONSIDERATION OF THE HUMAN FOOT Under this heading we must have a general review of the complete foot from the external surface. We have a member whose function is to supply means of locomotion to the body — a framework of bone Chart No. 37 Manner of Balance in Walking. supported by ligaments and muscles, and moved by muscles and their attachments through nerve impulses. With this combination the legs and feet in walking form a combined system of levers that work together. The ground under the feet is a fulcrum to this system. It carries the weight of the body and any burden in addition to it, and 102 MECHANICAL CONSIDERATION 103 when we examine the foot in detail we find almost every bone forms a lever, and every articulation a fulcrum, to the contracting - muscles and force. It is now established that the body's weight and its burden is carried into the foot, that it has a power of movements that propel the body, and it is now necessary to review the inner Longitudinal arch, the shorter or outer Longitudinal and Anterior Transverse arch. (Charts Nos. 36 and 37.) Chart No. 38 Weight Is Carried at the Three Points. Then the weight carrying points on the foot are the heel and the heads of the first and fifth of the Metatarsals. The movements in walking then may be described as follows : (See Chart No. 38.) Starting from a standing position, the body in erect attitude, and leading with the right foot, the first thing done is gently to throw the whole weight of the body upon the rear or left foot, and as soon as the right foot is relieved it leads off, the right leg being stretched forward while the foot is being at the same time extended by the 104 THE HUMAN FOOT contraction of the muscles of the calf of the leg and sole of the foot, so that the sole as it advances remains nearly parallel to the ground. The right leg and foot being thus extended, the center of gravity- is, by the force of other muscles of the body, also gradually thrown forward, while the heel of the left foot by itself, and the contrac- tion of the muscles of the calf of the leg and sole of the foot, is raised from the ground, and the whole weight of the body for a moment of time is being placed upon the base of the left foot ; then from this point the weight is thrown forward upon the right foot, and in this manner uniform progression is produced. The action of the center of gravity thus gradually brought forward from the right foot, the left foot at the same time being raised from the ground, is then moved past the right leg when it is next extended, so that step by step the force and center of gravity moving from foot to foot gives the movements of the foot in walking. As will be seen in the illustration, the heel strikes the ground first, with the toes slightly pointed upward; the ankle joint is held firmly by the muscular groups, the latter yielding as the center of gravity is advanced, and as more an ' more weight is thrown on one foot by propulsion from the other. In the method of walking and stepping lively there is a tendency to involuntary adduction to the fore part of the foot, but where a person walks slowly, lingering along, in order to maintain the equilibrium, the foot assumes an abducted position, and this position is a forerunner to weakened arch and later flat foot, due to the inward and downward rotation. ( See Chart Xo. 39.) Therefore, it can be seen that from a standpoint of flat foot it is less liable to occur in the fast walkers than those persons whose occupation or habits cause them to walk slowly and with the feet in an abducted position. The flexible, graceful movements of the feet in walking are due to the many anatomical points which we have considered in their structure. The Longitudinal and Transverse arches permit of con- siderable grace and elasticity to the steps, also give a fulcrum, strength and stability without diminishing the graceful, elastic move- ments. It is also through these many articular points that fracture of the foot is less liable. MECHANICAL CONSIDERATION 105 There has been much discussion as to the correct manner of walk- ing, whether the heel or toe walking is more correct, but it would appear from the careful study of the feet that as long as the heel reaches the ground at every step, the strong tendons and a soft pad covered with thick skin, makes it better adapted than any other part of the foot for contact with the ground. Perhaps this is not the Chart No. 39 Straight Leg Walking (After Bradford). A — Toe Walking. B— Heel Walking. reason for believing that the weight of the body is intended to fall upon the heel in walking, but it is admirably adapted for sustaining the weight of the body as it falls and is transmitted to the ground. When one has taken a long walk, and is quite fatigued, there is a natural desire and tendency to stand with legs spread, relaxing the 106 THE HUMAN FOOT muscles of the legs, and on doing so the toes are thrown outward, the muscles are relaxed, and the ligaments through their stretching and bracing action relieve the muscular pressure ; therefore, it is seen that the ligaments give support to the structures when the body is in a passive state, but ligaments are not adapted for a prolonged strain, and whether it be in walking or prolonged standing they must be relieved, otherwise their tone and strength is lost and flat foot develops. I have often had the point raised as to whether the well formed feet of the present date should be straight on the inside from heel to toe. It is true that in infancy the point of the great toe projects from the other toes, so that a straight line can be drawn through the center of the great toe and heel, but as the bones form and develop there is an enlargement of the Tarsal bones, increasing of thickness of the foot, owing to its mechanical covering, the shoe, and it gradually assumes a more pointed shape. Whether or not a shoe built over a last to conform to the theoretically normal foot would be practical on the present day type of feet of adults, who for many years have worn pointed shoes, is very doubtful because it would require a re- building or reforming action to the structures, which could only be accomplished by gradual change extending over a long period of time. The mechanical action of footwear is a deep study and one which requires close observation in each individual case. It is not at all difficult to interest the reader on a subject of this kind who recognizes that upon the foot depends greatly the physical well being of the body. When one considers the anatomy and physiology of the body, he can readily appreciate the close relationship of the feet to the other parts of the body — circulatory and central nervous systems are two of the important parts to be considered. This can readily be compared with the consequences arising from cold, wet feet, how they cause discomforts in wear and tear to the body, and how when the feet give rise to pain and discomfort one will decrease his daily exercise of walking. A weakened arch, a flat foot, or metatarsalgia, and all of these conditions give rise to bodily dis- comforts. Nervousness, stomach disorders, pelvic disorders, indiges- MECHANICAL CONSIDERATION 107 tion, headaches, spinal deformities, drop shoulders, rheumatics, neu- ralgia, and many other diseased conditions can be directly traced as caused by the feet, and thus one who is making a study of the feet can feel himself a humanitarian by providing relief and correcting any of the various minor foot deformities which can be consistently treated by mechanical means, and any cases which he cannot properly treat should be referred to the physician and surgeon. CHAPTER XVI EXAMINATIONS Believing that some procedure should be followed in making examinations, in order to facilitate diagnosis and diminish the fre- quency of errors, I have outlined the following : If in the shoe store, a quick examination can be made without removing the stocking, although for accuracy it is essential that it be removed. There are various ways of detecting foot trouble so as to be able to impress the patient that you are capable for the work. Inspection. — The patient's legs and feet should be minutely in- spected to discern the following abnormal conditions : a limp, abduc- tion of the foot, wearing of the shoe over the Internal Malleolus, prominence of the Inner Malleoli; if the feet are parallel or divergent when the patient stands; if the soles are flat on the ground, or are turned upward; if any of the joints, especially the first and fifth Metatarso-Phalangeal, is prominent through the shoe. Notice if the inner sole of the shoe is smooth or contains indenta- tions ; if the sole is worn through at one point while scarcely touched at another; if the great toe has forced a cavity or opening in the toe of the shoe, because too short. Another positive means without remov- ing the stocking is by palpation over the Dorsum and Plantar surface for any irregularities. History. — After a thorough inspection has been made the patient should be questioned to obtain a history of the case : information regarding recent illness and injuries; the occupation; customary use of the feet; the amount of dancing and participation in athletic events, and of what nature ; how long ago the feet were well, and when the present trouble began; if the patent was ever troubled before, and if entirely recovered; if the complSnt is that of weakness, or fatigue, or of pain; if the feet burn; if the pain is continuous or worse at 108 EXAMINATIONS 109 times ; if the latter, what appears to influence it ; if it is due to use of feet ; if so, of what kind and how much ; if it is worse in the night or morning; if it affects one or both feet; if one was affected before the other ; if they are both affected now. Inquiries of the family or Chart No. 40 Manner of Examination with Stocking Removed and Testing for Weak Foot Condition. personal history should be made in order to determine if there is any trace of constitutional diseases, such as tuberculosis, gonorrhea, syph- ilis or rachitis. As rheumatism and gout play an important part in localized foot troubles, inquiry should be made relative to previous 110 THE HUMAN FOOT treatment, as this will facilitate in determining- what treatment the patient requires. In making- complete examinations both feet and legs above the knee should be bared. Then the shoes should be carefully inspected, locat- Chart No. 41 Pointing Out Spreading of Foot Between First and Fifth Metatarsal, in which Case the Support is Elevated Between the Two Points. ing the parts most worn on the soles and heels ; noting if the uppers are stretched, consequently overlapping the heels on either side; if the sole on the inner side and heel are on a straight line; the height of the heel should be compared with that of the sole, to note whether EXAMINATIONS 111 there is even pressure at the heel and at the ball of the shoe, and if the center of the heel is under the center of the weight-bearing part of the foot. As stockings are a common evil in causing foot troubles, it should be given due consideration, thus a careful examination of them should also be made. It should be noted if they are damp ; if they are pointed; if they constrict the toes, and if so they should be drawn away from the Distal end of the Phalanges. The color of the skin should be observed to determine if the blood supply is faulty. The patient should then be told to stand, and the position of the toes noted : if they are flat on the ground, flexed, hyperextended or parallel ; Chart No. 42 Testing for Fiat-Foot. if there is a hallux valgus ; if the fore foot presents a flattened-out ap- pearance ; if it is unusually wide ; if there is a concavity or a bulging beneath the tuberosity of the Scaphoid. It should be noticed if the Malleoli are well defined, and if the outer one appears to be in its normal relation to the inner one, or is apparently advanced. EXAMINATION OF THE FOOT When examined from behind, does the Tendo-Achillis run in a ver- tical line down to the Os Calcis, or does it deviate to one side ; are the depressions on either side of the heel cord normal; and is the heel 112 THE HUMAN FOOT spread out on all sides? The patient should be asked to rise on his toes, and observed if it is done easily and without exertion. It should be noticed if the dome is heightened, or the ankles are thrown upward and outward; also if the patient can stand on the outer borders and invert the feet. Chart No. 43 Testing for Mobility in Tarsal Region. PALPATION The person making the examination should be seated in a chair lower than the one in which the patient is seated. The foot, if only one is complained of, should then be placed on your knee in such a way that the entire leg is relaxed and in a comfortable position. By feeling it will be noticed whether the local temperature is normal. The foot should then be examined carefully for evidences of friction EXAMINATIONS 113 or uneven pressure, such as corns and callouses; if there are any cal- losities present under the fore foot and are they beneath each one of the five Metatarsals or beneath only the middle three ; if there is a callous formation along- the outer border of the foot, or around the margin of the heel; if there is a bunion over the first Metatarso-Pha- Chart No. 44 Examination Shows Weak Foot. langeal joint, and also for ingrown toe-nails; the condition of the circulation of the foot. In a normal foot the lower posterior angle of the Internal Malleolus and the inferior external tuberosity at the head of the first Metatarsal should present a straight line connecting the two points with the tuberosity of the Scaphoid slightly above; 114 THE HUMAN FOOT also the Tarsometatarsal joint of the first toe is normally at middis- tance of the inner border of the foot, and if upon measuring it shows a lengthening- of the posterior half it indicates a lowering of the arch. If the toes are deformed they can be straightened by passive movements. The motion at the Medio-Tarsal joint can be ascer- tained if the Os Calcis is firmly held in one hand, with the tuberosity resting in the palm, and grasping the bone with the thumb and fingers Chart No. 45 Showing How Test is Made for Adhesions About the Medio-Tarsal Joint in Cases of Fiat-Foot. to arrest its movement, then with the other hand the motion can be felt by manipulating the foot. Inversion and eversion can also be tested by holding the leg firmly above the ankle with one hand and with the other grasping the Medio-Tarsal joint, manipulating the foot as above. Xext the ankle joint should be tested, and in order not to be mis- EXAMINATIONS 115 led by flexion and extension at the Medio-Tarsal joint, the foot should be firmly held, so that the Os Calcis moves at the same time with the Metatarsals. The foot should then be moved in a plane vertical with that of the leg; otherwise abduction in Dorsal flexion will exaggerate the true angle of flexion. With the foot in a position of rest, the range of active movement of all the joints can be determined. PAIN Although pain is not of essential importance in making a diagnosis of a normal or diseased foot, it aids materially in making a differen- tial diagnosis. Therefore painful spots should be definitely located. Pain that is caused by pressure over diseased or injured bone is usually more clearly defined and more readily located than the pain Chart Xo. 46 Heels Worn Down on Inside Indicate Weak Foot. from pressure on a strained or ruptured muscle or ligament. Muscles and ligaments that are strained or ruptured are always painful if stretched, and in a ligament pain is produced only by separating the ends ; but contraction will produce it in a muscle. When there is pain upon pressure over the body of the Os Calcis it is usually due to disease or injury to those bones. Pain over the Peroneal Tubercle on the external surface of the Os Calcis is due to tension of the 116 THE HUMAN FOOT synovial sheath of the Peroneal tendon dragging it away from its attachments to this tubercle. In cases of everted feet the pain about the External Malleolus is due to a crowding of the tissues against the External Malleolus from malposition of the Tarsus. Inflammation or strain of the Medio-Tarsal joint may produce pain about the inner side of it. Depressed Metatarsals in cases of Morton's Toe or Meta- tarsalgia, where pressure of walking has caused irritation, are painful to the touch and each one should be examined by pressure. CHAPTER XVII WEAKENED FOOT Under this heading I will endeavor to point out for the practi- tioner of mechanical orthopedics certain varieties of flat-foot condi- tions which I have found to be most prevalent, and I will commence by pointing out the weakened foot type of feet. Chart No. 47 Weak Foot, Although when Weight is off Foot Appears Normal. Weak foot consists of only a slight change in the structures when weight is placed upon the foot, and this condition is due to ligamen- tous causes. There is an abnormal laxity of the ligaments, which permits the weight as it is thrust into the foot to depress the Longi- tudinal arch and to cause a slight abduction of the foot, and while .the feet controlled by the muscles and connecting tendons are ap- 117 118 THE HUMAN FOOT parently normal, they are not afforded the protection against strain for which the ligaments provide when they are normal. Weakened foot is characterized by pain and sensitiveness through the heel and ankle and Internal Malleolus. There is a burning sensation on the sole, and the patient complains of the toes feeling cramped, of swelling through the ankle, aches in the calves, general fatigue and bodily weariness after much standing or walking. Chart No. 48 Testing for Weak Foot. When a patient stands, the foot has a tendency to abduction, and slight pronation is present. There may be an extreme tendency towards weak ankles. The patient may complain more of weak ankle than of the pains. Walking is dispensed with as much as pos- sible, and a constant fear of stepping on pebbles or over cobblestones is always present. Shoes are soon thrown out of shape, owing to the spreading tendency of the structures. WEAKENED FOOT 119 This acute weakened foot condition is found among men, women and children, and especially pronounced among growing children be- tween the ages of eight and fourteen. This condition is very infre- quently discovered by the patient before the latter stage of flattened foot develops. When weight is taken off the feet the Longitudinal arch assumes a practically normal position. When weight is placed upon the feet the degree of flattening varies considerably, depending upon Chart No. 49 Correcting with Foot-Eazer Which Should be Fitted to Contour of Arch. the severity of the weakened condition of the Longitudinal arch. In some cases the arch sinks considerably. In others there is only a slight sinking in the posterior region. Again there is a marked rotation of the foot at the Astragalo-Scaphoid region. Weak foot is found very common the present day among both sexes of all ages and classes. Those who have made radical and frequent changes in height of heels are more susceptible, due to the 120 THE HUMAN FOOT ligamentous strain, but an immediate change in the height of the heel is to be avoided. Weak feet of this type are found among men and women and growing children. When weight is removed from the foot it is ap- parently normal, but when the patient suffering from weak foot places his body's weight on the foot a slight elongation and forward rota- tion takes place. Women who wear extremely high heeled shoes, and who do constant standing or walking, are more prone to this disorder. If •mechanical treatment is resorted to at once, permanent correction can be accomplished by means of an arch support. The arch support should be very carefully fitted so as to correct the displacement and weakness, and to hold the foot in a normal attitude. In this way ligamentous strain is immediately removed and the muscles given their full range of motion. Care should be taken to see that the shoe worn by a patient is of sufficient length and width. Treatment. — The treatment of the weakened foot condition is prin- cipally mechanical. In the early and incipient stages pads of felt or leather may give relief, but are objectionable, as they depend upon the shank of the shoe for their base of support. It is very rare indeed that the shank of a shoe will provide strength enough to support the padding intended to hold up the weakened arch. I have obtained best results with the foot-eazer type of support, which is light, resilient and easily adjusted to accommodate the weakened foot and restore and permanently hold the structures until the ligaments have assumed their natural strength and tone. For weakened foot condition the foot-eazer or arch support must be fitted with the foot held in its normal relaxed state so as to hold the foot structures permanently in their natural position. Relief is usually immediate, and cure is effected in three to five months 5 time. Low-cut shoes are to be advised against if ankles appear weak, although if they are worn the arch supports must be used at all times. Massage and tip-toe exercises are recommended as an auxiliary treatment. WEAKENED FOOT 121 WEAK FLEXIBLE FOOT Of the many disturbances in structural and weak conditions of the foot one of the most numerous may be classified under the above heading. The symptoms of pain and distress are practically the same as weakened foot or flat foot, although the change in contour of the arch is only apparent when weight is placed upon the foot. In a Chart No. 50 Weak, Flexible, High Arched Foot. relaxed condition the shape of the foot is normal, the Longitudinal arch being high, and is usually found among persons who have been accustomed to wearing moderately high heels. The position of the Tarsus is rather contracted to admit of the positioning of the height of the heel. This gives the Longitudinal arch a higher curvature. The peculiar arrangement of the bones of the foot that make up the arch where the weight is carried and the adjustment of the struc- 122 THE HUMAN FOOT tures to the poise of the foot with weight upon it necessarily produce extreme pressure to the Anterior Transverse arch. In weakness of the Longitudinal arch added pressure and weight are thrown forward and upon the Anterior arch. Symptoms. — The foot is usually soft and flexible. By grasping the Os Calcis with the left hand and producing pressure upon the Anterior Plantar surface the foot elongates and assumes a flattened position. There is usually a complaint of weak ankles, fatigue, pain and tenderness in the heel, frequent cramping of the calf muscles, and a sensation of discomfort about the toes as though the shoe had insuf- Chart Xo. 51 Fitting Foot-Eazer to Weak Foot, Arching it to Give Correction When Walking. ficient length. There is a burning sensation to the sole or ball of the foot and a general sensation of discomfort due to swelling through the ankle or dorsum of the foot. Again there will be no swelling or localized pain present. Many persons thus afflicted are not aware of the structural weakness, due principally to the fact that the foot bears no appearance of abnormality. Treatment. — In all cases of weak flexible foot the first essential is to restore and maintain the natural balance of the body's weight as transmitted into the foot. This is accomplished by fitting arch supports to the patient's feet, being particular to make adjustment high WEAKENED FOOT 123 enough to fit the inner longitudinal border, creating only normal pres- sure sufficient to maintain the natural positions of the bone struc- tures. The support should be arched from a point commencing at the external Cuneiform inward and upward to the inner border of the arch, touching the anterior point of the Os Calcis, the lower facet of the Astragalus, Scaphoid, and the inner and middle Cunei- form. In doing so ligamentous strain is removed, muscular activity increased and normal action replaced. For this condition I use the tri-spring arch support, or foot-eazer, which must be carefully fitted Chart No. 52 Pointing Out How Weight is Thrown Upon First Metatarsal Joint Owing to Weakne'ss of Longitudinal Arch. to hold the heel of the foot well back in the heel of shoe and thereby prevent spreading and elongating. In these feet are also found a weakened condition in the Anterior arch, due probably to the extra pressure imposed upon that portion of the foot. Care should be taken to learn whether or not there is any slight displacement in the Anterior arch, and if found an Anterior Metatarsal arch support should be fitted. The style of shoe worn by the patient, as regards heel height, should not be changed, although care should be taken in advising a shoe of sufficient length and width, with snusr fit through the heel and waist. 124 THE HUMAN FOOT ACUTE WEAKENED FEET Characterized by pains and sensitiveness through the dorsum of the foot, same occurring through the heel and ankle and at the Ex- ternal Malleolus. In these cases strips of zinc oxide adhesive plaster, and a small felt pad firmly strapped up in the highest point of the arch to serve as a temporary support, should be used in the beginning of treatment. After a short time a light weight arch support properly fitted should be applied. In any condition of weakened foot, especially those feet poised with a contracted or shortened heel, care must be taken to advise the patient not to change the type of heel previously worn. The shoes are to be fitted closely through the heel and waist to afford snug fit and aid in supporting the weakened foot. CHAPTER XVIII FLAT-FOOT— BROKEN-DOWN ARCH The above subject is also known as valgus, splay-foot, pes valgus, pes planus, talipes valgus. This subject must be of intense interest to the student and practitioner alike, as full use and restoration of these most useful members, the feet, depend upon the proper diagnosing, ex- CharT No. S3 First Condition of Flat Foot, Showing the Weakened Condition. animation and treatment. It is a condition so commonly found among all ages, all classes and both sexes that there should be a constant watch for the recognition of the deformity. The flexibility, the grace- fulness and the general health of the physical body depend greatly upon the watchfulness and care in the proper handling of these cases. Flat-foot would indicate from the description of the term, as gen- erally used, a flattening of the arch or sole of the foot with all the 125 126 THE HUMAN FOOT pains and discomfort due to a broken-down arch, strain or abnormal condition, which would be diagnosed as flat-foot, but many are unable to recognize it on account of the misleading descriptive phrase and medical term generally used. Under this heading, however, we would define weak, broken-down arch, flat-foot, talipes valgus, etc., as a con- dition where the natural arch of the Plantar surface is interfered with, and in some instances partially or entirely lost, and with the foot usually everted and abducted at the Medio-Tarsal and Sub-Astragaloid Chart Xo. 54 Acquired Flat Foot in Second Stage. joints. When we consider again the anatomy of the foot, and me- chanical construction of the foot, and that the function of the foot is as a lever to raise and propel the body, and that this body's weight must be maintained by its particular fulcrum, it can be more easily understood why the deformity is so prevalent. Let us, therefore, review the construction of the Longitudinal arch, or the inner and outer Longitudinal arch, or where the weight is carried into the foot, and remember that the bones of the foot are BROKEN-DOWN ARCH 127 given their principal support by the ligaments and are only controlled by the muscles and their attachments. It should then be evident that if the structure is insufficiently supported by the ligaments, the mus- cular power must be insufficient and the weight of the body cannot be carried and properly balanced by the foot. In flat-foot cases the ligaments, generally on the inner and plantar surfaces of the bones, become strained and stretched, allowing the joint surfaces to separate at the bottom while at the top they are forced together. Flat-foot can be divided into four distinct conditions : First, the weakened foot just described. Second, the acquired flat-foot. Third, the congenital flat-foot. Fourth, the traumatic. Of these four, acquired flat-foot is most common. I could describe many varieties under the heading of acquired flat-foot, but with illus- trations and descriptions will endeavor to cover the subject as briefly as possible. ACQUIRED FLAT-FOOT In the first place I shall describe the form due to long standing, constant walking, weight-bearing and physical deficiency, which is the acquired form of flat-foot. With the acquired flat-foot the natural springy and flexible action of the foot is soon lost, and the patient notices the inability of constant use of the foot, with pain, and within a short time a gradual or complete change in the structure takes place. There is not always a complete flattening of the arch, but always a slight displacement of the Astragalus, which rotates inward and downward upon the Os Calcis, depressing its anterior and internal border until its movement is checked by the ligaments connecting the bones. The Scaphoid is also depressed, causing a further depressed condition of the arch, especially in the more severe cases where the entire sole of the foot touches the ground. The weight being transmitted by the Tibia upon 128 THE HUMAN FOOT the Astragalus, the displacement occurs at the inner Malleolus. The ligaments and supporting" muscles become stretched and weakened so that there is a gradual subluxation of the various articulations. Natural motion is gradually lost, the ankles are weakened, and by degrees injury is done to the articular surfaces, which is found in the thickened periosteum and cartilage. The foot is considerably length- en art No. 55 Severe Case of Acquired Fiat-Foot. ened and, on ac mr' c its weakness, also spreads in width The greatest amount p sion, however, is at the inner border of the Longitudinal arch. - 1 ch is due to the depression of the Astragalus inward and doi Arcing the remaining Tarsal and Metatarsal bones forward, while . , )s Calcis is forced downward and backward. BROKEX-DOWX ARCH 129 There are several degrees of acquired flat-foot. The first degree, or the incipient stage of flat-foot, is where, as we will remember, the displacements of the arch are naturally restored when the patient is seated, and when weight is removed from the feet. The latter condition implies that undue strain has been placed upon the ligaments rather than on the muscles. Chart No. 56 Acquired Weakened Foot, Early Stage. The second degree, or pronounced flat-f- 'cen-down arch, is where the bones of the arch of the foot c sb fe . / displaced and natural restoration of the arch is not accomp 1 when the patient is seated and the weight is removed from L . In this condi- tion there is considerable displacement of uie b n es and spasm of 9 130 THE HUMAN FOOT the Feroneal muscles, and by the displacement of the bones mus- cular action is interfered with. In this stage it will be noted that the normal motion of the foot is considerably diminished. There is more or less swelling- of the foot, and a slight deformity may exist. In Chart No. 57 Acquired Flat Foot. the third degree the deformity is accompanied by rigidity. There is more bone displacement downward, and the foot assumes a flattened appearance. The patient is unable to raise himself on tip-toes, and has the characteristic flat-foot attitude and flat-foot gait in walking. BROKEN-DOWN ARCH 131 Under this heading could also be mentioned the extreme rigid or osseous flat-foot, in which condition the position of the bones has changed. It is very difficult to successfully treat these cases, and great care should be exercised in applying mechanical aid. Osseous flat-foot is the result of unrelieved eversion and abduction ; it may or may not be a painful condition, but when it becomes firmly Chart No. 58 Acquired Flat Foot. established and there is no movement in the Intra-Tarsal joints, the pain arises from uneven Plantar pressure. As all the finer accommo- dating movements are lost, the bones cannot be shifted to accommodate themselves to alterations in the plane of the body containing the center of gravity, or to changes in those surfaces upon which the foot rests; therefore, callouses will form at those spots receiving the greatest 132 THE HUMAN FOOT weight, the pain conforming to the extent or condition of these cal- louses. In this deformed condition (which is a true flat-foot) the foot has lost all of its normal functions except that of support, which is in- animate rather than physiological. In some cases the pain is never Chart No. 59 Sole Impression of Flat Foot. Sole Impression of Normal Foot. severe, and in other cases the patient, having accommodated himself to this condition, is unaware of the existing deformity. Upon examination will be found a prominence at the head of the Astragalus, Scaphoid, and at the Internal Cuneiform, which is due to 3. partial dislocation. When the patient stands in bare feet there is a BROKEN-DOWN ARCH 133 decided abduction and pronation, and usually a swelling about the ankle and dorsum of the foot. Chart No. 60 Black Spot Shows Location of Pain. The arch is lowered and considerable pressure is brought to bear upon the inner border. The External Malleolus is depressed and points forward, while the Internal Malleolus becomes more prominent. Chart No. 61 Fiat-Foot, with Finger Pointing to Callous on Great Toe. Symptoms. — The earliest symptom is usually a sensation of dis- comfort, of tire, strain and general fatigue ; complaint is made that the shoes previously worn do not feel as comfortable, and not infrequently 134 THE HUMAN FOOT the sufferer purchases various styles and sizes of shoes, seeking relief. There is pain in the heel similar to stone bruise. There is a dull ache in the legs, pain in the knee and pains extending into the thigh, hips and back. There is a general tired, weakened sensation throughout the body, frequently loss of ambition and ability to make any progress either mentally or physically. The foot feels stiff and clumsy, as the finer flexible movements are completely lost. The patient soon finds that the habit of walking is changed to that of riding - on street cars or motors. The feet have lost their Chart No. 62 Showing Weakened Posterior Arch. springiness, and there is a general nervous disorder. There is an enlargement of the great toe joint; corns, cramped toes and cal- louses appear; the feet sometimes feel cold and numb, as the circu- lation is impaired. Again the feet perspire excessively, and there is a desire for standing on one foot and then on the other, also a desire to place the feet on some object, as the round of a ladder, edge of a desk, or round of a chair in an endeavor to obtain support. There is local tenderness and swelling, with pain, and there is a change of gait of the person ; instead of a quick, alert step, there is a slow, slovenly and dragging walk. Complaint is made of weak BROKEX-DOYVX ARCH 135 ankles. Shoes break open in the shanks, soon lose their shape, and heels are worn down at the inner border. Often the sufferer has pains simulating rheumatism and gout, and not infrequently diagnosed and treated as such. It is found among all ages, but principally those who are on their feet long hours and whose work or habits require them to remain in the same position. It is observed most frequently in the following occupations : Barbers, bartenders, porters, clerks, sales- Chaet No. 63 Severe Case of Flat Foot, Rigid Type. men, painters, plasterers, laborers, bookkeepers, policemen, motormen, street car conductors, nurses, etc. It is to be found more among persons who stand or walk slowly than those who walk rapidly. This is probably due to the necessity of obtaining a balance to the body in a tripod position, with the toes everted or abducted. This position permits an unusual strain on the ligaments which give way. DIAGNOSIS The most authoritative method of recognizing or diagnosing is by observing the attitude of the patient and the contour of the foot. Again, depressed articulations are manifested by callouses forming on the Plantar surface, sometimes at the heel, with a thickening and roughening of the skin, callouses at' the first and fifth Metatarso-Pha- 136 THE HUMAN FOOT langeal joints, and callouses along- the inner border of the great toe. Callouses at the latter point are caused by; the elongation or weakening of the foot, throwing dead weight and pressure on the distal phalanges and, in the endeavor of the foot to assume its correct attitude, pressure and irritation from the insole of the shoe is produced. Have the patient stand in stocking feet and notice the change of contour with the body's weight on and off the feet. In the examination, also, the hand should be inserted into the shoe and observations and examination of the inner sole made for location of depressions caused by the toes. In some instances the ball of the foot or the great toe causes a prominent indentation in the insole. If the symptoms are carefully studied and observed with the above sug- gestions, there will be no difficulty in making a proper diagnosis. CAUSES It has been found that the causes are principally mechanical; the strain and the pressure create a disturbance resulting in a weakness of the ligaments. The ligaments, when subject to a continuous strain, soon yield, so the causes are due to the strain produced upon the liga- ments. With the ligaments strained unduly, they are unable to hold the bones together, thus a slight separation at the articulations takes place, which in turn allows the bones to interfere with the muscular action. Long Standing. — Persons who have to stand much usually stand in an attitude of rest, with their feet slightly abducted. In a form of abduction we have seen that the inner edge of the foot is lengthened and there are no muscles actively contracting, so that the ligaments are strained to their utmost in their endeavor to keep the bones in their properly arched position. Excessive Weight Carrying. — Those who carry heavy weights, such as bricklayers, errand boys, mail carriers, ice men ; in such cases the muscles and the ligaments have to support heavy weights in addi- tion to the weight of the bodv. Illfkting, Improperly Made Shoes. — Shoes are probably responsible BROKEN-DOWN ARCH 137 for many cases of flat-foot. They may be termed as the predisposing and sometimes as the existing cause. The pointed toe, the shoe fitted too short and narrow, and the constant changing from one style of shoe to another, which change the articulations, have a tendency to weaken the ligaments. Chart No. 64 Severe Case of Fiat-Foot, Acquired. Heavy Weight Persons. — In obese persons, with excessive weight borne upon the feet, and the ligaments and muscles in a generally weakened, flabby condition, flat-foot very readily develops. Rapid Growth. — Children between the ages of nine and fourteen, a period when they grow rapidly and the tissues are expending their energy in progression, have little to spare to meet the extra exertion thrown upon them, and weak ankles and flat-foot develop. In this age flat-foot is very frequently associated with knock-knee and bow- legs. 138 THE HUMAN FOOT Short Limb. — Persons with a shortened limb caused by fracture, hip disease or other injury usually throw more weight and pressure on the one foot, producing excessive strain, and flat-foot develops. Chart No. 65 Flat Foot in Growing Child. Convalescent Patients.- — Those convalescent from acute and serious illness, find the structures in the foot unequal to the pressure of the weight imposed upon them and flat-foot results. Chart No. 66 Attitude of Child with Flat Foot, Associated with Bow Leg. Locomotor Ataxia. — Flat-foot is very common among these patients because of the impairment of muscular and ligamentous tone, and to the method of walking. They usually walk with a short rap which BROKEX-DROWX ARCH 139 tends to throw the posterior part of the Os Calais upward and the anterior end downward. This induces a gradual sinking and inward and downward rotation of the Astragalus, from which flat-foot results. Rickets. — Among children, flat-foot due to rickets and general health impairment, is very frequently noticed Gonorrheal Rheumatism, and general rheumatism, cause a weak- ness of the muscles and structures which allows the arch of the foot to become depressed. CONGENITAL FLAT-FOOT Considerable discussion arises over the correctness of congenital flat-foot. Although leading authorities disagree considerably on the subject, it has been shown that many cases are of congenital origin. Chart No. 67 Congenital .flat-Foot. The feet of new-born children are fiat, and although there is an in- herent tendency for the bones to develop and take shape and position of the bones in the well-formed adult foot, it is not until the child is of an age enabling it to walk that any noticeable development of the arch is apparent. This, however, can be explained by knowing that, bone formation in the infant is undeveloped but the heavy paddings 140 THE HUMAN FOOT of fat somewhat deceive the eye in the dourse of an ordinary examination. Congenital flat-foot gives little or no inconvenience to the patient other than the ungainly and ungraceful manner of walking. The foot is abducted, with the toes widely turned out, and with a considerable lack of elasticity and springiness possessed in the normal foot. There is a shuffling, dragging gait, and the foot presents an appearance very similar to that of acquired flat-foot, but there is more of a pronated position and downward sinking of the arch and less rotation of the bones at the Medio-Tarsal joint. Congenital flat-foot is often asso- ciated with bunion and hallux valgus condition, and a large percentage complain of no pain or disturbance due to the deformity. Others, whose history would indicate they were of congenital origin, com- plain of rheumatic pains in the feet, and also limbs, which most fre- quently occur during their later years of life. In some' instances the weight is carried upon the head of the As- tragalus and the foot is quite rigid. A form of ossification having taken place between the joints, these feet are very difficult to fit with shoes, and cause callouses and corns to form from the friction and pressure of the shoe. The treatment for these cases is practically the same as for acquired flat-foot in the more advanced degree. Manipu- lations, or massage, and forcible correction can also be used with success. TRAUMATIC FLAT-FOOT This type of flat-foot, or broken-down arch, is usually produced by a sudden fall, a blow;, or Aveight falling on the instep, jump- ing from a high distance on to the feet ; athletes striking on their feet in such a manner as to rupture and tear the ligaments, severe sprains, and any injury where the arches of the feet have been forced into the flattened position, causing displacement of the bones and complete or partial rupture of the ligaments and straining of the muscles. This is very evident in cases of Pott's fracture, or wdiere Pott's disease has not been properly treated. There is usually a displace- ment of the foot at the ankle joint, and unless properly treated in the BROKEN-DOWN ARCH 141 early stages, the weight of the body in standing and walking will further strain the attachments of the bones, causing a severe de- formity. There is a thickening of the skin and callouses form about the Internal Malleolus, with great pain when use of the foot is made. Chart No. 68 Traumatic Flat Foot, Caused by Fall From a Height. TREATMENT The treatment consists in restoring the bony structures, removing the strain and pressure, which is practically the same as under the head of acquired flat-foot, excepting that more direct pressure and complete restoration of the arches can be made with the aid of tri- spring or tru-span arch supports. CHAPTER XIX TREATMENT OF FLAT-FOOT The first object in mind is to remove the cause, to restore the foot structures to normal condition. The natural movements of the foot must be restored and maintained. Further, it is necessary, owing; to the weakened condition of the ligaments, which are unable to hold the bones in their proper position, that the arch be supported until this ob- Chart No. 69 Foot-Eazer Type of Mechanical Treatment of Weak Foot Applied to the Foot. ject has been attained. This method is known as mechanical treat- ment. Other treatments are bandaging with adhesive plaster, manipu- lating and massaging, exercise, complete rest, forcible correction (re- quiring hospital treatment), placing the feet in plaster of paris casts and operation or surgical treatment. Of these varieties, mechanical treatment is most successful because of the fact that persons with flat- foot are usually very active on their feet, and it would be impossible 142 TREATMENT OF FLAT-FOOT 143 Chart No. 70 Shoe Showing Effect of Flat Foot or Weakened Foot Where Pads Have Been Used. Chart No. 71 Same Shoe in Which Metal Support Bridges Weight from Heel Over Shank of Shoe. 144 THE HUMAN FOOT to give the medical or required hospital treatment to effect a per- manent cure. From my observations I have found numerous cases treated by forcible correction, use of plaster casts, and also rest cure, where pronounced symptoms of the former trouble would return upon active use of the feet. I have also known similar cases that have been subjected to me- chanical treatment, and have received immediate relief. Eventually the feet have been completely restored to usefulness, and this condi- tio m permanently maintained. The vast number of sufferers from this malady makes it important that a means of treatment be resorted to which will give quick relief in removing" the cause of pain and inability to use the feet, and gradually restore the foot to normal without the loss of time to the patient. With a properly constructed and fitted mechanical appli- ance we have a wonderful therapeutic agent, first, giving relief; second, removing the cause ; third, gradually rebuilding the structures ; fourth, stimulating muscular action and. fifth, permanently correcting the deformity. Owing to the vast number of theories advanced on what the proper support should consist of. I will briefly bring out what I consider the essentials in a mechanical aid for foot treatment, and I may mention in so doing that the appliances invented by myself have been used with great success in my own practice, and that of other leading physicians and surgeons. First. The appliance must be one that will give support and cor- rection to the foot quite independent of the shank of the shoe. Second. It should be constructed on anatomical and orthopedic principles. Third. It must be made of a material non-corrosive and non- rusting. Fourth. It must be constructed of a material and design which wdl permit the most minute adjustments to the requirements of individual cases. Fifth. It must be of the correct width and length to support the Plantar surface of the foot, and yet not interfere with the needed movements at the Metatarso-Phalangeal junction. TREATMENT OF FLAT-FOOT 145 Sixth. It must be so constructed that it can be worn in the regular type of shoe without destroying its shape, and the stock sup- port must be made in a range of sizes enabling quick and easy fitting and adjustment. Seventh. It must not be heavy, rigid or cause a feeling of encum- brance to the patient. Eighth. It should be made of light-weight materials for the light- weight person in incipient conditions, and more substantial for the heavy-weight persons with more developed conditions. With these essentials in mind I have carried out the construction of three models. First, a support made with the full supporting plate, having a rein- Chart No. 72 Tri-Spring Arch Support. forcing spring attached, which consists of an additional spring doubling upon itself in the center of the arch, forming a triple spring. The supporting surface of the tri-spring arch support differs from most arch supports in that the elevation of the inner border is more acute and is designed to supply greater force and elevation directly beneath the Astragaloid region. It has an inside flange and is leather covered to make fitting more convenient and to prevent displacement in the shoe. The outer surface of the plate extending under the outer Longitudinal arch is made lower, so as not to cause any pres- sure at that point. This support is indicated in the weak foot, the acquired, the congenital and traumatic types of flat-foot. It should be constantly 10 146 THE HUMAN FOOT borne in mind that the success of the appliance depends upon its careful adjustment and fitting. For the weak foot and the incipient stage of flat-foot, and in those cases of acquired flat-foot in their secondary degrees where Chart No. 73 Surgical Insole Plate for Flat-Foot. there is considerable sensitiveness, I use a double-spring constructed device made of springy German silver or silveroid so constructed that the top spring is free at the forward end, permitting a back- Chart No. 74 Surgical Insole Plate with Anterior Metatarsal Elevation. ward or sliding motion to the under or supporting spring and afford- ing resiliency, which is most beneficial in the rebuilding of the weakened and deficient arch. The forward motion permits of assist- Patented self adjusting feature"^ ^p~ Friction of Foot-Fazer top plate is on under spring Chart No. 75 Foot-Fazer for Weakened Arch, Incipient Flat Foot and Sensitive Feet. ing the articular action of the Anterior Metatarsal and Phalangeal articulations, and I use this, which is known as my foot-eazer, for flexible weak foot, for weakened foot and acquired flat-foot. It is TREATMENT OF FLAT-FOOT 147 especially recommended for the early stages where there is only a slight impairment of the ligaments noticeable, and where there are symptoms of weak foot development. The advantages I find in this Chart No. 76 Tru-Span Arch Support for Severe Cases. device are in its furnishing a quick and easy means of removing the strain and restoring the balance and equilibrium to the foot without resorting to the extreme measure in recommending change of shoes or Chart No. 77 Showing Tri-Spring Arch Support Fitted to Foot. requiring readjustment to the modes of walking. With the early symptoms of fatigue, cramping toes, aches and pains through the foot, a support which is easily adjusted will give immediate relief and re- 148 THE HUMAN FOOT store the foot so that the device may be discarded within a com- paratively short time. In the extreme rigid and osseous flat-foot and for severe cases where considerable resistance must be met, I construct a plate with a short depressed opening in which I insert a further strengthening plate, assembling the two to aid in furnishing the necessary support. This I term as tru-span, which I find most useful in the severer cases, And these three patterns, with the Anterior Metatarsal arch support, Chart No. 78 Tru-Span Arch Support for Heavy Weight and Severe Cases. afford the armamentary for all valgus conditions of flat-foot. These appliances are made of material that will permit the adjustment to each and every case, and which are undisputably necessary elements in the correction of foot troubles. As the subject of adjustment is a very important one in the treat- ment of foot deformities by mechanical appliances, I have written a special chapter showing how these appliances are adjusted to meet the requirement of each individual case. When the supports are TREATMENT OF FLAT-FOOT 149 properly fitted they should cause no discomfort and relief should be immediate, as the foot is held in a corrected position and the support becomes a positive aid in effecting a physiological cure. The length of time required to effect a cure depends upon the case, advancement of the weakness, mode of walking and the style of shoe worn. Great care must be exercised in advising that the shoe be of correct length and shape, snugly fitted through the waist and heel. Modified heels are recommended where the patient has not become thoroughly accustomed to an extreme hisrh heel, in which event the height of Chart Xo. 79 Showing How Weak Foot is Supported with Foot-Eazer without Depending on Shank of Shoe. Xote How Foot is Drawn Back and Held in Position. the heel should be gradually lowered. The supports are best fitted to the foot of the patient and adjustments made regularly until a cure is effected. These appliances may also be fitted to outlined or penciled diagrams of the feet, which may be taken by having the patient seated with a sheet of paper placed under both feet on the floor, and pencil outline drawn around the foot. Then, without lift- ing the foot, have patient stand with entire body weight on the feet and a second drawing made around the foot, indicating thereon any prominence as Rotated Astragalus, extreme Pronation, long or short heel. Then a line is drawn between the first Metatarso-Phalangeal 150 THE HUMAN FOOT joint to the fifth Metatarso-Phalangeal joint on the diagram. The support is then fitted to accommodate these lines. In no instance should these appliances be fitted according to shoe size. They may be fitted and also made over plaster paris casts taken of the foot. I have allotted a complete chapter on how to take plaster casts so that the student may have full directions before him in the event that these should be necessary. Read carefully Chapter XXI on fitting of appliances. Chart No. 80 Method of Strapping for Flat Foot, Single Strap. Bandaging and Strapping. — While the use of bandaging and strap- ping is not practical for general use, in some instances of acute attacks adhesive plaster bandages can be successfully used. This is done by first having the patient seated and placing the foot on a stool, •with the foot abducted, over-corrected; a strip of plaster 14 to 16 inches long and 2 to 3 inches wide is applied to the outer side of the ankle just below the External Malleolus. The foot is again care- fully abducted and corrected, and the plaster is then drawn tightly TREATMENT OF FLAT-FOOT 151 beneath the sole and up over the inner border of the arch and attached to the inner side of the leg. A second plaster strip may be applied in the same manner, and then with narrow bandages this is stayed in place. This is sometimes used in the early stages and worn from five to ten days, after which an arch support is properly fitted. Great Chart No. SI Method of Strapping for Weak or Flat Foot, Double Strap. care must be taken in applying the bandages, otherwise the restoring action and articulation will be impeded. This method is also used by placing a felt valgus pad in position beneath the arch and held in place by similar bandages. Exercises. — Certain exercises mav be used after the early stages 152 THE HUMAN FOOT of weak-foot development, which are often beneficial. The object of exercising is to develop muscular action where there is a deficiency, but not until the ligamentous causes have been removed by proper Chart No. 82 Method of Bandaging with Strapping for Severe Flat Foot. mechanical treatment. Inverting the feet, that is, standing with toes in, and rising on tiptoes ten to fifteen times, first very slowly and then more rapidly as soon as accustomed, and extending and flexing the toes, are also very helpful in restoring foot action. CHAPTER XX METATARSALGIA— MORTON'S TOE Weakened Transverse Arch. — This condition occurs in the An- terior Metatarsal arch, or what is known as the Anterior Transverse Chart No. 83 Case of Metatarsalgia Showing Callouses on Sole. arch, which is formed by the Metatarsal heads and consists of a dome-like shape between the first and fifth Metatarsals. The de- 153 154 THE HUMAN FOOT formity consists of a slight displacement or depression of one or more of the Metatarsal heads, and while there may be no particular dis- placement in the early stages, there is a weakened condition in the supporting ligaments which permits slight displacements in walking, or when weight is thrown upon the foot. Morton's Toe and Morton's Neuralgia were first described by Morton of Philadelphia. Other typical cases of this painful affection Chart No. 84 Finger Points to Usual Location of Pain. of the foot occur with severe pain and a sudden cramp-like sensa- tion between the third and fourth, or fourth and fifth Metatarso- phalangeal articulations. The pain may begin with burning, tender- ness and swelling, extending through the Dorsum of the foot, and it frequently extends to the extremity of the toe and up to the foot and leg. In some cases the pain is preceded by a sensation of slipping or moving of the joint. Again it is of a mild character, and in the MORTON'S TOE 155 severe cases the cramp-like pain comes on with such suddenness and severity that the sufferer is compelled to remove the shoe, compress the foot and relieve the pain by extending the toes and by manipula- tion to relieve the cramp. It is by continued stretching of the capsular Chart No. 85 Outline of Foot, with Depressed Metatarsals and Callouses. ligaments that the sensitive synovial ends of the bones are uncovered and exposed to pressure. The pain and excruciating cramp are caused by the impingement of a branch of the digital nerve. As our anatomy shows us the protective tissue over the Metatarsus 156 THE HUMAN FOOT is very thin and a giving- way of the Anterior arch at this point results in many cases of the joints becoming permanently and partially dislocated and displaced. With the giving way of the Anterior arch undue weight is thrown upon the displaced and frequently dropped Metatarsal heads, causing callosities to form and the resulting burn- ing sensation on the sole of the foot between the first and fifth Metatarsals. There is also a thickening of the anterior part of the Chart No. 86 X-Ray of Weakened Anterior Transverse Arch Showing How It is Spread Laterally. foot and usually manifested by severe hallux valgus, overlapping toes, enlargement at the first and fifth Metatarsals and the formation of corns on the top of the distorted toes. These conditions are found more frequently among women than among men, partially due to the fact that shoes with narrow toes, tight across the anterior part of the foot, higher heels which force the foot into a wedge-like shape, all have weakening effects on the foot structures. Again, in some in- MORTON'S TOE 157 stances, history would denote that it is a family inheritance ; the affec- tion is usually extremely chronic with recurring pains, the cramp- like attacks coming at the most unexpected time. This condition is without doubt the most prevalent of any foot disorder, yet one which is rarely recognized until the severe stage of pain. Chart No. 87 X-Ray Print Showing Metatarsal^ and Spreading of the Fifth Metatarsal Bone. In this condition weak ankles, loss of balance, weakened Longi- tudinal arch and elongated foot are also found. In some cases the concavity of the Transverse arch is entirely absent, so that a prominent convexity is formed with callouses covering the entire area. It usually occurs in one foot, but sometimes in both feet. There is numbness and swelling and local pain, and temperature may be present 158 THE HUMAN FOOT with severe pain following through the foot, leg, thigh and back. When weight is borne upon the foot, the foot elongates, widens and spreads, and weight is then thrown upon the weakened or displaced Metatarsal, which may be the third, fourth or fifth. Upon examina- tion will be found redness, tenderness and callosities ; sometimes in Chart No. 88 Metatarsalgia, with Painful Callouses and Ulcerations. spots, or sometimes in small areas ■ covering one or more of the Metatarsal heads; oftentimes the tissues seem to be dense and offer more protection, but with the toes contracted and dorsiflexed. In a few cases small bony enlargements have projected from the heads of the Metatarsal bones, and in others fibrous growths have MORTON'S TOE 159 been found in the subcutaneous tissues. In any event it is the cause of weakness, strain, pressure and dislocation or displacement. Diagnosis. — Diagnosis of this condition is first usually recognized by the description given by the patient and history of the case. Cases where there has been an impingement of the Digital nerves, or where the cramps and pains have been sudden and severe, to make examination, the heel should be grasped by the left hand and with the toes extended, pressure produced, and a test made for mobility of Chart Xo. 89 Aletatarsalgia with Pronounced Thickening Due to Depressed Metatarsals. the foot; then with both hands, with the foot still at rest, cause pres- sure to the Metatarsals with the thumbs. (Charts Xos. 91 and 93.) Make a test to discern whether the natural dome-like arch is lost, and to locate the positioning of the depressed Metatarsals ; as the greatest average of pain is found between the fourth' and fifth Metatar- sals the examination must be very carefully made in this region. If the toes assume a cramped, dorsiflexed position, or appear to be con- tracted, there is usually a marked prominence of the muscles and tendons of the Dorsal surface, and there is external indication of 160 THE HUMAN FOOT irritation at the base of the fifth Metatarsophalangeal joint, and usually redness. If the shoe worn by the patient is examined it will be found that the upper leather spreads considerably over the sole, Chart No. 90 Black Spot Indicates Location of Cramp and Severe Pain. Chart Xo. 91 Showing Where to Test Anterior Arch. and that the sole at the tread is worn very unevenly. This is brought on by the widening and thickening at the ball of the foot. In many cases the examination would show a normal foot other than the weak- MORTON'S TOE 161 ness apparent when weight is placed upon the foot and a spreading noticed between the first and fifth Metatarsals. (See outline diagrams, Chart No. 92.) One of the most usual symptoms for diagnostic purposes is the contour at the Anterior arch, cramped toes and thickening of the sole with callouses. This condition is found among men, women and growing children. Chart No. 92 Showing Abnormal Spreading and Widening Between AA and En- largement at First and Fifth Metatarsal Joint. Lines BB Show How Foot is Made Narrower when Transverse Arch is Supported. Treatment. — The treatment indicated in these cases is mechanical. Surgical operations are very rarely resorted to. The treatment should be of a local order, with an object in view of restoring the weakened structure and replacing the displaced Metatarsals. This is best accom- plished by an arch support especially constructed, with its object to remove all strain and pressure, to maintain the natural balance by 11 162 THE HUMAN FOOT supporting the Longitudinal arch thoroughly, and giving the right adjustment to the Anterior arch. The appliance which I have used since 1906 for this purpose is known as my Anterior Metatarsal arch support, which is constructed of a light-weight silveroid alloy metal, peculiarly shaped to fit the heads of the Metatarsals, having a wide Chart No. 93 Testing Foot for Anterior Arch with Thumbs. bearing point and a dome-like curvature between the first and fifth Metatarsals. The success of this support lies in the adaptability to the various conditions found in each individual case, which must serve to firmly support the Longitudinal arch, thereby removing consider- able weight and pressure from the Anterior arch. The plate must be MORTON'S TOE 163 Chart No. 94 Applying Anterior Metatarsal Arch Support with Flange to Foot for Size. Chart Xo. 95 Anterior Metatarsal Arch Supports in Three Patterns. 164 THE HUMAN FOOT of a full length, or nearly a full length from a point }i inch back of the Metatarso- Phalangeal articulation, extending back to the heel ; the degree of elevation to the Anterior arch depends upon the condi- tion of the foot. In mild cases restoring the natural dome of the Transverse arch is sufficient. In other cases an added elevation must be produced directly behind the displaced Metatarsals. Again it be- comes necessary to produce an elevation egg shaped, the size of a walnut, which has a tendency to tighten the ligaments controlling Chart No. 96 Anterior Metatarsal Arch Support, Fitted One with Stocking, Other Without. the Anterior arch. Care must be taken in fitting and adjusting the arch supports for these cases. In the milder cases of callosities I use my Anterior Metatarsal arch support with the flange, and in incipient cases I use an Anterior Metatarsal arch which is so constructed as to give support only to the Transverse arch in the anterior region. Occasionally a felt padding with kiro pads and a band of adhesive plaster drawn around the waist of the foot will give temporary aid. Mechanical supports, however, are usually more satisfactory because they do not rely upon the shoe for a base of support or strength, as MORTON'S TOE 165 would be the case with felt or leather paddings. Paddings attached to the inner sole of the shoe have also been used, but are not so success- ful because of the serious difficulty in properly arranging the pad. Chart No. 97 Kiro Pad for Giving Mild Suppor) to Transverse Arch. Then again in many instances, owing to weakness of the Longitudinal arch, the position of the Anterior arch changes considerably in the process of walking, and when my Anterior Metatarsal arch sup- Chart No. 98 Padding with Felt Kiro Pads and Z. O. Tape. port is properly adjusted it serves as a passive support and assists in holding the foot in its correct position. I have used this treatment for nine years, and clinical cards show that ninety per cent of the 166 THE HUMAN FOOT patients have obtained permanent relief from the painful condition treated. Massage, forcible correction and careful judgment in fitting the foot to modified shoes are also necessary. The sensitive callouses may be removed by the chiropodist's method or with pedico callous Chart Xo. 99 X-Ray Showing Anterior Metatarsal Arch Support in Position to Relieve Severe Cramp in Third and Fourth Toes. Xote Plate Cut Away Under First Metatarsal Head. salve, but it should be borne in mind that the callouses are the result of the constant pressure and irritation of one or more of the Metatarso-Phalangeal articulations, in which a positive cure can only be assured by supporting the arch and removing the friction and pressure with the Anterior Metatarsal arch supports. MORTON'S TOE 167 A Typical Case. — To show the necessity of mechanical correc- tion, the history of a typical case is here given. It is the case of a young lady who was twenty years of age when the case was first brought to the author's attention. At the age of thirteen she became aware of pains in her feet and limbs, and developed extreme nervousness. Her physician said she had been studying too hard and advised a rest from school. Six months' absence failed to stop the nervous irritation or the cramps in her feet. Internal remedies and tonics did no good. A New York specialist prescribed gymnasium exercises, loose clothing and a dis- continuance of her studies. Finding no relief she consulted an orthopedic surgeon who recom- mended specially made shoes, which gave relief when first worn, but the trouble returned and she was advised to go to a hospital. There her feet were placed in plaster of paris casts for six weeks, the period of enforced rest bringing temporary relief. Soon there- after the pains and nervous condition returned. Then an orthopedic shoemaker came into the case at considerable expense to the patient for shoes and service, but she still obtained no relief. Some time after this the case was brought to the author's atten- tion, without any of the particulars being given him at that time relative to former treatments. The trouble was soon located, the young lady fitted to a pair of Anterior Metatarsal arch supports and told to walk around for half an hour to test the fit. Expressing great satisfaction at the com- fort 'and relief afforded, she admitted it was the first time in years that her feet had really felt comfortable. A week later she reported that she was still enjoying perfect foot comfort and entire relief from nervousness, together with great general improvement in health. The third week she had another pair fitted and was advised to purchase shoes that would fit the heel and waist more snugly and allow plenty of toe room. This she did and her report of over a month later expressed the greatest satisfaction. She said she had no pains or discomfort whatever and her health was excellent. CHAPTER XXI METHOD OF FITTING ARCH SUPPORTS I have so frequently been requested by students and by prac- titioners to give them an outline as to my method of fitting' corrective appliances, that I believe a chapter on this subject will be of great value and interest to the reader. It is very important to recognize that in mechanical appliances we have an armamentary of undis- puted value in the treatment of foot deformities, but the success of these treatments and devices depends greatly upon their application Chart No. 100 Arch Fitter and Rawhide Hammer to Take Place of Vise and Anvil. and upon the intelligent selection and fitting, adjustment and advice to the patient regarding their wearing. Using the words of a prominent orthopedic surgeon, "there is also associated in the minds of the laity and the profession that the treatment of all foot troubles is the question of arch supports. Few patients complaining of their feet come to the orthopedic surgeon who have not worn at least one of the variety on the market and, 168 FITTING ARCH SUPPORTS 169 PART OF ANVIL FOR CON FORMINO ANVIL MAKING ADJUSTMENT ON ANTERIOR META TARSAL ARCH SUPPORTS WOODEN PRESSURE BLOCK COVERED WITH LEATHER THAT IS PRESSED INTO HIGH PART OF ARCH ADJUSTING LEVER WHICH LOCKS AUTOMATICALLY AND HOLDS ARCH IN POSITION ADJUSTMENT SCREW FOR <^o£o LARGER 0R SMALLER SUPPORT IS PLACED FO R SIZES TO ADJUST PRES- ADJUSTMENT SURE OF THE BLOCK AGAINST ARCH SUPPORT Showing Chart No. 101 Mechanical Parts of Patented Arch Fitter. Chart No. 102 Diagram Showing Correct Length of Arch Support Leather from Point C to Line of Metatarso-Phalangeal Articulation A. Metal Extends Within f£ inch or at Line B so as not to Interfere with Ball Movement. 170 THE HUMAN FOOT although the practice of nnprofessionally prescribing arch supports should be unreservedly condemned, I should not be surprised if shoemakers and salesmen of these articles have cured as many pain- Chaet No. 103 Selecting Correct Length Flush with Rounded Fart of Heel to Metatarso-Phalangeal Joint. Chart No. 104 Diagram Showing Points to be Fitted with Arch Supports to Extend from A to B. ful feet as have physicians/' A statement of this kind confirms my belief that it is within the power of the shoe-fitter and the chiropodist to do much toward alleviating, through correctly fitted mechanical devices, the pains and annoyance caused by foot deformities, but it is FITTING ARCH SUPPORTS 171 certainly important and necessary to base the fitting and adjustment upon physiological and anatomical facts. Experimentation and "try this" or "that" method should not be resorted to. There are laws of balance, of gravitation, centralization and correction in this work that should govern us. We know fully too well how closely allied are the arteries, bones, nerves and important tissues of the foot to other parts of the body, and in the fitting of appliances these structures must be given consideration. I take it for granted that the selection of the arch support has Chart No. 105 Diagram Showing Shortly Fitted Arch Support Held to Foot. Leather Part Should Fit from A to B, while Metal Should Fit to C, to Span Weight Over Shank of Shoe. been made, as I firmly believe that properly constructed stock arch supports, when there is choice of selection, are in an average run of cases as practical and adequate as making supports from individual casts. (I refer to those made on practical and scientific lines.) The supports, however, must be built on principles that are orthopedically correct and must be constructed of material which will permit the 172 THE HUMAN FOOT necessary adjustment to be made. Now that we are supplied with the arch supports, without question the next point to consider is a means by which these particular adjustments can be made. I use a patented arch fitter and a steel rawhide faced hammer for the purpose of adjustments and fittings. (See Chart No. 100.) This arch fitter is constructed of malleable iron and steel to act as an automatic vise, having a steel conforming anvil and wooden pressure block and \ Y / Chart No. 106 Showing Foot-Fazer Fitted too Long. Correct Length is from Point A to B for Leather, while Metal Should Come to Point C. adjustment screw, with a lever for manipulating. (See Chart No. 101.) It affords a quick and accurate means of making adjustments without resorting to the blacksmith shop anvil method. (See Chart No. 114.) Although the beating out, or hammering to shape, plates of German silver, soft steel, brass, copper, etc., has been the old-time method of the bracemaker, I believe that to be efficient the orthopedist should be qualified to gauge his adjustment according to the condition of the case being treated. There are no two feet exactly alike, and it is FITTING ARCH SUPPORTS 173 not at all uncommon to find it necessary to make adjustment for one foot entirely different from that for another. This is very nicely handled with the use of this arch fitter. Selecting the right size and the correct length of the arch supports is of the utmost importance. Those varieties that are covered with leather for additional protection to the foot should be selected to extend from the point flush with the rounded part of the heel so the thinly skived point of the leather reaches the first Metatarso-Phalangeal joint. (See Chart No. 103.) Chart No. 107 Dotted Lines Indicate Where Most Pressure Should Le Given in Fitting Supports for x\rch Trouble. In the construction of my appliances I always allow three-eighths of an inch from the forward edge of the metal to the extreme edge of the thin part of the leather covering. In that way I may gauge my correct fitting by the lengths of the leather, as noted in diagram. (See Chart No. 103.) This shows the flush fitting at the heel and the articular point to avoid at the Metatarsal arch. I show in my diagram 174 THE HUMAN FOOT the stockinged foot, as it is more convenient and more practical as a rule to fit over the stocking. The arch support or foot-eazer should then fit in length from the heel part forward to the first Metatarso- phalangeal joint or at the ball of the foot where the foot bends. In the selection of the size of the arch support to be fitted to the weak flexible foot, where considerable elevation and adjustment is to be made, a longer size must be selected to allow for the shortening or drawing up of the appliance in the process of elevation. Care must be taken to obtain the correct length, as a shortly fitted appliance Chart No. 108 Care to See That Leather Extends Flush Under Heel Above Shows Fiat-Foot Properly Fitted so That Support Touches All Points Evenly. rests upon the shank of the shoe, which is insufficient to bear the weight, and in a very short time breaks down, creating a very poor appearance of the outlines of the shoe. Selecting the proper width is also very important. I find it necessary to construct the supports in two widths, wide and narrow, and this applies to the metal springs as well as the leather. Wide, short or fleshy feet should be fitted wide so that a substantial bearing point for the Plantar surface may be had, yet not so that the support will distort the shoe. If an all-metal plate or surgical insole be fitted it must then FITTING ARCH SUPPORTS 17= .be fitted three-eighths of an inch behind the Metatarsophalangeal joints. There are variations to consider, especially where there is undue prominence of the Metatarsal head, from which pressure should be avoided. Now, with the arch fitter securely fastened so that it may be manipulated without shifting, you are now ready for adjust- ment. First select the size of support; then, placing the support against the Plantar surface of the foot, notice whether it touches all Chart No. 109 Showing Correct Length of Anterior Metatarsal Arch Support. Leather to Fit to Dotted Line. points of the Longitudinal arch evenly. The patient's foot is to be relaxed and the fitting done with the foot in a position of rest. If not, the necessary adjustments must be made. When the support is properly fitted it will touch all points of the arch smoothly and evenly, holding the foot in its correct position. Several adjustments and operations may be necessary on the support before it will absolutely fit the condition. When the fitting is made properly there is an 176 THE HUMAN FOOT evenly distributed, well directed pressure at all points which insures comfort and relief at once. Care must be taken that there is sufficient length of leather or a bit of metal plate immediately under the heel, so that there is a pad for the heel to rest upon. (See Chart No. 108.) If the arch is considerably displaced and flattened, so that the arch support appears too high, it is then best to commence the fitting by first lowering the support. To do this place the support on the con- forming anvil, metal part down, and with the rawhide faced hammer " '■"' ^\C ' -• "' ! 1 / Chart No. 110 Placed to Plantar Surface to See What Adjustments are to be Made. tap the top side of the leather support gently but firmly, then apply to the Plantar surface of the arch and notice where the elevations are to be made. Then place the support between the conforming anvil and pressure block, drawing the leather toward you, and tapping that part of the support to be raised with the rawhide faced hammer. (See Chart No. 114.) It must be borne in mind that rigid flat-foot cannot withstand the same amount of pressure as the flexible flat-foot, or the weakened flexible foot, either of which may withstand a erreater amount of cor- FITTING ARCH SUPPORTS 177 rection or pressure from the supports. To obtain adjustments to these conditions the same rule should apply in selecting the length and ele- vating the support so as to touch all points of the Plantar arch evenly and smoothly, but not severely. Chart No. Ill Elongating Heel so as to Make a Heel Bed for the Depressed Os Calcis or Elongated Heel. In those cases where the posterior region of the Longitudinal arch may be affected, the Os Calcis is forced down and backward, making a long heel, and more flattened surface under the heel. For this con- dition the heel part of the arch support should be elongated, giving a 12 178 THE HUMAN FOOT longer surface for the heel to rest upon. This is done by placing the support between the conforming anvil and pressure block (see Chart No. Ill), having the heel part drawn out away from the machine until the distance between the end of the heel part of support and extreme edge of the conforming anvil is the distance where elongation adjust- ment is required. Then gently tap the metal part at the heel, straightening it as shown in Chart No. 113. Then again fit to the patient's foot, noting what further changes are needed, and readjust Chart No. 112 Showing Foot-Fazer Adjusted to Fit Long Heel. Note Heel Bed A to B. so that the entire support fits all points of the foot. The manipulation of this particular adjustment for elongated heel is very important, for if it is not properly done the support is apt to slide forward so that the heel of the foot is not protected all over by the leather covered base. After the foot is properly fitted with the arch support then place in the patient's shoe and learn if the support sits firmly in the heel seat, and at the point forward of the shank, and fits so that no weight or strength is thrown upon or required of the shank part of the shoe. (See Chart FITTING ARCH SUPPORTS 179 No. 116.) It is very important to be sure that there is no rocking or tilting of the support inside the shoe, and that it sits firmly in the heel seat and forward part of the shank. Arch supports, when fitted to the foot, should then be fitted to that particular type of shoe. The poise of the foot is changed in various extreme styles of footwear. High heels and low heels considerably alter the poise and balance of the Chart No. 113 After Heel is Elongated as No. Ill, Support is Placed on Rounded Part of Conforming Anvil to Straighten Any Uneven Points. foot, and the support should first be fitted to the foot and then placed in the shoe to make sure that it fits at both points, heel seat and for- ward of shank, and if so there should be no slipping or forcing the heel out of the shoe. (See Chart No. 117.) The rule, as I have given you above, applies to the fitting of the Anterior or Transverse arch. The metal part of the support should 180 THE HUMAN FOOT always remain about three-eighths of an inch from the Metatarsal articulations, and the style of Metatarsal arch support for Metatar- salgia and Morton's toe must be governed by the age of the patient, condition of foot and severity of the case. When there is pressure Chart No. 114 Elevating Arch Support. Note Line on Which the Rawhide Hammer is to be Used. upon the third or fourth Metatarsal head, which is indicated by cal- losity and tenderness, the elevation to the anterior part should be made in a dome-like shape from the first to the fifth Metatarsal, but most exaggerated just beneath and behind the dropped Metatarsal. FITTING ARCH SUPPORTS 181 In severe cases of Morton's toe and Metatarsal pains the elevation may be placed between the third and fourth Metatarsal heads. Some- times it is necessary to make these elevations the size and shape of a large olive, and again only a slight oval shape is necessary. These elevations and fittings are very easily accomplished by my method, and the use of the arch fitter, as the conforming anvil has an Chart No. 115 Dotted Lines Indicate Where Most Pressure is Required for Metatarsalgia. oval depression in which the metal may be hammered to shape. The following schedule may be used as a guide in determining the adjust- ment : Weak Flexible Foot — Relaxed Foot. — Use light spring support snugly fitted, most elevation directly beneath Inner Malleolus. Moderate Fiat-Foot, where structural change has taken place, re- 182 THE HUMAN FOOT quires support fitted evenly, but not extremely high. Adjust when the weight is off the foot. Extreme Fiat-Foot With Swelling. — Fit all points of arch when the weight is off the foot. Make adjustment low. Rigid Fiat-Foot With Adhesions. — Fit arch support extremely low, taking care to prevent skin or local irritation from pressure at any near point of the flange of the arch support. Weak Arch With Enlargement at First Metatarso-Phalangeal Joint. — Fit arch supports to all points of Longitudinal arch snugly, Chakt No. 116 Shows Support After Adjustment and It is at Once Obvious That Room has Been Given for the Heel to Sink Before Actual Arching of the Support Takes Place. then give added elevation to furnish added support just behind en- larged joint to remove dead weight and pressure. Light, springy support is indicated. Weak Ankles and Inward Rotation. — Fit supports to permit sup- port and pressure directly beneath ankle joint to hold it firmly in position. Extreme High and Contracted Arch. — Fit arch support high in center allowing space of approximately one-eighth inch between highest point of arch and highest point of arch support. Support FITTING ARCH SUPPORTS 183 Chart No. 117 After Support is Fitted to Foot, Place Shoe to Test Fit in Heel Seat to Prevent Slipping. Chart No. 118 X-Ray of Woman's Foot, Fitted to Arch Support which Also Shows Bearing Points of the Support Inside the Shoe. 184 THE HUMAN FOOT should be fitted a trifle longer than ordinarily, to give slight super- expansion forward. Metatarsalgia and Morton's Toe, Cramped Toes and Displaced Metatarsal. — Use Anterior Metatarsal arch support. Fit contour of Longitudinal arch, make transverse elevation just behind location of severe cramps and depressed Metatarsal. Chart No. 119 Crosses Point Heads of Metatarsals at Transverse Arch and Cross at Heel Points Tuberosity of Os Calcis. Support Should not be Fitted Beyond the Forward Points. Callouses On Ball of Foot. — Fit light, springy support and adjust evenly to Plantar surface of arch, with added slight elevation at for- ward end. For Painful Heel and for Bursitis, Spur of the Os Calcis, Etc. — Fit arch supports high at weight carrying points beneath Scaphoid FITTING ARCH SUPPORTS 185 and Astragalus, adjusting so that the metal of the support remains one-quarter inch from heel of foot when the support fits all other points of the arch by removing all pressure possible from the Os Calcis. For Weak Foot With a Tendency of Rolling Outward, a thin wedgelike piece of sole leather may be inserted between the leather and metal part of the support, to prevent the foot from sliding off after regular usual adjustment has been made. For Foot Strain, causing bodily fatigue, use lightweight foot- eazer. Adjust to fit contour of foot, to relieve ligamentous strain. Chart No. 120 Method of Lowering Arch Support to Any Given Point. Cramped Toes. — Fit lightweight foot-eazer to hold arch in posi- tion, to equalize weight and to prevent foot from slipping forward into toe of shoe. Children's Weak Ankles. — Where weakness is in ankle articu- lation, fit lightweight support, forcibly correcting condition by well elevating support. HOW TO MAKE SECONDARY ADJUSTMENT Since the patient has been properly fitted, and the foot restored to a degree of usefulness and comfort, progressive elevation and correc- tion can be accomplished by having the patient return in two or three 186 THE HUMAN FOOT weeks for a further and final adjustment. In that way the minor details of adjusting can be carefully followed up, and if there is any slight local irritation the pressure may be removed from the foot in one place and added pressure restored to another, so that a permanent cure may be effected within a reasonable time. # CRYSTALLIZATION OF METALS FROM WHICH ARCH SUPPORTS ARE MADE One of the difficulties encountered in the construction of ortho- pedic appliances, and particularly arch supports and those appliances Chart No. 121 Showing How Elevation to Anterior Arch is Made by Placing Over Oval Opening, in Conforming Anvil and Using Rawhide Hammer. worn inside the shoe, has been to secure a durable, rust-resisting, light- weight metal. Steel is unexcelled for lightness and strength when made of a fine gauge and highly tempered, but will not admit of ad- justment. Brass is subject to deterioration, and is very difficult to work up. German silver is most easily worked and fashioned into FITTING -ARCH SUPPORTS 187 shape, but is quite heavy, and is subject to crystallization. Other metals are bronze, silveroid, durabellum, magni bronze and hyolite bronze and aluminum. Nearly all these metals are subject to laws of crystallization, and in time will so harden from the constant springing and strain of carrying of one's weight that they will crack and break, and it is advisable to explain this to the patient, as many shoe dealers, chiropodists and physicians are of the opinion that these supports are indestructible. CHAPTER XXII HALLUX VALGUS AND BUNION Hallux valgus is a term applied to a partial displacement or out- ward dislocation of the great toe at the Metatarso-Phalangeal joint. The srreat toe is forced outward, sometimes under and at other times Chart No. 122 X-Ray Showing Bone Displacement in Hallux Valgus. overlapping the other toes. In its displaced position the cartilaginous surface of the head of the Metatarsal becomes inflamed, which later involves the soft tissue. HALLUX VALGUS AND BUNION 189 This frequently leads to confusion as hallux valgus condition, which is accompanied by enlargement at the great toe joint, seems to be regarded by the public as a bunion, when as a matter of fact Chaet No. 123 Bunion with Hallux Valgus. hallux valgus, strictly speaking, consists of the deformity of the bone which in severe cases does cause an enlargement at the Metatarso- phalangeal joint. Bunion is most generally associated with hallux valgus. Using 190 THE HUMAN FOOT the public phraseology and definition, a bunion is any enlargement at the first Metatarso-Phalangeal joint. A bunion consists of an inflam- mation of the soft tissues over the great toe joint, generally produc- ing a bursa. This part is swollen, tender and red, and may even sup- purate, the abscess often involving the joint. In the treatment of foot deformities there is probably no malforma- tion or deformity so easily recognized externally as hallux valgus. Chart No. 124 Bunions of Long Standing Accompanied with Flat Foot. There are various causes, but the most marked are mechanical causes, and under this head the wearing of short, pointed toe, narrow, re- stricted shapes are the most frequent causes, for when pressure is brought to bear upon the foot full expansion is not permitted and the great toe is forced backward and outward. Hosiery worn short and pointed at the toe is another frequent cause. Rheumatism, gout, HALLUX VALGUS AND BUNION 191 rheumatoid arthritis, osseo-arthritis also produce a defect. Weak arch and flat-foot condition can be traced in a great number of cases as being the direct cause. The deformity is one slowly produced, over a considerable period of time, and with the first toe is being gradually displaced. The pain is not greatly felt until a new irritation, caused by pressure, brings it to the sufferer's attention. It is not unusual to Chart No. 125 X-Ray of Bunion Foot After Hallux Valgus Opera- tion Showing Head of First Metatarsal Excised and Second Toe Removed Owing to Underlapped Position. find the Phalanges in the second toe distorted through crowding up- ward of the great toe, sometimes under and sometimes over. Corns and callosities very frequently form which become very painful. If the hallux valgus foot is examined with the X-ray it will be found that the first Phalanx is more or less displaced, as also the outer sur- face of the head of the first Metatarsal bone. It will be found in a 192 THE HUMAN FOOT position of subluxation, or partial dislocation. The Internal Lateral ligament is elongated and often thickened, and the External Lateral ligament is shortened. Sometimes the inflammation at the point of the deformity may cause suppuration, and an abscess may open externally or into the joint, or into both directions, but this is only found in the most severe and rare cases. In the acquired cases the toe can easily be placed to a straight line with the foot by taking hold of the Distal Phalanx and stretching the toe inward, but in the more severe cases Chart No. 126 Bunion with Overlapping Second Toe. and cases of long standing this is more difficult. There are found per- sons with hallux valgus which may be traced to hereditary causes. These, as a rule, are not as painful and distressing, except by the annoyance of being improperly fitted with footwear. The deformity is more common in women than in men, probably due to the fact that the shoes worn by women are of a more pointed toe shape. Treatment. — The treatment indicated in hallux valgus and bunion is usually mechanical. The first essential is to remove the cause. If HALLUX VALGUS AND BUNION 193 short stockings, short shoes or pointed toe shoes have 'been worn replace with the correct styles and sizes. Then the object is to straighten the deformed toe to a straight line of the foot. This, in milder cases, may be effected by use of a spool toe post, known as a bunion-right, or toe flex. These devices are made of rubber and have a top and bottom shield so as to exert a continuous pressure to hold the displaced member to its normal position. These devices are espe- cially essential in the early stages and in those cases that are not flexible and subject to traction. If these devices are worn during Chart No. 127 Note Flexibility of Same Foot. the day in a shoe that will permit the straightening of the toe, con- siderable relief can be secured. For night wear a bunion spring is indicated. By far the most practical that has yet been placed upon the market for the use of the orthopedic operator consists of a spring made of metal, having an oval opening over the enlarged joint, padded with soft felt to relieve it from pressure, and with a means of holding to the foot so as to act as a lever in drawing the displaced toe to a 13 194 THE HUMAN FOOT straight line of the foot. The author's bunion spring, such as described above, has an added spring which is attached to the lever with a pivot extending under the ball of the foot, which prevents displacement either in the shoe or, if worn at night, by the bed clothing. This Metatarsal spring by its support offers a means of raising the Met- atarsal arch which relaxes the Internal Lateral ligaments. It can be adjusted by lacing, whereb} T gradual correction can be had. The W I I Chart No. 128 Toe Flex Placed in Position Bringing Toe to Normal Position and Correcting Overlapping Second Toe. spring, as described above and illustrated in Charts Xos. 129 and 130, can be worn in a large shoe for day wear, but is most practical for night wear. Where there is considerable tenderness and external pressure produced by the shoe, a shield made of gutta percha or rubber molded to conform to the actual lines of the foot, having a shoulder at the posterior part of the Metatarsus slightly concaved at the forward inner edsre so as to allow room for the srreat toe to assume HALLUX VALGUS AND BUNION 195 its normal position, is most efficacious in relieving pain and pres- sure. Where there is considerable superfluous tissue or enlargement, or local inflammation, or tenderness, this shield, known as bunion re- ducer, as named by me, will create a mild hyperemia, stimulating cir- culation and reducing the enlargement. The bunion reducer is worn directly over the affected joint and when fitted properly in that way will not shift out of position. The advantages also in this reducer are in the relieving of shoe pressure and also to maintain the original shape of the shoe so as to hide the deformity. These rubber reducers are Chart No. 129 Bunion Spring Applied. made in stock sizes to fit all ordinary cases and can be vulcanized from casts of the enlarged joint in more severe or peculiarly shaped con- ditions. In all instances where the Longitudinal arch is weakened, or where the dead weight of the body is thrown upon the first Metatarso- phalangeal joint, due to weakness or constant use of the feet, an arch support should be fitted to the foot. The springy support of two pieces, allowing free movement anteriorally, should be used, and in the adjustment it is advantageous to posterially lift the enlarged 196 THE HUMAN FOOT joint. It should be borne in mind by the practitioner that relief is the essential thing to consider, and frequently the foot-eazer, fitted to support the arch, will give immediate relief. Toe-free hosiery is 1 V Chart No. 130 Top View of Bunion Spring in Position. also indicated. In the more severe cases surgical operation must be resorted to if correction of the deformity is desired. Chart No. 131 Rubber Bunion Reducer Applied to Foot. HALLUX VALGUS AND BUNION 197 FELT PADDING Concaved pads of felt, smoothly skived, that can be placed about the affected area to remove pressure, are very useful and frequently used by those who have the deformity of long standing, as well as the hereditary cases, and where there appears to be but little mobility in the joint. The object of the pad is to relieve pressure of the L,.C3 ■,(.■;.-; ^<^^:;'.'' v ' v, -" :: - ; 'S- : . : Chart No. 132 Skived Kiro Pad for Bunion Joint. shoe. Kiro pads are most useful for the practitioner, inasmuch as they are automatically skived by patented process, leaving the inner surface concave to fit the foot externally and shaped so as to admit the wearing of the usual shoe. Another means which I have used very successfully, and which is desirable in the extremely prominent Chart No. 133 Skived Concave Kiro Pad. joint where bunion growth is apparent, is the method of padding the inside of the shoe with specially shaped pads known as Strait-Shu Bunion Pads. Two pads are necessary, one behind the bunion, which is longer and thicker, although concave, and the forward one, which is shorter and thinner and convex. They are applied by a suitable 198 THE HUMAN FOOT Chart No. 134 Kiro Pad with Thick Shoulder and Center Opening. Chart No. 133 Kiro Pad with Shoulder Behind, Enlarged Joint. HALLUX VALGUS AND BUNION 199 adhesive which must be moisture-proof and are placed in position in the inside lining of the shoe so that the enlarged joint positions itself between the two pads. This method has been so successful Chart No. 136 Kiro Pad Applied Over Bunion Joint. that many patients have their shoe dealer affix the pads to each pair of new shoes. Medical treatment consists of applying Wenal, which can be followed by cold applications; wet dressings, hot boric poultices, oint- Chart No. 137 Strait-Shu Bunion Pads Attached to Inner Lining of Shoe. ment, etc., are frequently used with a purpose of alleviating the pain. Felt rings or washers, plasters, etc., should be avoided as they only tend 'to aggravate the condition. 200 THE HUMAN FOOT TREATMENT OF BUNION Bunion is so frequently associated with hallux valgus, as previously- stated, that it becomes necessary to describe treatment for this in- flammatory condition in conjunction with the foregoing. Remove pressure of the shoe and, if very badly inflamed, give absolute rest Chart No. 138 Bandaging After Kiro Pad Has Been Applied. to the foot by elevating same after a warm foot bath. Then apply Wenal ointment to the parts. The following day soft felt Kiro pads are applied until all inflammation desists. Should there be any sup- puration or abscess, same should be treated surgically. CHAPTER XXIII HALLUX RIGIDUS OR PAINFUL GREAT TOE— HALLUX VARUS OR PIGEON TOE HALLUX RIGIDUS OR PAINFUL GREAT TOE Painful Great Toe is also known as flexus, hallux rigidus and hallux dolorosus. This condition of painful great toe is attended with great pain in the first Metatarso-Phalangeal joint, and consists of ankylosis of the Metatarso-Phalangeal joint of the great toe. When the toe is moved external inflammation appears. There is but slight rigidity, but considerable pain and occasionally slight swelling. This Chart No. 139 Painful Great Toe with Weakened Arch. is invariably caused by a condition of flat-foot, incipient flat-foot, or with shoes that are fitted too short, but is sometimes caused by an injury to these parts. A weakened foot elongates and slides forward into the toe of the shoe, which doesn't permit the foot to stretch out to its entire length, creating an inflammation at the Metatarso-Pha- langeal joint. This condition is most frequently found in growing 201 202 THE HUMAN FOOT boys and girls and it can be detected by movement of the great toe and by careful examination for weak flat-foot. Treatment. — Fit the Longitudinal arch to an arch support or foot- eazer, so that the Longitudinal arch will have an even bearing at all points, the object being to remove the pressure on the painful joint and to restore the natural motion of the foot, removing muscular and ligamentous strain, also the pressure of the body's, weight at the affected joint. These conditions should be handled in the same manner as weak foot or incipient flat-foot. Care must be taken that the shoe is of sufficient length and no restricting action produced by the stocking. Where considerable pain is present, a stiffening device should be inserted between the soles of the shoes. HALLUX VARUS OR PIGEON TOE Hallux Varus is also known as pigeon toe. It is of little impor- tance and usually congenital in origin. Occasionally it may be seen Chart No. 140 Showing Method of Wedge feather Application to the Sole for Pigeon Toe. in children with flat-foot, also in cases of overcorrected club-foot, usually resulting in valgus. It consists of a toeing in or abnormal adduction of the great toe. HALLUX VARUS 203 While in pigeon toe an adduction of all the toes is present, it is mostly congenital and in the latter it is generally due to a rotation of the entire limb while in the former the great toe seems to be re- laxed, allowing it to adduct. At times it has been found in connection with severe cases of knock-knee. Treatment. — While bandaging in the opposite direction of the deformity can be used with considerable aid in the early stage, from my observation I find that by adding to the outsole of the shoe a triangular-shaped piece of sole leather on the inner side from a line drawn at the center of the sole of the shoe to just behind the ball definite results will be obtained. (See Chart No. 140.) CHAPTER XXIV PAINFUL HEEL As a rule, pain and tenderness in the heel are caused by bruise, pressure and strain directly brought on by overuse of the feet. It is also frequently found among persons who do constant standing or walking, and who are developing a condition of flat-foot. This pain- ful condition is frequently known as policeman's heel. Again the pain Chart No. 141 Arch Support or Foot Rest in Position. Sponge Rubber Pad Beneath Heel. is produced by inflammation of the Calcaneal Bursa, which is known as bursitis. There are other cases where the pain and disturbances are caused by growth or spur on the Os Calcis, and in any of these cases, whether from the last mentioned causes, or which may be ver- ified as a symptom of weak or broken-down arch, examination of the foot should be made the same as for flat-foot or arch trouble to learn whether the pain is caused by flat-foot condition. Treatment. — The first necessary element is to relieve the pressure on the Os Calcis or heel. This is best done by fitting the patient to 204 PAINFUL HEEL 205 a pair of arch supports, taking special care to remove all pressure from the sensitive, painful area, which is best done by the Tri-spring arch support as illustrated. Supports should be elevated posterially to remove the pressure, and whether the pain is caused by oncoming flat-foot, by foot strain, or is the result of inflammation of the Bursa, or caused by the irritation produced by the growth, this method will give relief. Pads of soft felt, sponge rubber, etc., hollowed out to receive the heel, have also been used but not with such marked success. In fitting the arch support, care must be taken to fit the support so that the plate part exending under the heel remains away from Chart No. 142 Korrecto Arch Support Fitted to Relieve Painful Heel. the Os Calcis so that the actual bearing point comes forward. (See Chart Xo. 143.) Achillotenontitis is an inflammation of the tendon itself or its sheath. The lower part of the tendon is abnormally enlarged and tender. Bandaging with pads on either side of the tendon is benefi- cial, although arch supports fitted to remove excessive pressure should be advised. Rest is also very effective. Climbing of stairs should be avoided. Talagia and Osteophytes of the Os Calcis. — The Os Calcis is not infrequently the seat of tuberculous disease and must be treated as a tubercular affection, also frequently the seat of gonorrheal infection, 206 THE HUMAN FOOT when it is often enlarged and tender to lateral and plantar pressure, a painful point over the tuberosity of the Os Calcis persistent and troublesome. Skiagraphy shows that the cause is frequently irrita- tion and osteophytes, and on their removal disappears. This tender heel has been called Bursitis, and is probably due to a bursitis. It is usually an accompaniment of flat-foot, due to the Chart No. 143 Tri-Spring Arch Support Fitted to Relieve Painful Heel. irritation at the insertion of the Plantar ligaments. When this con- dition is caused by gonorrheal infection, the trouble is often diffused through the Tarsus, or causes swelling and tenderness about the Astragalo-Scaphoid joint. Strains and wrenches of the foot fre- quently result in acute tenosynovitis of the Extensor or other tendons. The tendons affected are swollen and motion is very painful. Rest, PAINFUL HEEL 207 tincture of iodine applied locally, bandaging and the application of an arch support which has been fitted to the Plantar arch so as to remove pressure from the heel usually effect a cure in a short time. In- juries of the foot, when accompanied by much ecchymosis or pain at a definite point, should be skiagraphed to ascertain if a fracture is present. CHAPTER XXV HAMMER TOE Hammer Toe is a contraction of one of the toes, usually the second or the third. The condition is one of flexion of the second Phalanx with extension of the third, causing the pressure on the ground to be sustained by the Distal Phalanx. There is a complete or partial contraction of the ligaments, and the controlling muscles are also Chart No. 144 Foot Shoeing Hammer Toe — Second Toe. sometimes involved. A callous and corn are usually found over the upward projecting joint, which may cause considerable annoyance. The deformity may be congenital but in the milder forms it is ac- quired principally by narrow, short shoes. In the early stages little difficulty is experienced by the patient. However, later locomotion is difficult and painful. In all but the most severe cases the de- formity can be corrected by simple mechanical treatment. 208 HAMMER TOE 209 Chart No. 145 Hammer Toe Spring Adjusted to Toe and Foot. Chart No. 146 Bottom View of Hammer Toe Spring. 14 210 THE HUMAN FOOT If the case is not of too long standing, the hammer toe spring will be found of special benefit, and will gradually straighten the toe. Author uses two patterns of this spring — one with extension under the Plantar surface of the foot to give added correction, while the other is made with a short spring having a loop for the toe or toes as shown in the illustrations. (See Charts Nos. 146 and 147.) When Chart Nc. 147 Spring for Hammer Toe, Short Spring. more than one toe is affected a special hammer toe plate with straps going over and between the toes is used. Kiro or absorbo pads, to relieve the pressure of the shoe from the apex of the contracted joint, are also beneficial, affording relief from pain and discomfort. A contracted position of several toes is often encountered, which is usually due to improper shoes or the result of previous paralysis ■ HAMMER TOE 211 of some muscles of the foot. It is also found in connection with the condition spoken of as contracted foot. The tendons and fasciae are found to be shortened. This deformity- may be treated in the same way as a contracted toe. Properly made shoes in an affection of this kind should be as in all other deformities. Chart No. 148 Kiro Pads for Hammer or Contracted Toe. OVERLAPPING TOES Very common among adults. Owing to the pressure of narrow shoes, we find a condition of overlapping toes. Xot infrequently de- formities of this kind are seen in infancy and are apparently congenital. The greater number, however, are acquired. Deflected or deformed toes may be treated by manipulation and by supporting with toe flex, or toe-right, or with strips of adhesive plaster. In severe cases the hammer toe spring or special plate should be used. Care should be taken to avoid crowding the toes into shoes of insufficient length and width. This deformity, acquired in childhood, usually can be cor- rected with exercise and proper shoes. CHAPTER XXVI WEAK ANKLE— SPRAINED ANKLE- TUBERCULAR ANKLE WEAK ANKLE Weak Ankle (In Ankle) is a posture of weakness in which the Inner Malleolus descends and becomes prominent. It is often associated with the out-toeing, abducted and everted foot, and also with knock- Chart No. 149 Showing Bulging Ankle and Rotation of Inner Malleolus. 212 WEAK ANKLE 213 knee. Very frequently weak arch or fiat-foot is diagnosed as weak ankle. The weakness usually occurs at the junction of the Inner Malleolus and Astragaloid region. There is a relaxing and stretching of the ligaments, which permit an inward rotation as the weight is transmitted into the foot. The treatment is that of weak-foot, giving mechanical support to the Plantar arch directly beneath the Inner Malleolus. Weak ankle is very frequently found among children, and is associated with flat-foot. Adhesive strapping, stiffened shoe counters, elastic bandages and corset ankle supporters are also used. The author's method is to give mechanical support to the Plantar arch — ankle articulation. (See Treatment of Weak Foot — Chapter XVII.) Chart No. 150 Ankle Support for Children. SPRAINED ANKLE Sprain of ankle is a common injury, which consists in the rupture of some of the fibers of the lateral ligament, usually the external of the ankle joint. It is a result of direct or indirect violence which may rupture or tear the ligaments. Swelling, pain, tenderness, dis- ability and ecchymosis follow rapidly upon the injury. Recovery under local applications or plaster of paris splinting is slow. If severe, the patient should be made comfortable and the foot elevated to a position of absolute rest, with applications of cold and warm water alternately. Ligtone, arnica or other evaporating lotions may 214 THE HUMAN FOOT be used. Then the foot and ankle may be strapped with adhesive and firmly supported to prevent any further strain. Wearing - an arch support in the shoe after it has been properly fitted will be found a great aid. Soreness and lameness may persist for months. In injuries with great ecchymosis. fracture of the tip of the Malleolus should be expected and a skiagraph taken. TUBERCULOSIS OF THE ANKLE Tuberculosis of the ankle occurs usually as an infection from one of the neighboring bones, especially from the Astragalus or lower end of the Tibia. In children this disease often recovers under immobilization of the foot and ankle, with an ankle brace, or with gypsum splint, and sus- pension of the limb by crutches, or a Thomas splint, and the usual tonic treatment for tubercular affections. In other cases sinuses will appear which may heal under simple aseptic dressings or the injection of a saturated solution of iodoform in ether, or the bismuth vaseline mixture. Sometimes the ankle joint has to be opened and the diseased tissues removed, including the original focus. This often involves the removal of the Astragalus. The location of the bone disease may be determined by skiagraphy. It is very important that the orthopedic operator make careful diagnosis of tubercular ankle as it sometimes has the appearance of flat-foot or other common foot deformities. CHAPTER XXVII TALIPES OR CLUB-FOOT Is a deformity characterized by an inversion, torsion and depression of the front part of the foot, with an elevated heel. In walking- on a foot deformed in this manner the weight of the body is not borne Chart No. 151 Talipes Varus. by the sole of the foot, but by the outer side, and in extreme cases by the dorsum of the foot. There are four varieties of club foot, but in any case the foot is twisted out of its natural shape and an actual deformed condition exists. The varieties are : 215 216 THE HUMAN FOOT Talipes Equinus, where the heel is elevated, foot extended and the patient walks on the balls of the toes. (See Chart No. 153.) Talipes Varus, the inner side of the foot raised and adducted so that the weight falls to the outside portion of the foot. Talipes Valgus is just the reverse of Talipes Varus, the foot being abducted so that the weight falls on the inner portion of the foot. Talipes Calcaneus, the toes are raised and most weight is carried on the heel. It may either be congenital or acquired. The tissues are all necessarily affected by the abnormal position, and the skin, muscles, tendons and fascia are all altered. In congenital cases of club-foot, even in cases at full term, the Scaphoid articulates with the side of the head of the Astragalus in- stead of with the anterior surface. The articulation is also more towards the underside of the Astragalus, the head being uncovered. The Scaphoid may be displaced to such an extent at one side as to articulate at one end with the tip of the Internal Malleolus. The distortion in the shape of the bones in infants is of little importance, as the ends are largely cartilaginous. The Tarsal bones, however, are not in a normal position. As the Cuneiform bones are intimately connected with the Scaphoid, it is also displaced, the same being true of the Metatarsals and the Phalanges. The long axis of the front part of the foot forms a right angle, sometimes an acute angle, with the axis of the leg. The Cuboid is also displaced and does not artic- ulate with the front of the Os Calcis, the Facet also inclining ob- liquely to the inner side. In cases that are fully developed, and in older children or adults, there is a marked alteration in the shape of the bones. The bones noticed to have been altered in shape and position are the following, viz., the Os Calcis, Cuboid, Astragalus and Scaphoid. By the elevation of its tuberosity the Os Calcis is drawn from a horizontal into a position nearly vertical. It is more or less rotated on its vertical axis, its anterior extremity being directed outward and the posterior extremity inward, this causing the anterior articulating facet to be oblique to the axis of the bone. TALIPES OR CLUB-FOOT 217 The connection of the Cuboid with the Os Calcis remains, but follows the inward direction of the anterior extremity of the foot. The Astragalus does not rotate on the vertical axis, but is de- pressed forward on its horizontal axis so that only the posterior por- tion of its superior articular surface is in contact with the inferior articular surface of the Tibia, the anterior part of its anterior facet projecting beneath the skin of the Dorsum of the foot. Other than the displacement previously mentioned, it is altered by the twisting Chart No. 152 Double Talipes Varus. inward of the head and neck, so that the anterior articular surface looks inward instead of forward, and the disposition of the cartilage at the articulating surface of the head of the Astragalus is neces- sarily altered. The three Cuneiforms and the three Metatarsal bones being closely connected with the Scaphoid, are more twisted to the inner side than is the case with the Cuboid. The Metatarsals are not all alike involved in the rotation from without inward, and are 218 THE HUMAN FOOT spread out in such a way that the anterior part of the foot is abnor- mally enlarged. There are other alterations in the position of the foot which take place, due to pressure and the effect of locomotion on the distorted bones. The different tendons take an abnormal direc- tion and in general are carried farther to the inner side than is normal, especially that of the Tibialis Anticus, which is the common extensor of the toes and the long extensor of the great toe. Synovial Bursae may form on the outer edge and back of the foot, which at times become inflamed and purulent. There are often corns and callosities present on the skin, due to the pressure from walking. In cases of club-foot no changes have been as yet found in the nerves or spinal cord. In severe cases there may be slight alteration in the shape of the Femur and a laxity at the knee joint. The Tibia and Fibula have been found altered. In congenital club-foot the muscles are never par- alyzed, but the contracted muscles appear more developed than the lengthened ones. From disuse the muscles of the leg atrophy, con- sequently making the leg smaller and the foot shorter than normal. There is also a change in the ligaments and fascia, not confined to the severe and older cases but always present. The ligaments and fascia affected by contraction are the Plantar ligaments and fascia, the internal, lateral and posterior ligaments. Causes. — Club-foot is usually a congenital deformity, but it can also be acquired after the impairment of muscular power, such as in paralysis, and after accident. The chief theories advanced in explaining the origin of club-foot are as follows : 1. Abnormal compression while in utero. 2. Retraction or paralysis of muscles, depending or not on lesions of the nervous system occurring in utero. 3. A malformation depending upon arrest of development of the foot. Diagnosis. — In walking, club-foot causes great inconvenience to the patient, although in uncorrected cases skill and agility of locomo- TALIPES OR CLUB-FOOT 219 tion are acquired even though the deformity remains unchanged. Dis- comfort is also occasioned by the formation of bursae and callosities which inflame over the unprotected portion of the foot, limiting the patient's amount of activity. The distortion presents an inward twist of the foot, with a de- pressed position of the outer edge. To the touch the Tendo-Achillis is firm and hard; the Plantar fascia will also be found short and hard on palpation. (There is a projection on the inner side of the ver- tical axis of the leg, the fore part of the foot.) The fore part of the foot projects to the inner side of the vertical axis of the leg, the ten- dinous end of the Os Calcis being raised and turned inward. The head of the Astragalus and Cuboid project under the skin, and there is usually an atrophy of the muscles of the leg. There is a prominence of the External Malleolus, while the internal cannot readily be felt. Club-foot is readily recognized. By obtaining a history of the case, diagnosis can be established between the congenital and noncongenital forms of club-foot. Par- alysis is the only common cause of acquired club-foot, and it can be recognized by the evidence of paralysis of the muscles on the anterior and external surface of the leg. The deformity will not correct itself, and if left uncorrected re- mains the most obstinate of malformations. If skilled care and attention is given, the deformity is said to be always curable. Treatment. — Treatment of club-foot varies according to the patient and the duration and nature of the deformity. The treatment should be purely mechanical, or operative and mechanical. The object of treatment is to correct the distortion and to retain the foot in a correct position until any return of the deformity is impossible. Specially made braces of a scientific corrective nature, when ap- plied to the child, will do much in assisting toward a cure. Shoes built with a corrective object in mind also aid, although in the adult shoes 220 THE HUMAN FOOT and braces can only add to the comfort and possibly remove undue and uneven pressure. TALIPES EQUINUS Is the name given to a condition in which the foot is held in a position of Plantar flexion, and rendering Dorsal flexion to the proper extent impossible. It is known also as pes equinus and horse heel. It is very rarely a congenital deformity but. as an acquired one, it Chart No. 153 Talipes Equinus. is very common, especially in its milder degree. In the acquired form all degrees are encountered, from a condition in which the foot can- not be flexed beyond a right angle to one in which the foot and leg are nearly in a continuous line. In milder forms the deformity is of less importance than other forms of talipes. TALIPES OR CLUB-FOOT 221 This affection in a light degree may cause a person to limp in walking, because in carrying the leg back at the end of the step the foot must be bent more than to a right angle. The changes of the structure in talipes equinus are slight. In many cases there is a shortening of the Tendo-Achillis and a conse- quent alteration in the shape of the bones of the foot. a 1 '£&/<■ i <,•') ■",■' bP& i pt& -.<± Kff'£->V i % 4 a wjgj?v ? ' >^ Gallo-Roman Sandal. Greek Sandal. ^. I rt^•}.1^? < *•' > ' , Roman Sandal. Chart No. 191 Bohemian Child's Shoe. HISTORY OF FOOTWEAR 299 manship, were commonly worn by the Egyptians. We have also ample proof by the splendid examples exhibited in the Egyptian de- partment of the British Museum. Footwear of the Greeks and Romans. Taking a long stride from the remote to that of the Greek and Roman, and later to the medieval era, we find the art of shoe and sandal making continues to play an important part in the civilized world. The feet of the ancient Greeks frequently were left entirely bare, sometimes protected underneath by a simple sole tied with thongs or strings disposed in a variety of elegant ways across the instep and around the ankle. They were often shielded above by means of shoes or half-boots, laced before and lined with the fur of animals of the feline tribe, whose muzzles and claws were disposed in front. The Romans had a great variety of sandals, the greater portion being similar to those worn by the Greeks, one kind covering the whole leg, called Ypodementa; in the Greek and in the Latin by several names, viz., calceus, mulleus, pero and phsecosium. Another variety known covered only the sole of the foot, and were made of leather or other materials. These were called by the Greeks pedita, but were demonstrated in various ways by the Romans as caliga, solea, campagus, baxea, sandalium, crepida and sicyonia. To all the term "calceus" was invariably applied. A shoe, usually of a scarlet color, but sometimes purple, called "mulleus," was forbidden to be worn by the common people. The phaecosium, a light thin shoe, was worn by the priests of Athens and also by the Romans. It covered the entire foot and was made of leather. The shoes worn by the people of ancient Latium were made of untanned leather, and in later times were worn by the rustic people of the lower classes. This type of shoe was called the "pero." The campagus and the caliga were sandals, worn by the military. The sole of the latter was large and strengthened with nails, and chiefly 300 THE HUMAN FOOT A Wide-Toed Shoe of Henry the VIII Time, Without the Heel Piece. This Fash- ion Prevailed with the Military in the Steel Soleret. It Measures 9 inches in Length and 6 inches Across the Toes. Chart No. A Riding Boot or Buskin. This Undoubtedly Belorge^ to Queen Elizabeth. 192 HISTORY OF FOOTWEAR 301 appropriated to the common soldiers. The campagus was worn by the emperors and generals of the army, it differing little in form from the caliga, but the ligatures were more closely interwoven with each other and were more often crossed over the foot, producing a resem- blance of network. The Emperor Gallienus wore the caliga orna- mented with jewels in preference to the campagus, which he scorn- fully described as nothing but nets. The caliga, the crepida, and of course the sandalium, were all of these species of sandals fastened about the feet and ankles by fillets, or thongs, but though each had its peculiarities it is at this late date impossible to ascertain them. The solea, we are informed, could not in strict decorum be worn with the toga, and it was considered effemi- nate to appear in the streets of Rome with them. However, regard- less of this rule, the Emperor Caligula not only wore the solea in public, but permitted all who pleased to follow his example. The baxea, also of the sandal kind, was originally worn, according to Arnobius and Tertullian, by the Grecian philosophers, and as it ap- pears from the former author, was manufactured from the leaves of the palm. Here Plantius notices the baxea, but nothing respecting their form is specified. Cicero tells us the sicyonia was used in races, and from this we infer it must have been a very light kind of sandal. Lucian speaks of it as being worn with white socks. A shoe or sandal called the "gallica" was adopted from the Gauls, but was for- bidden to be worn with the toga, and to these may be added the saulponese, worn by the country people; also the solea, a shoe with soles of wood called in Latin solea ligncc (wooden sole), used by the poor. Of household words which occur in the catalogue of Roman foot- gear two names are familiar, the sock and the buskin. The sock, or "soccus," as it was called, is stated to have been a plain kind of shoe, amply large enough to receive the foot with the caliga, crepida or any other kind of shoe upon it. The buskin (cothurnus) was anciently worn by the Phrygians and the Greeks, deriving its reputation from being introduced to the stage 302 THE HUMAN FOOT by Sophocles in his tragedies. It was a boot laced up the front of the leg, at times covering the toes entirely, and at others a stay passed between the great toe and the next connecting the sole with the upper portion, which met together over the instep and were from this point laced up the front similar to half-boots worn at present. The cothurnus was worn by both sexes in Rome, as they were in Phrygia, but from the circumstances mentioned above it has especially been associated with tragedy. The soccus was worn by the comic actors because in like manner it was typical of comedy. Socks, or covering for the feet made of wool or goat's hair, called "udones," were used by the Romans, but the men who wore them were regarded as effeminate. Painted shoes of various colors, often sumptuously adorned with gold, silver and precious stones, were worn by the wealthy. Em- peror Heliogabalus had his set with diamonds interspersed with other jewels. Emperor Amelian did not favor painted shoes, considering them too effeminate for men, and therefore prohibited the use by them of the mullei, which were red, white, yellow and green. The latter he called "ivy leaf colored" calcei hidracei, a type of shoe turned up, and with pointed toes called calcei repondi, or bowed shoes, a fashion adopted from the East; and subsequently carried to such extravagance in the middle ages. Black leather boots reaching from the middle of the leg are said to have been worn by the senators from the time of Casus Marcus. (See chart No. 191.) Footwear of Anglo-Saxons. There is nothing more interesting in the history of civilization than the varying changes in dress and fashion. After the dissolution of the Roman Empire, the different tribes who settled in its provinces appear in general to have adopted the civil costumes of the conquered Romans, while they probably re- HISTORY OF FOOTWEAR 303 A Chopine for the Right Foot of Coarse Workmanship. The Sole of This is Made of Layers or Blocks of Cork, the Center Being Hollow. A Wooden Patten Made of Two Flat Pieces Overlap- ping in the Center and Hinged with Leather. It is 10J/2 inches in Length and 2 inches at the Widest Part of the Sole. A Wooden Patten 10 J4 inches Long and 33 inches at Its Widest. Worn During 14th and 15th Centuries. A 14th Century Steel Soleret (Poulaine) An Example of the Extravagant and Singular Fashion of the Shoes of the 14th Century. Chart No. 193 304 THE HUMAN FOOT tained with tenacity the arms and military customs of their fore- fathers. There was. a general resemblance between the dress of the Anglo-Saxons, the Franks, and other nations of the West. In the manuscripts the form of shoes as represented is nearly uniform. They cover the foot to the ankle, are tied with a thong, having an opening down the instep, and are usually painted black, except those worn by the princes and great persons, who had them frequently gilt or covered with gold. Anglo-Norman Footwear 1060-1200 A. D. The civil costume of the Anglo-Normans at first did not differ widely from that of the Anglo-Saxons, their shoes being almost similar. Near the end of the century shoes were constructed dif- ferently, being profusely ornamented. Knights and people of fashion wore long, pointed shoes, which were often turned up at the points. Long pantaloons with feet to them, with shoes or sometimes short boots, were worn by the middle or lower classes. Shoes Worn in the Thirteenth Century. The shoes worn in the Thirteenth century were long-toed, and among the rich they were very elaborate, being elegantly embroidered in fretwork. Shoes Worn in the Fourteenth Century. On the character of the costume the reign of Henry VI. has nothing very decided. It may be regarded as a period of transition between the reign of Edward I. and that of Edward III. The dress of the male continued much the same as in the preced- ing reign, except that near the end of this reign it was distinguished by the accumulation of finery which became so obnoxious to the reforming lollards in the latter part of this century. It appears that many fashions of this reign have been brought from Germany. The footwear, as described by a contemporary writer of the time, is thus : HISTORY OF FOOTWEAR 305 "Their shoes and patterns are snouted and piked more than a finger- long bending upward, which they call crakowes, resembling the claws of devils, and fastened to the knee with chains of gold and silver." (See Chart No. 193.) Shoes Worn in the Fifteenth Century. After Henry the IV. acceded to the throne various attempts were made to reform the extravagant fashions and expensive apparel worn in the preceding reigns, severe sumptuary laws being repeatedly en- acted, but with only partial success. With the reign of Henry VI. we enter a new period of the history of costume. The principal characteristics were long, tight hose with feet, and sometimes short boots or buskins, after boots reaching to the middle of the thigh called galoches ; or very long-toed shoes with high fronts arid backs that turn over each way. At no period of the Fifteenth century was the extravagance of dress more remarkable than during the reign of Henry VII., but the most remarkable characteristic of the latter part of this century was the extreme broadness of the toes of the shoes, which suddenly usurped the place of the long, pointed shoes of the preceding reigns. Paradin, an old French writer, describing the manners of this century, says that at first "Men wore shoes with a point before half a foot long; the rich and more extravagant personages wore them a foot long, and princes two feet long, which was the most ridiculous thing that ever was seen; and when men became tired of these pointed shoes, which were called poulaines, they adopted others in their places which were named duck-bills, having a bill or beak before of four or five fingers in length. Afterward assuming a contrary fashion, they wore shoes so very broad in front as to exceed the measure of a good foot." The shoes of the ladies during this century were made so small that they could hardly walk in them, frequently causing their feet to be made lame, sore and full of corns. This condition was described by a French moralist as being "the greatest evil of the age." In the 20 306 THE HUMAN FOOT Shoes of Charles the First. S ^ . 3111 \k : ; -" . 3s§£ ^'f %i ' s>^S>j^-£ £?- jj? /J* .... Ji2*Ssl»3 ' > *' ftp* A Square Toed 15th Century Black Leather Shoe Minus the Heel and Side Leather. The Left Shoe of a Handsome White Satin A Shoe of Elizabeth, Queen of Bohemia, 17th Pair which Belonged to Queen Elizabeth. Century. Chart No. 194 HISTORY OF FOOTWEAR 307 reign of Henry VIII. we enter upon an entirely new period of cos- tume and art, differing in every possible respect from the preceding ages. In this reign the former splendors of the feudal baronage were disappearing, and the gorgeous pageantry of the Roman church was on the point of being abolished ; thus it was in this century under Edward VI. and Mary that shoes similar to those of the present came into vogue. (See Chart Xo. 194.) Tudor Period, Sixteenth Century. During the Tudor period the common form of footgear was the low shoe with a big Tudor ribbon rose. Another kind of shoe for outdoor wear excited the merriment of those who held aloof from the new fashions because it caused the wearer to shuffle. This shoe was called the "pantofle," and originally was a much plainer kind of shoe to be strapped over the other as a protection. The pantofle was a modified form of the "chopines," being worn in Italy at this time, and ladies' high-heeled shoes in England were frequently called chopines. Coryate describes the Italian chopine as follows : "Of a great height, even half a yard high ; and by how much the nobler a woman is, by so much the higher are her chopines. All their gentlewomen, and most of their wives and widows that are of any wealth, are assisted and supported either by men or women when they walk abroad, so that they may not fall." It is said that English ladies never wore any such absurd articles, though the heels to their slippers were extremely high and unsuited to pedestrian exercise. There were in vogue more comfortable shoes, and one of the Tudor princesses had black velvet buskins, or short boots, lined with fur. (See Chart No. 195.) Stuart Period of the Seventeenth Century. Boots appear to have been generally worn by all classes of society under the Stuarts, and thus the Spanish Ambassador Gondemar said to James, "I shall amaze my countrymen by letting them know at 308 THE HUMAN FOOT \ *-.*»***' f^M**'" 1 iW"" .;J- ■•# A Good Example of the 15th Century Period, Pointed or Poulaine Shoe with Strap for Tying It Over the Instep. Examples of Broad Toed Leather Shoes of Early 16th Century Date. "A Sole of a 15th Century Peaked Shoe. t^^f***** ^ j gTj ■ W »wgg*g& '.--'.' A Fa ixr ° f Crimson Morocco Leather Shoes, A Broad Black Leather Toe Piece Pounced Worn During Middle 18th Century. and Slashed. It Measures 5]/ 2 inches Across. Chart No 195 HISTORY OF FOOTWEAR 309 my return that all London is booted and apparently ready to walk out of town." In this period, at the beginning of the Civil War, when England was divided in two great camps, Royalists and Republicans, the Royal- ists, or Cavaliers, were as much distinguished from the Republicans, or Roundheads, in their dress as in political principle. The dress of the Cavalier embodied all that savored of graceful ease and luxury. In place of the trunk hose, long breeches or short trousers, which were finished off with ribbons and fringe below the knee, were worn. Nearly meeting these, came the boots with wide ruffles at the tops, which were often the cause of mishaps, as an unlucky gentleman remarks : "One of the rowels catched hold of the ruffle of my boot, and being Spanish leather, and subject to tear, overthrew me, rends me two pair of silk stockings, that I put on, being somewhat of a raw morning, a. peach color and another." This proves to us that ruffles were made of leather like the boot. It must have been much finer and softer to admit of being pulled and fringed out at the edge, as was commonly the case. Indoors the Cavalier wore what was more becoming, viz., low shoes with rosettes, which showed the smart silk stockings to ad- tantage. Shoe tyes that go under the name of roses cost from thirty shillings to three, four and five pounds. Yea, a gallant of the line not long since paid thirty pounds for the pair. The dress of the Puritans was very sombre, not because it was imposed on them, or because their rank and position made luxury unseemly, but from choice. To the Puritan all adornment was abhorrent, beauty a curse, and luxury a crime. The boots worn in the Cromwell era were principally made of Spanish buff leather. They were plain to ugliness, and were armed with a square piece of leather in front to keep the pressure of the stirrups from the instep. During the existence of the commonwealth, and for a long time after, the tops of the boots were of enormous width. The shoes worn during the reign of Charles II. and James II. were distinguished by their high heels and long toes tapering towards 310 THE HUMAN FOOT A Chinese Shoe for a Child. An Eastern Shoe Made of Hempen Strings. An Eastern Pair of Wooden Soled Shoes. Wooden Ch opine or Clog Worn by Turkish Women. This is 8 inches High. A Lady's Shoe of the Middle 18th Century. A Turkish Lady's Slipper Made of Green Leather. Chart No. 196 HISTORY OF FOOTWEAR 311 IN' 1 1 Lady's Shoe of the 18th Century Worn with a Clog. Jack-Boot Worn During the Cromwellian Period. A 17th Century Lady's Shoe of Beautiful Workmanship, Made of Crimson Morocco Leather. x xgm i^^T*^. *«■ Stoe which Belonged to King Charles. " "\--Jk 17th Century Leather Shoe 'An 18th Century Shoe. Chart No. 197 312 THE HUMAN FOOT the points, but cut square at the ends, the uppers of which not only covered the instep but extended far over the shins of the wearer. Women of all degrees appear from the pictures we see to have indulged in high heeled shoes. Even a country lass, with her short skirt and basket on her arm, was perched up on heels which would not disgrace a fashionable bootmaker today. Sometimes the Puritan women wore the more sensible clog, or what was similar to that footgear, strapped across the foot, and keep- ing her well out of the mud. The citizeness of the richer class wore large rosettes on her shoes, and when she walked would hold up her gown over a lace-trimmed petticoat. Shoes of Spanish leather laced with gold were commonly worn, those worn by the men of fashion being squarer or less pointed toes with huge flaps ornamented with small buckles, the heels being somewhat higher and covered with colored leather. It is said that buckles were first used in the reign of William III., but if this is true, how is it that the brass monument of Robert Attelath, at Lymm, who died in 1376, is depicted with shoes having buckles? It is fair to say that some are disposed to believe that the buckles worn prior to William III. were only used as ornaments. These buckles, worn so much at the time, were very costly, and it is beyond doubt, from the fact that they were often made from the most precious metals and studded with brilliants. William himself wore high jack boots, differing slightly in form from those of his predecessors, having the same instep guards and cut as ugly as can be imagined. The shoes of the ladies had high heels, and it was quite common to bridge them with a leather clog. During the reign of George I. and II. the high-cut quarter shoe was continued to be worn by men, red being the fashionable color for the heels, and adorned with buckles of large dimensions. The shoes worn by the ladies were much handsomer than those worn by their immediate predecessors, the ugly square toes having been super- seded by toes less broad and more sightly. HISTORY OF FOOTWEAR 313 North American Moccasin. U * 4 An Indian Child's Shoe. ".'■Uy.Si^ A Brown Leather Shoe with Double Latchets, Crossing Extremely High Instep Flaps and Fastening at the Sides by Means of a Button and Hook. African Sandal of Niger River District. The Ringed Receptacle for the Great Toe is a Feature in the Sandal. African Sandal of Plain Character. A Sandal from the Niger Rh-er District. Chart No. 198 314 THE HUMAN FOOT 17th Century Shoe. A Beautiful Shoe of the 18th Century Made of Crimson Velvet Embroidered with Gold. 17th Century Lady's Shoe. A Common Every-Day Leather Shoe Worn _ During the 17th Century. Chart No. 199 HISTORY OF FOOTWEAR 315 The clog worn was also improved by having the heel sunk to receive the heel of the shoe. The uppers were cut from silks and satins, and were richly embroidered. The heels of these shoes were made of wood, covered with silk, satin and fancy leather. With the advancement of time shoe quarters were cut lower and the heel "brought more forward. The short, varying shoes worn by the ladies came into vogue in the year 1790, and were of necessity low in the quarters, and they scarcely had any heel. Shoes with buckles lasted to the commencement of the present period or, rather, revived at that time. They were speedily succeeded by shoes fastened with strings. The buckle makers, being nearly ruined by this new mode in shoes, peti- tioned the then Prince of Wales to prohibit the wearing of shoe- strings in favor of buckles, but his readiness to oblige the petitioners did not materially serve them. In the reign of George III. close fitting top-boots, the legs of which were cut from grained leather, were very commonly worn, the upper portion being cut to resemble the form of the leg, and it was finished with a turnover, or a top, as it was afterward called. Boots not so high were difficult to get on or off and in the process of time the height of leg was lowered. In many of these boots the turnover reached down to the ankle. It was during this reign that the Hessian came into fashion, conceded to be the handsomest boot ever worn. This boot was a German importation, but boots cut similar to this were known to have been worn in Bohemia as early as 1700. This was followed by the Wellington. In the reign of George IV. the boots worn by the ladies were laced up the front. Side lacings revived in that of the succeeding monarch, and the "Adelaide'"' boot took, its name from William's consort. Sandalled slippers were also worn and remained in fashion to the early portion of Queen Victoria's reign. Ribbons for shoestrings were commonly employed at this period. The cut of the quarters has since undergone many changes, mili- tary laced boots having become quite common for ladies' wear. There 316 THE HUMAN FOOT Walking Shoe with Rubber Heel. Blucher Oxford. Fancy Cloth Top Button Boot. Patent Leather Dress Pump. Chart No. 200 HISTORY OF FOOTWEAR 317 was an interval when the high heel was superseded by the low, roon after the high heel again asserted itself, and has remained popular to the present. Blucher shoes, which came into fashion in the early part of the Eighteenth century, continued in favor down to a very recent date, and are not yet entirely displaced. The modern shoes are now constructed on more hygienic lines, yet with a great variety of patterns, with variations in material. (See Chart No. 200.) CHAPTER XL FOOTWEAR AND FITTING OF SHOES In the preceding chapter we have given a general history of shoes and footwear up to the present century, and if this general history is carefully read it will be seen why and how shoes are the principal cause of mechanical disturbances of the normal foot. It is shown that from the early ages considerable thought was given to style and fads rather than to the scientific requirements. This subject has been discussed in various publications, but the writers' opinions differ as to the fitting of the shoe, the construction of the last, and the size and height of the heel because, generally speaking, their deduc- tions were based on the consideration of the perfectly normal foot. My belief is that the feet of today — the feet that are fitted — are the ones to be considered, and these considerations should be governed by the size and shape of the foot, the style of the shoe desired by the shoe patron, the style and pattern of shoe the patron had pre- viously worn, and the pliability and general condition of the foot. In order to understand the subject thoroughly, it is first necessary to know of the general construction of the shoes of today, the meas- urements over which they are made, sizes, etc., which will be given in the following chapters. Measurements of Last — The foundation and principle in shoe making is founded on the measurements and the wood put into t he- last or form over which the shoe is made. All last makers tell us that the fixed standard of measurements and sizes are carefully fol- lowed out regardless of the style or shape of last to be constructed Thus, if this is true, the proportions while differing in shape are still of the same basic measurements. Now this would not necessarily mean that the shoe produced over a size 6E on one style of last would fit the same foot made in the same measurements with dif- ferent shaping of the wood. For this reason the student should 318 FOOTWEAR AND FITTING OF SHOES 319 qualify by knowing the foot and last measurements, and study the conditions of the foot to be fitted. The following are measurements adopted in the U. S. A. by the National Association of Retailers for standard shoe lasts: Standard Shoe Last MEN'S Measurements Sizes 6 6h 7 7| 8 8i 9 % 10 m 11 Hi 9! 12 fBall .... 76 ' 8 71 8 8! 81 81 8! 81 m 81 9 91 A J Waist . . n 7% 71 8 8! 81 81 8! 81 81 85 9 9! I Instep . . m 8| 8| 81 8| 81 9 9! 91 91 9! 91 9% [.Heel ... HI HI HI HI 12 12 8 121 121 12! 12| 12f 121 13 fBall .... 8 8! 81 8| 8t 81 81 81 9 9! 91 91 9* g J Waist . . n 8 8* 81 81 8! 88 81 8? 9 9! 91 91 I Instep . . 8! 81 81 8? 9 9 8 91 91 9! 91 91 91 10 [Heel ... m 11? 12 12 8 121 121 12! ■121 12| 12J 13 13! 131 fBall .... 81 81 8* 81 8 R 81 9 91 91 91 94 91 f 9l q 1 Waist . . I Instep . . 8 S 81 8| 8f 81 81 8 7 °8 9 9! 91 92 9! 91 8« °8 81 9 9 R 91 91 9! 91 9£ 91 10 10! 101 |_Heel ... 12 12 8 121 12| 12| 1^1 121 121 13 13| 131 131 13| fBall .... 8! 81 81 81 9 9i -*8 91 91 Q4 91 91 91 10 j) J Waist . . 8 3 h 8! 81 81 81 9 91 7 8 91 Q3 9! 91 9% 91 ] Instep . 9 9* n y* 9! 91 Q6 "8 91 10 10! 101 101 10! 1 Heel ... 12| 121 12| 12| 121 125 13 13! 131 131 13! 131 13| fBall .... 81 81 9 n 91 91 9! Q5 -*8 91 01 10 105 101 E 1 Waist . . 1 Instep . . 8* 81 81 9 9! 91 91 9! 91 91 91 10 10! 91 n y* 91 9§ 91 10 10! 101 101 10! 101 101 1 Heel ... 12| 121 12| 121 13 13! 13| 131 13! 131 13| 13| 14 fBall .... 9 9, 91 91 91 91 91 10 1 Oh- 101 101 10* p J Waist . . 1 Instep . . 85 9 9! 91 Q3 -*8 9! 91 91 91 io 10! 101 101 9! n y* % 10 10* 101 101 10! 101 101 101 11 iHeel ... 12| 121 13 13 8 131 13| 13* 131 131 131 14 14! 14| Standard Shoe Last LADIES' Measurements Sizes 2£ 3 31 4 41 5 Si 6 61 7 fBall ... 61 7 71- 71 7\ 7* ' 8 7 s ' 8 71 7T- ' 8 8 A -\ Waist . 61 61 7 7! 7% 73 ' 8 ^ ^ ^1 /I I. Instep . 7% 7! 7\ 76 ' 8 71 8 8! 81 81 8! fBall ... 7\ 73 71 7i 7% 76 ' 8 '8 8 8! 81 B ] Waist . 7 7+' 71 73 7% n 76 y* 8 8! L Instep . 7 s - ' 8 76 ' 8 71 8 8! *i 81 8! 8 8 8* fBall ... 71 71 71' 76 ' 8 71 ' 8 8 8! 81 8| 8! C ■{ Waist . 7% 7.3 7* 7* 71 n 8 8! 81 81 1 Instep . 71 8 8£ 8! 8| 81 85 8f 84 9 320 THE HUMAN FOOT Standard Shoe Last LADIES'— Continued Measurements Sizes 21 3 3£ 4 4h 5 51 6 6h 7 f Ball . . . D j Waist.. 1 Instep. . 7\ n 8 S L 7" ' 8 71 81 7 7 71 81 8 7| 8| 8 81 8| 81 8| 8| 8! 8| 8! 81 9 81 8| 9s- 81 81 9| f Ball . . . E i Waist.. L Instep. . n 7% 81 8 71 8| 81 8 8| 81 8£ 81 81 81 81 8| 81 9 81 8f 9 8 81 81 8J 81 91 9 8? 9| Standard Shoe Last MISSES' Measurements Sizes A f Ba11 • A -j Waist L Instep f Ball . B 4 Waist L Instep fBall . C -i Waist L Instep .Ball . -I Waist Instep Ball . 2 «J Waist Instep 11 111 12 121 13 131 1 11 51 ss 6 6* 61 61 6* 6f 51 si 5* 6 61 61 6? 6* 61 61 6f 6f 6| 61 7 71 6 61 6§ 6£ 6* 6| 61 61 5* 6 61 61 61- 6| 61 6 a 61 61 61 6| / 7i 61 7f 7| 6| 6£ 6^ 61 61 7 71 61 61 61 6* 61 6% 6* 7 6| 6| 7 H 71 n 7f 7f 6i 61 61 61 7 7\ 7| 7| 6£ 6f 61 6£ 6* 7 7* 71 7 71 7| n 7* ' 1 7\ 7§ 71 61 6J 7 7^ 71 71 7f 7% 61 61 6* 7 7* 71 7f 7% 7\ 71 7| 7| 7| 74 8 81 7 6\ n_ I* ?* li. 7i 71 71 7i Standard Shoe Last BOYS' Measurements Sizes 1 u 2 21 3 31 4 41 5 51 f Ball . . . 6* 61 61 63 7 7& 71 7i 7% 71 A J } Va / st • Instep . 6* 61 6| 61 6g 7 7 S 71 7% 7% 7 71 71 71 7f 71 71 71 8 K 1 Heel . . 10 101 101 101 lot 10| 101 101 11 111 f Ball . . . 6| 61 7 71 7|- 7f 7* 7| 71 7' ■d J W aist . D 1 Instep . 61 61 61 7 71 71 73 '3 7% 71 7\ 71 7| 7* 7f 7| 71 8 81 81 81 1 Heel . . 10| 101 10| 101 1UJ 101 11 111 11! 11! FOOTWEAR AND FITTING OF SHOES 321 Standard Shoe Last BOYS'— Continued Measurements Sizes 1 li 2 21 3 3i 4 4§ 5 5* f Ball .. 7 7| 71 71 7* ' 8 7 s 76 71 8 81 q 1 Waist 61 7 n 71 7a ' 8 7-5 7« 7| 7\ 8 1 Instep n 71 71 71 8 8* 81 81 8| 8f L Heel . 10| 10| 10| 101 11 HI HI HI HI HI f Ball . . . 7| 73 ' 8 7 4 ' 8 7| 7& 7- 7 8 81 8| 8? jj J Waist 1 Instep . 7 1 ' 8 71 ' 8 73 ' 8 7% 7| 76 ' 8 11 ' g 8 81 81 7| 71 8 81 81 81 8| 8 5 °8 81 81 L Heel . 10| 10| 11 HI HI HI lit HI HI Hi f Ball . . . 7* 7| 76 71 8 8| 81 81 8* 8| E J Waist ] Instep . 73 '8 7f 7| 7| 7 1 ' 8 8 81 81 81 81 8 81 8| 81 8| 8| 81 8 S 9 91- 1 Heel . 11 HI HI HI Hf HI HI HI 12 m f Ball . . 76 7" ' 8 8 81 8f 81 8t 81 8! 81 F Waist 7f 7| n 8 8J 81 81 81 8| 81 Instep 8| 81 st 81 8| 8? 9 9* 91 91 I Heel . HI HI in Hi HI in 12 12| 121 12| Standard Shoe Last YOUTHS' Measurements E Sizes Ball .. Waist Instep Heel . Ball .. Waist Instep Heel . Ball .. Waist Instep Heel . Ball .. Waist Instep Heel . Ball .. Waist Instep Heel . Ball .. Waist Instep Heel . C 6 C22 3 S 2 73 '32 CIS J32 Ci.4 D 3 2 C3 ^ :>. :> 58 6 J 3 2 511 6 A 811 6ft C3 J 3 2 Us 2 U 32 63V 611 811 8* 6H 611 6 3 ft u 3? QJL -'3 2 =U3 J32 5ft 5SI 8ft 5Si 511 63*2 Sal 5§2 6ft 841 6ft 6ft 641 6JI 6ft 6§§ 9ft 6ii 611 7ft 9ft C24 J 3 2 5|° 2 6ft 811 6 C28 J 32" 6J-I 6ft 6ft 612- 6J| 65; 9,* 6|f 611 7ft 9!I 5 3 § 5^§ 5Si 511 63^ 6ft 511 6M 611 6ft 611 6il 6SI 9 3 7 2 611 6§i 7ft 9JI 10 cao D 32 C26 J3J u 3 2 6ft 6ft 61-1 611 611 611 9ft 611 611 7_8- '32 9 x ft y 3% °32 ^26 710 '32 Ql 8 m 11 511 5 Si 6 3 D 2 8sl 6ft 6i§ 81i 6ft 6ft 6S1 655 641 63I 9ft 6SI 6§i 7ft 941 7ft 6 SI 741 9Si 51 51 61 61 6 6-1 6f 61 61 6| 7 91 74 7 7! 91 Hi 6 51 6* 6| 61 6f 12 64 6f 61 6! 9 61 6f 61 94 61 6f 74 9| 71 74 71 94 61 63 71 94 74 7 7| 9: 71 7| 76 '5 10 124 61 61 61 6f 74 9f 7 61 71 91 7% 7i 91 7 4 ' 8 71 71 104 13 64 6! 6| 9 61 61 7 91 74 7 92 7| 7| 74 10 71 13i 6f 61 64 94 61 74 9! 7 61 71 9f 72 'F 7J- ' 8 7% 91 71 71 71 101 7| 7| 101 10f 21 322 Standard Shoe Last THE HUMAN FOOT CHILD'S Measurements Sizes fBall .. A -I Waist Llnstep fBall .. B 4 Waist Llnstep fBall ., C A Waist Llnstep fBall . D 4 Waist Llnstep fBall .. E -i Waist Llnstep 41! 411 •5-*- ^32 5U SB 514 eon J 32 6 C2S J 3 2 C2fi OiT5 4|* 411 544 5 3 7 2 5& 541 C15 032 541 515 Sli 514 5§4 511 644 7 5r 3 5 5H cio «* 3 2 C22 •JS5 KSA ^3 2 J 3 2 6- 6 - 6 A 6 6M 74 5 3 % 5^2 541 541 544 5§i 514 548 6& 511 5ii 6 a 9 5 6 3 5 2 641 5- 8 - J 3 2 J 3 2 C20 Jffl ■Jig °32 C14 °3 2 C2S C24 C2 2 °3 2 6A Can J 35 641 84 5 3 9 2 511 541 545 514 5U 6 3 7 2 6 3 3 2 6^ 643 644 6 3 9 2 611 •j 3 2 J 3 2 C2R Js5 5|| 5!§ 6A 63% 6A 641 6H 05-5 9* 545 541 511 5§i 511 6^2 6& 514 64! 6 3 °2 6 3 7 2 614 645 64i 611 10 C2(1 3 5 2" Cl 8 °3"2 6 C28 J3 2 C2fi ->3^ 6A 6ft 6ft 641 641 641 611 6|| 64 § 7 104 511 514 6ft 5§4 5§1 644 6ft 6ft 641 641 641 615 611 614 7 3 3 2 These sizes are divided, for the convenience of the student inter- ested in shoe fitting - , into the following classes. They show also the measurements and lengths of the various sizes by inches. Infants' Sizes to 5 Size measures in length 4 inches. Size 1 measures in length 4^ inches. Size 2 measures in length A 2 /s inches. Size 3 measures in length 5 inches. Size 4 measures in length 5 l /i inches. Size 5 measures in length S 2 /$ inches. Children's Sizes Run from Sizes 6 to 8 Size 6 measures in length 6 inches. Size 7 measures in length 6 l /i inches. Size 8 measures in length 6 2 /s inches. Children's Sizes, Second Run, 9 to 11 Size 9 measures in length 7 inches. Size 10 measures in length 7 T /3 inches. Size 11 measures in length 7 2 /z inches. FOOTWEAR AND FITTING OF SHOES 323 Youths' and Misses' Sizes, 12 to 2 Size 12 measures in length 8 inches. Size 13 measures in length 8^ inches. Size 1 measures in length 8^3 inches. Size 2 measures in length 9 inches. Boys' Sizes, iy z to 5 Size 2y 2 measures in length 9j4 inches. Size 3 measures in length 9Vz inches. Size 4 measures in length 9 2 /z inches. Size 5 measures in length 10 inches. Women's Sizes 2 to 8 Size 2 measures in length 9 inches. Size 3 measures in length 9 T /s inches. Size 4 measures in length 9 2 /z inches. Size 5 measures in length 10 inches. Size 6 measures in length lOj/3 inches. Size 7 measures in length 10^ inches. Size 8 measures in length 11 inches. Men's Sizes 6 to 12 Size 6 measures in length 10j^ inches. Size 7 measures in length lO^ inches. Size 8 measures in length 11 inches. Size 9 measures in length II3/3 inches. Size 10 measures in length 11^ inches. Size 11 measures in length 12 inches. Size 12 measures in length 12^ inches. The above measurements in length are the measurements at the ball, waist and heel. These are the principal measurements to be considered. 324 THE HUMAN FOOT METHOD OF MEASURING THE FOOT FOR FITTING READY-TO-WEAR SHOES The equipment for shoe fitters is, first, the standard measurement stick, a rule showing the measurements in inches and the measure- Chart No. 201 Illustrating Measurements and Manner of Taking Measurements. ments of shoes in sizes given on the top surface of the rule. As an adjunct a shoemaker's measuring tape should be used. (See Charts Nos. 202 and 203.) Chart No. 202 Standard Measurement Stick for Shoe Fitters. The present method of shoe fitting and measurements is based principally on the length, and the fitting of the shoe in Avidth is left to the discretion and good judgment of the fitter. The shoe dealer or shoe fitter who has had sufficient experience can usually recognize FOOTWEAR AND FITTING OF SHOES 325 the width of shoe by the appearance of the foot, with the help of the measurement of the length of foot on the measuring- stick. Chart No. 203 Shoemaker's Measuring Tape The measuring of the length in fitting shoes is very important, because more malformations and deformities are caused by shoes fitted too short, than by those fitted too narrow or too wide. Chart No. 204 Foot Being Measured without Weight on. The foot is placed on the measuring stick and the weight of the body borne on it. The reason for this is to allow for the natural expansion of the normal foot and the elongation of the abnormal, weakened or flat-foot, so as to still allow sufficient length to the foot in the standing upright position. 326 THE HUMAN FOOT Practically all feet expand slightly when the weight of the body is placed upon them. The natural expansion should not be over one-sixteenth to one-quarter inch. If there is more elongation present it is due to weakness of the Longitudinal arch, allowing the foot to spread and elongate. When the foot is measured with the weight upon it, an allowance of one and one-half to two and one-half sizes for proper length should be made. In other words, the length of shoe selected should measure that much longer than the entire length of the foot in a standing position. Chart No. 205 Same Foot Measured with Weight on, Showing Elongation of One Full Size. Any disturbances of the foot, such as deformed toes, ingrowing toe-nails, weakened transverse arch, weakened longitudinal arch, broken-up arch, can be traced directly to the wearing of short shoes. Bunions, enlarged joints, crooked toes, can also be traced to short shoes. Now, as regards to what constitutes a good fit, the following rules should be carefully carried out : First, the correct length, one and one- half to two and one-half sizes longer than the actual measurement, of the foot; second, width, sufficient width at the ball to allow for the natural spread of the foot at that point without compressing the foot ; third, a snug fit through the heel and instep ; fourth, if a lace FOOTWEAR AND FITTING OF SHOES 327 shoe, the top stay should not come close together, but expanding enough to permit of enough space to enable one to draw the top or instep of the shoe snug without meeting. Care should be taken in the selection of a shoe so as to allow a sufficient space over the toe cap or seams to prevent restriction to foot action. The style of heel must depend upon the customer or patient, and the style of heel pre- viously worn must be taken into consideration. Women who have habitually walked on high heels should be permitted to continue to wear them unless the change is made by very small degrees. If a foot poised for a high heel is put into a low heel shoe, you disturb the balancing of the whole body, to say nothing of what it will do to the foot; but remember that a great many disturbances, nervousness and other conditions result. The poise of the foot ac- customs itself, and the ligamentous and muscular attachments are likewise adjusted to that poise. In the fitting of shoes, and in the correction of foot troubles, it is necessary to take into consideration the fact that nearly everyone has deformed feet as a result of improper shoes since childhood, and after they have reached an age in life where development is com- pleted it is quite difficult to make any alterations in the skeleton of the foot. This is a very broad and useful rule and understanding to have in shoe fitting, and in the selection of footgear for corrective purposes. The flat heeled, broad toed type of shoe, and the extreme patterns of corrective shoes following the theory of Meyer in drawing a straight line through the center of the heel to the center of the great toe, cannot be thoroughly depended upon as good fitters for reasons previ- ously stated. Therefore, shoes should be constructed over lasts de- signed on anatomical principles constituting a perfectly normal foot. And while, in so doing, one is carried a considerable distance from the present day type, that construction will permit nature to assert herself. Shoes having a straight or nearly straight inside line are preferable. There is probably no factor so important in the causation of foot weakness and disturbances as that of the shoe. Shoe fitters and shoe 328 THE HUMAN FOOT salesmen and, clerks in retail stores should be posted on the mechan- ical construction of the foot, which has been thoroughly discussed in the preceding chapter. They must understand that there are various types of feet, those having high arches, low arches, the long, slender foot, the^ short, wide foot, and the feet that are abnormally thick and abnormally thin, in large and small sizes. Then, one must know the elastic movements of the foot, and what is required in dif- ferent ages and in different occupations and climates, and it has been Chart No. 206 Showing Meyer's Line. proved time and again that the requirements of the foot are different at different ages. In infancy the foot is broad at the toes and narrow at the heel, and the bones are soft and tender. It is at this period that the foot is growing rapidly, and like all other organized bodies under similar circumstances, the feet are very easily distorted and injured by external pressure. Therefore, at this age great care must be taken so that the child arrives at maturity free from deformity caused by ill-fitting shoes. I am glad to notice that within the past FOOTWEAR AND FITTING OF SHOES 329 ten years wonderful strides in the manufacture of children's shoes have been made, and instead of crowding the foot into a pointed toe shoe it is now allowed to glide into the orthopedic shape shoe, leaving room for the five toes. Chart No. 207 A — Straight Inside Line Shoe with Broad Toe. I! — Straight Inside Line Shoe with Modified Toe. C — Broad Toe with Swing to Outside, Away from Straight Inside Line. D — Narrow Toe with Swing to Outside, Away from Straight Inside Line. Between the ages of nine and fourteen extreme care must be taken in fitting children's feet, because there is considerable expansion and growth at this period, and but very little thought or care is given to the feet by themselves. From the age of fourteen to twenty-one years the foot gradually assumes a more mature form, the Tarsus becoming thicker, but during this age young people are more apt to 330 THE HUMAN FOOT Chart No. 208 Foot Thick Through Heel and Ankle, with Enlarged Great Toe Joint. Chart No. 209 Foot with Low Instep at Waist, Otherwise Normal. Chart No. 210 Foot Showing Normal Arch. FOOTWEAR AND FITTING OF SHOES 331 have notions of fashion and style, and cramp their feet into narrow- toed and short shoes. There is much to be said also in the application of the shoe fitting- knowledge to persons of old age. The foot having attained its ma- turity is still, however, subject to changes peculiar to organic life, such as the daily waste repairs, and wear and tear from exercise, con- sequently provision must be made allowing free action in these respects. It is in older age that muscular weakness, such as weakened foot and flat-foot, develops. Then again provision must be made for the corpulent men and women, where there is rigidity of the structure of the feet and limbs, and a further provision must be made for occupations requiring per- sons to be long hours on their feet. If feet are fitted properly, and no structural weakness exists, there should be no more discomfort to the feet than to the hands, inde- pendent of the fact that the body's weight is carried constantly on them. It must be stated that the mechanical construction of the human body is such that due allowance has been made for the work imposed upon its members. SUMMARY The shoe fitter, then, should possess the necessary qualifications, and following knowledge : First. Knowledge of the structure of the human foot, bones, muscles, ligaments and tendons. Second. Be able to recognize abnormal from normal feet. Third. Be able to detect the variations in feet, and intelligently assist in fitting the normal foot to preserve its normal condition. Fourth. Abnormal feet should be carefully examined and inquiry made as to the cause, and the right method of fitting or correcting the cause ascertained. Fifth. To know from symptoms, such as callosities, corns, soft corns, bunions, etc., that these may be produced by slight bone dis- placements, and to have the correct shoes and appliances to relieve 332 THE HUMAN FOOT the underlying cause, with an object in view of correcting the ab- normality. Sixth. To be able to detect the weak, flexible foot that requires mechanical aid, and a knowledge of fitting and adjusting appliances to give relief. Seventh. To have a knowledge of shoe making, of modern shoe construction, and be able to judge the fitting qualities of shoes, whether they are extreme fashions or modified orthopedic shoes, and apply the right shoe on the right foot. Eighth. To be. able to recognize abnormal conditions from symp- toms easily traced by the manner in which the old shoes have been worn. All men and women do not walk in the same manner. They do not throw or roll about their shoes in the same manner. This may be caused by physical defects, weakness in the muscular control, false positioning of the structures, and also due to occupations in the varied walks of life. Old men and women walk considerably different, due to the general declining condition of the tissues. Tall persons walk with a different stride than the short, stout people. Old people who' walk with their heads bowed are obliged to bend the knees to preserve their equilibrium. Women who have always worn high heel shoes and have then changed to low heels are obliged to change their gait to maintain their equilibrium. "Women, towards the end of pregnancy, walk with the upper part of their frame thrown upward to maintain their equilibrium, which changes their gait in walking. Persons whose shoes are short make indentations in the inner cap of the toe of the shoe, and the end of the toe of the sole is usually stubbed off. Persons with severe, irritating corns throw their weight on the heel so as to avoid pressure. Persons with bunions, enlarged toe joints, which may be caused by weak arch or flat-foot, wear their shoes to the outside in an endeavor to avoid pressure. Those with weak ankle and flat-foot wear off the inner border of the heels, owing to the over- balancing of the weight on the inner border of the arch. Persons having Metatarsalgia or weakened foot in the anterior arch spread the uppers of the shoe across the ball of the foot from the out- FOOTWEAR AND FITTING OF SHOES 333 side edge of the sole, and will irankly admit that no shoe seems to hold its shape. Women having arch weakness complain of slippers and low shoes bulging on the sides, and are not successful in securing a neat fit. Slipping at the heel is also frequently due to a weakness of the arch. CHAPTER XLI HOSIERY This is a very important subject to the practitioner of mechanical orthopedics, inasmuch as socks and stockings have a vast influence in causing disturbances of the foot. Indeed, it is not uncommon to know or to notice cases of foot distortions due primarily to pointed toe and short, unyielding stockings. Fig. A Chart No. 211 X-Ray Showing Foot in Pointed Toe Hose and in Toe Free Hose. A, X-Ray Showing How Ordinary Stocking Crowds the Toes. B, X-Ray Showing the Same Foot in Toe Free Stocking. You have all experienced at some time or other the agony of being required to thrust your foot into a stocking possibly of wool or other material which had been badly shrunken, and how uncomfortable and annoying they were to the feet until by actual pressure and expansion created by the foot that yielding of the yarn was made possible. I have frequently noticed this in my practice where mothers are com- 334 HOSIERY 335 pelled to stretch and pull the stocking in order to be able to draw it over the infant's chubby foot and leg. No Pressure at Fifth Toe. Cramped Toes. Chart No. 212 Showing Correct and Incorrect Hose. Great care should be taken from the first wearing of socks or stockings, beginning with the child. For children, the stockings in summer should be made of fine white cotton or silk, or silk and wool; then in winter or cold weather they may be made of a light woolen 336 THE HUMAN FOOT fabric, knit flexible enough to cling to the foot but not disturb the natural little motions. Extreme care must be taken in having the stocking sufficiently long and wide at the toes. It is true in the infant that as much action is given to the toes as to the fingers, and these little motions which mean much in the development of the muscles of the lower limbs Chart No. 213 Digitated Hose. should not be interfered with. In adults the result of the early wear- ing of short, pointed toe hosiery may be found in such distortions as hammer toes, bunions and flat-foot. In practically all cases of struc- tural weakness it will be found upon careful investigation that stock- ings have contributed their destructive work through interfering with the natural motions of the foot. Not uncommonly will you find a patient well fitted in two shoes, HOSIERY 337 but the foot actions restricted by the pointed toe short hose. Among women this is very common where the combination hose supporters are worn, as the action of walking and body motion has a tendency to draw the stocking tight around the foot and toes, and among most women and children the action of walking and stepping has a tendency of drawing the stocking tight about the foot as one would work the fingers of a glove over the hand. Chart No. 214 Hose with Compartment for Great Toe. Again, the modern way of knitting hosiery to a point requires the foot to labor considerably before space for the five toes has been located. In the mechanical treatment of hallux valgus, hammer toes and contracted toes, where mechanical treatment has been resorted to, extreme care must be observed in giving advice to the patient as to hosiery. 22 ]38 THE HUMAN FOOT Chart Xo. 213 represents a digitated hose, affording- a separate com- partment for each toe, constructed along the same line as the glove having separate fingers for the hand. This permits complete mobility and action to the toes and the muscular attachments, but is not so practical for general purposes, as an extremely wide shoe is required to permit of the additional space necessary due to the double layers of materials between the toes. The digitated toe stockings are indi- cated, however, in many deformities of the toes. Chart Xo. 214 shows a very practical stocking, which is constructed to have a compartment for the great toe only. When made of the Chart No. 215 A Right and Left Style of Hosiery. right material and correct shape, permitting space for the remaining four toes without hampering, this style of stocking can be made prac- tical use of in bunions or dislocation of the first phalanx of the great toe and is especially indicated. It is also very useful where bunion right or toe flex devices are worn to support the great toe and hold it to its natural position. Chart No. 215 represents the right and left style of stockings, which are very practical from the orthopedic standpoint, but are rather diffi- cult for the person wearing them unless they are continuously worn on the same feet. HOSIERY 339 Chart No. 216 represents the most practical and ingeniously de- signed stocking, which can be worn with a greater degree of comfort, and have the greatest prophylactic value in preserving the natural movement of the foot. It is knitted over a model or frame, which permits its being worn on either right or left foot, and being quite nearly square with only sufficient tapering to overcome any extreme fullness, permitting the natural toe movements. This style of stock- Chart No. 216 Toe-Free Hose. ing has been used by the author in his many years of practice with success, and is known as the toe-free hose. I am sure the ortho- pedic practitioner will appreciate the many advantages and the wide range of usefulness that this hosiery will command. In the X-ray plates (Chart Xo. 211) Fig. A indicates the ordinary stocking or sock with distorted phalanx while Fig. B shows an X-ray of the toe-free pattern, indicating perfect freedom of the Phalanges. 340 THE HUMAN FOOT Summary. The stocking, to assist in foot treatment, should then consist of : First. One made of a smooth weave, free from wrinkles, seams, etc. Second. If feet are tender, toe part or foot of stocking should be made of a soft undyed yarn. Third. Never allow fancy dyed hosiery to be worn by persons having any skin abrasions, blisters, excessive perspiration or ten- derness. Fourth. The size of the stocking should be selected according to measurement. In men's sizes they range from 9^4 to size 12. The usual size markings indicate inches, and one-half inch should be added to the measurement of the foot. Fifth. When the stocking is on the foot there should be no sen- sation of pressure about the toes, and the length from heel to toe should be sufficient to permit the natural expansion of the foot when the weight is placed upon it. Sixth. Don't have the stocking too large or too long. Wrinkles will form and blisters may result. Seventh. The stockings must be kept absolutely clean. They should be thoroughly washed with warm water and soap, thoroughly rinsed and dried in the sun. A clean pair should be worn each day. Where stockings are not washed each day they should be worn alter- nately. Eighth. Dusting the inside of the stocking with an antiseptic foot powder will reduce friction and act as a disinfectant, and has a cor- rective action on the skin. CHAPTER XLII CARE OF THE FEET As considerable comfort and pleasure depend on keeping the feet in a state of health, I will discuss in this chapter the care and atten- tion feet require. From the time shoes and stockings are first worn care and attention is essential. The feet should be washed thoroughly with a good antiseptic soap, the granular form being the most benefi- cial ; they should then be wiped and thoroughly dried, particularly between the toes. The nails should be cut square, and not often, care being taken that they are not cut below the top of the toes, as they are likely to result in onychia (ingrowing toe-nail). In addition to washing, the feet should be bathed, this being neces- sary in various conditions of the feet. The proper and most con- venient time is at night just before retiring, but under peculiar cir- cumstances they may require bathing at other times during the day. The use of hot or cold water for bathing the feet depends greatly on the difference, and constitution, and habits ; thus, for persons ad- vanced in years the tepid bath is preferable, especially if they are sub- ject to gout or rheumatism. A change of temperature in such cases may cause serious results, and this treatment is to be deferred while the patient is suffering from either of those disorders. As a rule, it is not advisable for old people to bathe the feet ; however, great com- fort may be derived from sponging them once or twice a week, using a granular antiseptic soap and warm water, which will soften the scales and cuticle, and can subsequently be rubbed off with a coarse towel. When the feet become fatigued and inflamed after a day's use, they should be bathed in a hot antiseptic solution for about fifteen or twenty minutes. As soon as the feet have been dried, the callosities and excrescences can be rubbed off with a coarse towel. Then the; 341 342 THE HUMAN FOOT feet should be thoroughly massaged, using the healing, penetrating pedico foot balm. If the skin is naturally soft and moist, an astring- ent solution should be used. When the skin on the Plantar surface is hard and chapped, it must be rubbed until it becomes smooth, after which the foot is massaged with soothing balm. If the fissures ex- tend through the skin after the thickening has been removed, their sides should be kept in apposition with strips of adhesive plaster drawn tightly over the Dorsal side. The perspiration of the feet rarely if ever requires medical atten- tion, unless it is so excessive as to be a source of annoyance, or the odor so disagreeable as to be offensive. The latter causes the person affected much discomfort. The odor in warm weather or hot rooms is most perceptible, and in many cases so fetid that the society of the person affected is avoided. There is not any permanent cure, but bathing the feet in antiseptic and astringent solutions, with frequent change of stockings in which a good foot powder has been previously sprinkled, usually ameliorates the condition. Feet that are cold and clammy denote debility, and only temporary relief can be expected from external applications. The feet, like the face, hands and hair, should be carefully attended to each day as a matter of comfort and refinement. They should be washed well with pedico granular soap, massaged with pedico foot balm and then antiseptic powder should be sprinkled over the feet and in the stockings. Change stockings each day and alternate the wear of shoes. CHAPTER XLIII METHOD OF MAKING PLASTER OF PARIS CAST OF THE FOOT The making of a good plaster of paris model of the foot is not a difficult operation, and can be readily learned with a little practice and adherence to the following directions. As the quantity of plaster Chart No. 217 After Foot Has Been Lubricated It is Placed in Plaster. required to make the mixture depends on atmospheric conditions and grades of plaster used, we have selected for convenience the standard plaster known as "New York Dental Grade," and which requires about four pounds to a quart of water. 343 344 THE HUMAN FOOT In preparing the plaster for making the cast, it should be grad- ually added to the water, stirring it with the hands or a spoon until thoroughly mixed to the consistency of a heavy cream. When taking a Plantar or sole impression of the foot, procure a shallow box, or lid of a shoe carton, large enough to permit the entrance of the entire foot; previously lined with a towel covered with tissue paper, which is to hold the plaster of paris. In order to prevent the adherence of plaster to the flesh, cold cream or vaseline should be applied to that part from which the cast Chart No. 218 Heaping Plaster Under the Arch. is to be made. If the patient has a heavy growth of hair, it is ad- visable to shave that portion coming in contact with the cast. Now that all is in readiness, prepare the plaster as described above and pour it into the box, heaping it up well under the arch, being care- ful that it is of the proper consistency; otherwise it will flow over the edge of the container. The patient should then be seated in a comfortable position, with his foot resting in the plaster as in Chart No. 217, exerting sufficient pressure to take an impression of the heel and toes. When the foot is firmly settled, grasp the towel and paper as in Chart No. 218, and draw the plaster up towards the instep on the inner side of the foot. HOW TO MAKE PLASTER CASTS 345 Chart No. 219 Grasping Towel Containing the Plaster and Heaping It Against Arch. Chart No. 220 After Cast of Sole Surface is Lubricated, Plaster Mixture is Poured Into It. 346 THE HUMAN FOOT Chart No. 219 gives you another view of the same operation, show- ing' the other foot. This is the method to follow for taking Plantar or sole impressions. Chart No. 221 breaking Plaster Cast Away from Positive or Counter Cast. IhHS Jfk. ' "' A k. _^rfltf 9 1 ■i : 1 Chart No. 222 Cast Freed from Negative. When the plaster of paris becomes thoroughly set or hard, remove the foot by carefully lifting out the heel and then drawing the foot back and upward. After five or ten minutes this cast is to be lubri- cated with cold cream, oil or vaseline. HOW TO MAKE PLASTER CASTS 347 The lubricant is put into the negative cast and on the outer edges around the impression to prevent the counter or positive cast from adhering. Another batch of plaster should now be mixed and poured into the negative, as illustrated in Chart No. 220, permitting it to work its way around the entire cast, thus preventing air-bells or bubbles. "When the plaster becomes heavier add a sufficient quantity to fill the depression, allowing it to set for about twenty minutes, when the negative may be broken and the positive removed. The best way to remove the positive or positive cast is by taking a hammer as in Chart No. 221 and breaking first the outer side, then the toe part. After this has been done you will find the cast is now entirely free from the shell or negative as in Chart No. 222. To Take a Plaster Cast of the Entire Foot Above the Ankle. The previous method of taking a Plantar surface impression should be followed, but the foot is not to be removed. A double layer of tissue paper is evenly placed around the foot over the sole impres- sion, instead of oiling to prevent the adherence of the other wet plaster added above. Now obtain a strong piece of white cord, which is tied around the leg above the ankle, as in Chart No. 223, one end dropped down back over the Tendo-Achillis and the other end for- ward down the center of and over the Dorsum of the foot to the second toe. The purpose of this string is to cut the upper cast be- fore it is entirely set. Now mix the plaster in the usual manner, somewhat thinner than before, and place it around the foot with your hands, entirely covering it, as in Chart No. 224, being careful that the cord closely adheres to the flesh, and that the plaster is smoothly applied. To mix the first batch, a pound of plaster to ten ounces, a little over a half pint, of water is sufficient. Allow this to set for a few minutes ; in the intervening time mix another batch using about four pounds of plaster, somewhat thinner than usual but heavier than the previous mixture. 348 THE HUMAN FOOT Chart No. 223 Cord Tied Around Top and on Front and Back of Foot to Separate Cast. Chart No. 224 Placing Plaster Around Foot Over the Cord. HOW TO MAKE PLASTER CASTS 349 Chart No. 225 Drawing Ends of Cord Through the Plaster. Chart No. 226 Showing How Flesh is Drawn Away from Cast. 350 THE HUMAN FOOT Chart Xo. 227 Separating the Two Halves. Chart No. 228 Casts of Sole and Two Sides Removed from Foot Ready for Lubricating HOW TO MAKE PLASTER CASTS 351 Apply this over the now forming shell until a firm and heavy coat- ing is obtained, as in Chart No. 224. When the plaster starts to set take both cords in your hands and draw them up, cutting through Chart No. 229 Pouring Plaster in Negative After Being Tied Together. the plaster as you would cut a bar of soap. Now remove the cord, as in Chart No. 225, and allow the plaster to set until it becomes hard. Do not remove the cord before the plaster starts to set, as it will wash together; also do not let it set too hard, as you will be unable 352 THE HUMAN FOOT to remove it, and consequently will have to break the shell in order to remove it from the foot. To free the hair from the cast before it becomes entirely hard, grasp the leg" as in Chart No. 226 and draw the flesh away from the Chart No. 230 Pouring Plaster Back Into Bowl. cast. Generally it requires about six or seven minutes for the plaster to set, but this varies according to climatic conditions and to the nature of your preparation. HOW TO MAKE PLASTER CASTS 353 It can be seen in Chart Xo. 227 how two halves can be readily freed by gently prying in the front and back with a screwdriver. Chart Xo. 228 shows three parts of the cast all ready for lubri- cating, which may be plastered or tied together with cord. As you now have a complete negative cast of the foot, and are ready for the positive or counter cast, prepare your mixture, which is to have the consistency of cream ; then place your cast at an angle, IIt^T ^^Bi ilk-Jfe^Hiri pftr 's ■MB WMfcr\ W? ..- . ^ A ■w.^aw -^ - T^, Chart No. 231 Shell is Broken and Cast is Removed. as in Chart Xo. 229, in order that the plaster will flow evenly into all points of the cast. You then fill the cast about half full, rotating it to wash the plaster, avoiding air-bells or bubbles ; it is then poured back into the bowl as in Chart Xo. 230 This operation should be repeated two or three times until an inner coat, three-fourths to an inch in thickness, is formed on the entire inner side of the shell or negative, and in which time will become quite hard and unable to run. 23 354 THE HUMAN FOOT By following these directions a firm, strong- cast, light in weight, can be made. It requires about thirty-six hours to thoroughly dry out. Chart No. 232 Finished Cast and Original Foot. If a solid cast is desired the same method should be pursued, finally filling the entire shell. HOW TO MAKE PLASTER CASTS 355 This is set aside for twenty minutes to a half hour and the shell then broken and removed as shown in Chart No. 231. Chart No. 233 Plaster is Poured into Towel or Paper Placed in Palm of Hand. Chart No. 234 Placed About Part to be TaKen. If these directions are adhered to and the work carefully performed, the completed cast will be a perfect reproduction of the patient's foot, showing in detail every line of demarkation and deformities as found in the natural foot. (See Chart No. 232.) 356 THE HUMAN FOOT Chart No. 235 Removing Hand, Towel or Paper. Chart No. 236 Negative Removed Ready for Counter Cast HOW TO MAKE PLASTER CASTS 357 Method of Taking Cast of Bunion or Enlarged Toe Joint. The surface of the foot about the bunion is lubricated as previously described. Having the mixture prepared, a double layer of towels or newspapers is placed in the palm of the hand as in Chart Xo. 233, Chart No. 237 Removing the Cast from Negative Showing Exact Reproduction of Enlarged Toe Joint. then placed directly over and around the part from which the cast is to be taken. (See Chart Xo. 234.) Allow to set for about eight to ten minutes, when the towel should be removed as in Chart Xo. 235, then gently loosen and remove the negative from the foot. (See Chart Xo. 236.) Permit 358 THE HUMAN FOOT this to set for thirty minutes, lubricate inside and around the top edge, then prepare the mixture and pour it into the negative cast, allowing it to set for fifteen minutes when it may be removed. (See Chart No. 237.) These casts are necessary and convenient when a special bunion reducer is to be fitted ; also when the reducer or shield is to be made to the order of the patient. Index to Illustrations Anatomy, Comparative Chart Xo. 33 92 Ankle, Weak Chart Xo. 149 212 " 150 213 Arch, Broken-down Chart Xo. 53 125 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 126 128 129 130 131 132 133 133 134 135 137 138 138 139 141 Arch Supports, Method of Fitting Chart Xo. 100 101 102 103 104 105 106 107 108 109 168 169 169 170 170 171 172 173 174 175 Chart Xo. 110 « m " 112 .. .. - " " 113 .... " 114.... " 115 .... " 116.... " 117 .... " 118 .... " 119 .... " 120 . . . . " 121 .... Arches of the Foot Chart Xo. 4 .... " 5 .... 6 .... " A6 .... Arteries of the Foot Chart Xo. 21 . . . 22 . . . " A23 23 24 Bandaging and Strapping Chart Xo. 80 " 81 " 82 Bones of the Leg and Foot Chart Xo. Al 1 2 A3 3 7 176 177 178 179 180 181 182 183 183 184 185 186 25 26 27 28 67 69 71 74 75 150 151 152 11 13 14 15 16 23 359 360 THE HUMAN FOOT Bow-Legs Chart No. 160 229 " 161 230 " 162 232 Bunion, Hallux Valgus and Chart No. 122 188 " 123 189 " 124 190 " 125 191 " 126 192 " 127 193 " 128 194 " 129 195 " ' " 130 196 " 131 196 Bunion, Treatment of Chart No. 138 200 Callosities Chart No. 178 285 " 179 286 " 180 286 " 181 287 " 182 287 " 183 288 " 184 288 Callous Chart No. 178 285 " 179 286 " 180 286 " 181 287 " 182 287 " 183 288 " 184 288 Casts, Plaster, Method of Making Chart No. 217 343 " 218 344 " 219 345 " 220 345 " 221 346 " 222 346 lart No. 223 348 " 224 348 " 225 349 " 226 349 " 227 350 " 228 350 " 229 351 " 230 352 " 231 353 " 232 354 " 233 355 " 234 355 " 235 356 " 236 356 " 237 357 Club-Foot Chart No. 151 215 " 152 217 " 153 220 " 154 221 Comparative Anatomy Chart No. 33 92 Consideration of the Foot, Mechanical Chart No. 37 102 " 38 103 " 39 105 Corns (Cornu, Horn) Chart No. 167 275 " 168 275 " 169 276 " 170 276 " 171 277 " 172 277 " 173 278 " 174 278 " 175 279 " 176 280 " 177 281 INDEX TO ILLUSTRATIONS 361 Examining, Method of Chart No. 40 109 " 41 ' 110 " 42 Ill " 43 112 " 44 113 " 45 114 " 48 118 " 93 162 Feet, Fractures Affecting the Chart No. 165 259 " 166 260 Felt Padding Chart No. 132 197 " 133 197 " 134 198 " 135 198 " 136 199 " 137 199 Fitting Arch Supports, Method of Chart No. 100 168 " 101 169 " 102 169 " 103 170 " 104 : . . 170 " 105 171 " 106 172 " 107 173 " 108 174 " 109 175 " 110 176 " 111 177 " 112 178 " 113 179 " 114 180 " 115 181 " 116 182 " 117 183 " 118 183 Chart No. 119 184 " 120 185 " 121 186 Fitting of Shoes, Footwear and Chart No. 207 329 " 208 330 " 209 330 " 210 330 Fitting Ready-to-Wear Shoes Chart No. 201 324 202 203 204 205 206 207 208 209 210 324 325 325 326 328 329 330 330 330 Fiat-Foot — Broken-down Arch Chart No. 53 125 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 126 128 129 130 131 132 133 133 134 135 137 138 138 139 141 Fiat-Foot, Treatment of Chart No. 69 142 " 70 143 " 71 143 362 THE HUMAN FOOT Chart No. 72 145 " 73 146 " 74 146 " 75 146 " 76 147 " 77 147 " 78 148 " 79 149 " 80 150 " 81 151 " 82 152 Foot, Arches of the Chart No. 4 25 5 26 6 27 " A6 28 Foot, Arteries of the Chart No. 21 67 "22 69 " A23 71 23 74 " . 24 75 Foot, Bones of the Leg and Chart No. Al 11 1 13 2 14 " A3 15 " 3 16 7 23 Foot, Club Chart No. 151 215 " 152 217 " 153 220 " 154 221 Foot, Flat Chart No. 53 125 " 54 126 " 55 128 " 56 129 Chart No. 57 130 " 58 131 " 59 132 " 60 133 " 61 133 " 62 134 " 63 135 " 64 137 "65 138 " 66 138 " 67 139 " 68 141 Foot, Flat, Treatment of Chart No. 69 142 " 70 143 " 71 143 " 72 145 " 73 146 " 74 146 " 75 146 " 76 147 " 77 147 " 78 148 " 79 149 " 80 150 " 81 151 " 82 152 Foot, Ligaments of the Chart No. 8 34 9 36 10 38 11 39 " A12 41 Foot, Measuring, Method of Chart No. 201 324 " 202 324 " 203 325 " 204 325 " 205 326 " 206 328 INDEX TO ILLUSTRATIONS 363 Foot, Mechanical Considera- tion of the Chart No. 37 102 " 38 103 " 39 105 Foot, Muscles and Tendons of the Chart No. B16 55 " C16 57 16 58 17 60 18 61 19 63 20 64 Foot, Nerves of the Leg and Chart No. 27 82 " 28 83 " 29 84 " 30 86 Foot, Veins of the Leg and Chart No. 25 78 " 26 79 Foot, Weak Chart No. 46 115 " 47 117 " 48 118 " 50 121 " 52 123 " 56 129 Foot, Weak, Mechanical Correction of Chart No. 49 119 " 51 122 " 69 142 " 79 149 Footwear, History of Chart No. 191 298 " 192 300 " 193 303 " " 194 306 Chart No. 195 308 " " 196 310 a " 197 311 u " 198 313 a " 199 314 a " 200 316 Fractures Affecting the Feet Chart No. 165 259 (< " 166 260 Hallux Rigidus or Painful Great Toe Chart No. 139 201 Hallux Valgus and Bunion Chart No. 122 188 " " 123 189 " " 124 190 " " 125 191 (< " 126 192 a " 127 193 << " 128 194 <( " 129 195 << " 130 196 •< " 131 196 Hallux Varus or Pigeon Toe Chart No. 140 .. 202 Heel, Painful Chart No. 141 204 a " 142 205 it " 143 206 Hosiery Chart No. 211 334 (< " 212 -... 335 << " 213 336 « " 214 .. . .L_^^ 337 << " 215 o3"8- ct " 216 339 Knee, Knock Chart No. 158 227 « " 159 228 364 THE HUMAN FOOT Knee, Tubercular Chart No. 163 234 Leg, Muscles and Tendons of the Chart No. 12 13 14 15 " A16 Leg and Foot, Bones of the Chart No. Al 11 45 47 48 50 53 1 2 A3 3 7 13 14 15 16 23 Leg and Foot, Nerves of the Chart No. 27 82 "28 83 "29 84 " 30 86 Leg and Foot, Veins of the Chart No. 25 78 " 26 79 Ligaments of the Foot Chart No. 8 34 9 36 10 38 11 39 " A12 41 Mechanical Consideration of the Foot Chart No. 37 102 " 38 103 " 39 105 Metatarsalgia — Morton's Toe Chart No. 83 153 " 84 154 " 85 155 " 86 156 Chart No. 87 157 " 88 158 89 90 91 92 93 159 160 160 161 162 Metatarsalgia, Treatment of Chart No. 94 163 95 96 97 98 99 163 164 165 165 166 Morton's Toe Chart No. 83 153 84 85 86 87 88 89 90 91 92 93 154 155 156 157 158 159 160 160 161 162 Morton's Toe, Treatment of Chart No. 94 163 95 96 97 98 99 Muscles and Tendons of the Foot Chart No. B16 " C16 16 17 18 163 164 165 165 166 f-5 57 58 60 61 INDEX TO ILLUSTRATIONS 365 Chart No. 19 63 20 64 Muscles and Tendons of the Leg Chart No. 12 45 13 47 14 48 15 50 " A16 53 Nail, Ingrowing Toe Chart No. 185 289 " 186 290 Nails, The Skin and Chart No. 31 89 Nerves of the Leg and Foot Chart No. 27 82 " 28 83 " 29 84 " 30 86 Padding, Felt Chart No. 132 197 133 134 135 136 137 197 198 198 199 199 Pes Cavus or Contracted Foot Chart No. 155 224 " 156 225 Physiology Chart No. 34 35 36 99 100 101 Pigeon Toe Chart No. 140 202 Skiagraphy Chart No. 187 293 " 188 294 " 189 295 " 190 295 Skin and Nails Chart No. 31 89 Strapping, Bandaging and Chart No. 80 150 " 81 151 " 82 152 Supernumerary Toes Chart No. 164 246 Talipes or Club-Foot Chart No. 151 215 " 152 217 " 153 220 " 154 221 Tendons of the Foot, Muscles and Chart No. B16 55 " C16 57 16 58 17 60 18 61 19 63 " 20 64 Tendons of the Leg, Muscles and Chart No. 12 45 13 47 14 48 15 50 " A16 53 Toe, Great, Painful Chart No. 139 201 Toe, Hammer Chart No. 144 208 " 145 209 " 146 209 " 147 210 " 148 211 Toe, Morton's Chart No. 83 153 " 84 154 366 THE HUMAN FOOT Chart No. 85 155 " 86 156 " 87 157 " 88 158 " 89 159 " 90 160 " 91 160 " 92 161 " 93 162 Toe, Morton's, Treatment of Chart No. 94 163 " 95 163 " 96 164 " 97 165 " 98 165 " 99 166 Toe-Nail, Ingrowing Chart No. 185 289 ". 186 290 Toe, Pigeon Chart No. 140 707 Toes, Supernumerary Chart No. 164 246 Veins of the Leg and Foot Chart No. 25 7f^ " 26 79 Walking Chart No. 37 107 " 39 105 Weak Foot Chart No. 46 115 " 47 117 " 48 118 " 50 121 " 52 173 " 56 179 Weak Foot, Mechanical Correction of Chart No. 49 119 " 51 177 " 69 147 " « 79 149 Index to Subjects A Abduction of the foot 98 Fractures by eversion and 259 Abductor Minimi Digiti 59 pollicis 58 Abductors 63 Accessorius, Flexor 59 Accidents to the Patella and its ligaments 233 Achillis, Tendo 49 Achillotenontitis 205 Acuminata, Verruca 245 Acuminatum, Condyloma 245 Adduction of the foot 98 Adductor pollicis 62 Adductors 64 Adjustment, How to make secondary 185 Affections, Joint, simulating rheumatism 237 Anatomy, comparative 91 Ancients, Footwear of the 297 Anglo-Norman footwear 304 -Saxon footwear 302 Anhidrosis, or scanty perspiration 249 Ankle, Dislocations at or near the 266 joint, Ligaments of the 35 Sprained 213 Tuberculosis of the 214 Weak 212 Ankles, weak, and inward rotation, Fitting for 182 weak, Children's, Fitting for 185 Ankylosis 244 of the patella 234 Annular ligament, Anterior 54 External 55 Internal 54 367 368 THE HUMAN FOOT Anterior fasciculus 36 group of extensor muscles of the leg 44 inferior tibio-fibular ligament 34 ligament 35 peroneal branch of the posterior tibial artery 73 tibial artery 66 tibial nerve 86 tibio-tarsal ligament 35 Anticus, Tibialis 44 Appendages of the skin 89 Arch, Broken-down 125 Extreme high and contracted, Fitting for 182 Inner longitudinal 25 Outer longitudinal 26 supports, Method of fitting 168 Transverse, or anterior 26 Weak, with enlargement at first metatarsophalangeal joint, Fitting for 182 Weakened transverse 153 Arteries 31 of the foot 66 Anterior tibial 66 External malleolar branch 68 Internal malleolar branch 68 Muscular branches 68 Recurrent tibial branch 68 Dorsalis pedis 70 Communicating branch 72 Dorsalis pollicis 72 Interosseous branches 70 Metatarsal branch 70 Tarsal branch 70 External plantar 74 Anterior perforating, or digital branches 76 Posterior perforating branches 75 Internal plantar 74 Popliteal artery 66 Posterior tibial 72 Communicating branch 73 Internal calcanean 73 INDEX 369 Posterior tibial artery — Continued. Muscular branches 73 Nutrient branch . . 73 Peroneal artery 73 Anterior artery 73 Articular branches of internal popliteal nerve 81 Astragalo-calcaneoid joint, Dislocation of 269 -scaphoid joint, Dislocation of 269 Astragalus 18 dislocation of the, Total 271 Fracture of the 261 B Ball of foot, callouses on, Fitting for. 184 Bandaging and strapping 150 Bent bone % 254 Blister 252 Bone, Astragalus 18 Bent 254 Cuboid 19 Fibula 24 Os Calcis 18 Scaphoid 19 Tibia 22 Bones, The 11 Cuneiform 19 human body, of the 12 Metatarsal 21 Metatarsus, The 21 Phalanges 22 Tarsus, The 18 Bow-legs • 229 Boys' shoes, sizes and measurements 320, 323 Brevis digitorum, Extensor 56 Flexor 58 minimi digiti, Flexor 62 Peroneus 52 pollicis, Flexor 61 Broken-down arch 125 Bromidrosis, or fetid perspiration 249 370 THE HUMAN FOOT Bunion, Hallux valgus and 188 Taking plaster cast of 357 Treatment of 200 Bursitis about the knee 232 Fitting for 184 Prepatellar, or housemaid's knee 232 Pretibial 233 Pretubercular 233 Calcanean branch of the posterior tibial artery, internal 73 Calcaneo-Astragaloid ligament, external 37 posterior 37 -Cuboid ligament, internal 39 long 39 short 40 superior 38 -Scaphoid ligament, inferior 40 superior 40 Calcaneum, Dislocations of the 272 fracture of the 261 Calcaneus, Talipes 223 Callous 285 Callouses on ball of foot, Fitting for 184 Callosities 285 Care of the Feet 341 Case of Metatarsalgia, Typical 167 Casts, plaster, Method of making 343 of plantar impression 344 of entire foot 347 of bunion or enlarged toe joint 357 Cavus, Pes 224 Chilblains 247 Children's shoes, sizes and measurements 322 weak ankles, Fitting for 185 Claw-Foot, Hollow 226 Club-Foot 215 Non-deforming 222 INDEX 371 Communicating branch of dorsalis pedis artery 72 of posterior tibial artery 73 Comparative Anatomy 94 Complete Fractures , 255 Compound Fracture 257 Condyloma Acuminatum 245 Congelation 248 Congenital deformities of the knee „ 230 flat-foot 139 hyperextension of the knee 230 Consideration of the foot, Mechanical 102 Contracted arch, extreme high and, Fitting for 182 foot 222 Convalescent patients 138 Corns 274 Hard 274, 275 Nervo- Vascular 274, 283 Soft 274, 281 Suppurated 274, 282 Vascular 274, 284 Cramped toes, Fitting for 185 Crystallization of metals from which arch supports are made. . . . 186 Cuboid bone 19 Dislocations of 272 Cuneiform bones 19 External 20 Internal 19 Middle 20 Dislocations of the 272 Cutaneous branch of the internal popliteal nerve 81 Cuticle 88 D Deep or muscular branch of the external plantar nerve 85 transverse fascia 49 Deformities, Acquired 231 Congenital 230 of the knee 230 acquired deformities 231 bursitis about the knee 232 372 THE HUMAN FOOT Deformities — Continued. bursitis, prepatellar, housemaid's knee 232 pretibial 233 pretubercular 233 congenital deformities 230 congenital hyperextension of the knee 230 Deltoid Ligament 35 Depressions 254 Derma 88 Digital branches of the external plantar artery 76 Digiti, Abductor minimi 59 Flexor brevis minimi 62 Digitorum, Extensor brevis 56 Extensor longus 44 Flexor brevis 58 Flexor longus 51 Disease, Raynaud's 242 Diseases affecting the feet 240 Ankylosis 244 Infantile paralysis 240 Myasthenia (Intermittent limping ) . . 241 Raynaud's Disease 242 Rickets 243 Syphilis 241 Varicose Veins 243 of the feet 245 Anhidrosis or scanty perspiration 249 Blister 252 Bromidrosis or fetid perspiration 249 Chilblains (pernio) 247 Eczema 250 Frost bite 248 Hyperidrosis or excessive perspiration 248 Osteoma 251 Perforating ulcer of the foot 247 Plantar neuralgia 251 Supernumerary toes (polydactylism) 246 Syphilis 250 Verruca or wart 245 Webbed finsrers and toes 246 INDEX 373 Dislocation of the Astragalus, Total 271 Medio-Tarsal 271 Dislocations affecting the feet 264 at or near the ankle 266 of the astragalo-calcaneoid and astragalo-scaphoid joints... 269 backward 270 forward 270 inward or inward and backward 269 of the Fibula 265 backward 265 forward 265 of the lower end 265 of the upper end 265 upward 265 of the foot (Tibio-Tarsal ) 267 backward 267 compound and complicated 269 forward 268 inward 268 outward 268 of the Metatarsal bones from the Tarsus and from one another 272 Metatarso-phalangeal 272 of the phalanges 2/3 of the Tarsal and Metatarsal bones 272 Calcaneum 272 Cuboid 272 Cuneiform bones 272 Scaphoid 272 of the Tibia, of the lower end of the, forward 267 of the Toes 272 of the Great Toe 272 of the other toes 273 Sub-Astragaloid 269 Displaced metatarsals, Fitting for 184 Dorsal interossei " 62 ligaments of the Tarsus ^7 ligaments (Tarso-Metatarsal; 40 Dorsalis pedis artery 70 pollicis 72 374 THE HUMAN FOOT E Eczema 250 Enlarged toe joint, making cast of 357 Epidermis 88 Epiphysis, Separation of the 256 Separation of a Splinter of an 255 Equinus, Talipes .' 220 Erythromelalgia 251 Eversion of the foot 98 and abduction of the foot, Fracture by. . . 259 Examination of the foot Ill Examinations 108 Excessive perspiration 248 weight carrying 136 Exercises 151 Extension of the foot .• 98 Extensor brevis digitorum 56 longus digitorum 44 muscles of the leg 44 Anterior group 44 Extensor longus digitorum 44 Extensor proprius pollicis 44 Peroneus tertius 46 Tibialis anticus 44 Fibular group 52 Peroneus brevis 52 Peroneus longus 52 Posterior group 46 Deep layer 49 Flexor longus digitorum 51 Flexor longus pollicis 51 Popliteus 51 Tibialis posticus 51 Superficial layer 46 Gastrocnemius 46 Plantaris 49 Soleus 48 Tendo-Achillis . 49 proprius pollicis 44 Extensors 65 INDEX 375 External annular ligament 55 branch of the Anterior tibial nerve 87 branch of the Musculo-Cutaneous nerve 87 calcaneo-astragaloid ligament 37 cuneiform bone 20 lateral ligament 36 Anterior fasciculus 36 Middle fasciculus 36 Posterior fasciculus 36 malleolar branch of the anterior tibial artery 68 or short Saphenous nerve 81 or short Saphenous vein 80 peroneal nerve 85 plantar artery 74 plantar nerve 85 popliteal nerve 85 Extreme flat-foot with swelling, Fitting for 182 high and contracted arch, Fitting for 182 F Fascia, Deep transverse 49 Plantar 55 Central portion 56 Inner portion 56 Outer portion 56 Feet, Care of the 341 Diseases affecting the 240 Diseases of the 245 Dislocations affecting the 264 Fractures affecting the 253 Felt padding 197 Fetid perspiration 249 Fibula 24 Dislocations of the 265 Fracture of the 261 Fracture of the upper end of Tibia and 257 Fibular group of extensor muscles of the leg 52 Fifteenth century, Shoes of the 305 Filiformis, Verruca • 245 Fingers and Toes, Webbed 246 376 THE HUMAN FOOT Fitting Arch Supports, Method of 168 for bursitis 184 callouses on ball of foot 184 children's weak ankles 185 cramped toes 185 displaced metatarsals 184 extreme high and contracted arch 182 flat-foot, extreme, with swelling 182 flat-foot, moderate 181 flat-foot, rigid, with adhesions 182 foot strain 185 heel, painful, spur of Os calcis, etc 184 Metatarsalgia 184 Morton's toe 184 weak ankles and inward rotation 182 weak arch Avith enlargement at first metatarso-phalangeal joint 182 weak flexible foot 181 weak foot with tendency of rolling outward 185 of shoes 318 ready-to-wear shoes, Measuring for 324 Flat-foot 125 Acquired 127 causes 136 Congenital 139 Fitting arch supports for. . . 181 Traumatic 140 Treatment of 142 Flexion of the foot 98 Flexor accessorius 59 brevis digitorum 58 brevis pollicis 61 brevis minimi digiti 62 longus digitorum 51 longus pollicis 51 Flexors 65 Foot, abduction of the 98 Acute weakened 124 Adduction of the 98 Arteries of the 66 1 INDEX 377 Foot — Continued. Bones of the 11 Callouses on ball of, Fitting for 184 Cast of, plaster, method of making 343, 347 Claw, Hollow • 226 Club 215 Contracted 222 Dislocations of the (Tibio-Tarsal) 267 Eversion of the 98 Examination of the Ill Extension of the ; 98 Flat ..' 125 Flexion of the 98 Fractures by eversion and abduction of 259 Functions of the 97 Gonorrheal infection of the 238 . Hollow 224 Hollow claw 226 Hump 226 Inversion of the 98 Measuring the, for fitting ready-to-wear shoes 324 Mechanical consideration of the 102 Movements of the 98 Muscles and tendons of the 54 Perforating ulcer of the 247 Soft structures of the 29 strain, Fitting for 185 Ulcer, perforating, of the 247 Weakened 117 Weak flexible 121 Footwear, History of 297 of the ancients 297 Anglo-Normans 304 Anglo-Saxons 302 fifteenth century • 305 fourteenth century 304 Greeks and Romans 299 seventeenth century, Stuart period 307 sixteenth century, Tudor period 307 thirteenth century 304 378 THE HUMAN FOOT Footwear and fitting of shoes 318 Measurements of last 318 Standard shoe last measurements 319 Measurements and lengths 322 Fourteenth century, Shoes of the 304 Frost Bite 248 Fractures affecting the feet 253 Articular, Intra-articular or 256 Bent bone 254 by eversion and abduction of the foot 259 Complete 255 Compound 257 Depressions 254 First aid for 262 "Green stick" 254 Incomplete 254 Intra-articular or articular 256 Longitudinal 255 Multiple , 257 Oblique 258 of the Astragalus 261 of the Calcaneum 261 of the Fibula 261 of the lower end of leg 258 of the Metatarsal bones 262 of the Os calcis 261 of the Patella 257 of the Phalanges 262 of the Sustentaculum tali 262 of the upper end of the tibia and fibula 257 Pott's 259 Signs of 262 Spiral 255 Splintered 255 Transverse : 255 Varieties depending upon the seat of 256 Functions of the foot 97 G Gastrocnemius 46 General review 90 INDEX 379 Genu valgum , . , 227 varum „ 229 Glands, Sebaceous 89 Sudoriferous 89 Sweat 89 Gonorrheal infection of the foot , 238 rheumatism 139 Gout 236 Great Sciatic Nerve , 81 External popliteal or peroneal nerve 85 Anterior tibial nerve 86 External or tarsal branch 87 Internal branch 87 Musculo-Cutaneous nerve 87 External branch 87 Internal branch 87 Internal Popliteal nerve 81 Articular branches 81 Cutaneous branch 81 External or short Saphenous nerve 81 Muscular branches 81 Posterior tibial nerve 81 External plantar nerve 85 Deep or muscular branch 85 Superficial branch 85 Internal plantar nerve 84 Great toe, Dislocations of 272 Painful 201 Greeks, Footwear of the 299 "Green stick" fracture 254 Growth, Rapid 137 H Hair 89 Hallux rigidus or painful great toe 201 valgus and bunion 188 varus or pigeon toe 202 Hammer toe 208 Hard corns 274, 275 Heavyweight persons 137 380 THE HUMAN FOOT Heel, Painful 204 Fitting for 184 High contracted arch, extreme, Fitting for 182 History of footwear 297 Hollow claw-foot 226 Hollow-foot 224 Hosiery 334 Housemaid's knee 232 Human body, Bones of the 12 Hump-foot 226 Hyperextension of the knee, Congenital 230 Hyperidrosis or excessive perspiration 248 I Ill-fitting, improperly made shoes 136 Impression, plantar, Making plaster cast of 344 Incomplete fracture 254 Infantile paralysis 240 Infants' shoes, sizes and measurements. . '. 322 Infection of the foot, Gonorrheal 238 Inferior calcaneo-scaphoid ligament 40 tibio-fibular ligaments 33 Anterior inferior ,tibio-fibular ligament 34 Inferior osseous ligament 35 Posterior inferior tibio-fibular ligament 34 Transverse ligament 34 Ingrowing toe nail 289 In-knee 227 Inner longitudinal arch 25 Intermittent limping 241 Internal annular ligament 54 branch of the anterior tibial nerve 87 branch of the musculocutaneous nerve .• . 87 calcaneal! branch of the posterior tibial artery 73 calcaneo-cuboid ligament 39 cuneiform bone 19 lateral ligament 35 malleolar branch of the anterior tibial artery 68 or long saphenous vein 79 plantar artery 74 INDEX 381 Internal — Continued. plantar nerve 84 popliteal nerve 81 Interossei, Dorsal 62 Plantar 62 Interosseous branches of the dorsalis pedis artery 70 Interosseous ligaments 38, 41 Intra-articular or articular fracture 256 Inversion of the foot 98 Inward rotation, weak ankles and, Fitting for 182 J Joint affections simulating rheumatism 237 ankle, Ligaments of the 35 enlarged toe, Making plaster cast of 357 K Keratosis Pigmentosa 245 Knee, Bursitis about the '...." 232 Deformities of the 230 Acquired deformities 231 Bursitis about the knee 232 Congenital deformities ■ 230 Congenital hyperextension of the knee 230 Prepatellar bursitis or housemaid's knee 232 Pretibial bursitis 233 Pretubercular bursitis 233 Housemaid's 232 Knock 227 Knock-knee 227 with weak foot 229 L Ladies' shoes, sizes and measurements 319, 323 Last, measurements of 318 measurements, Standard shoe 319 Leg, Extensor muscles of the 44 Fracture of the lower end of the 258 Muscles and tendons of the 43 Nerves of the 81 382 THE HUMAN FOOT Leg — Continued. Veins of the 77 Lengths, Measurements and : 322 Ligaments 29, 33 Annular, Anterior 54 External 55 Internal 54 Metatarsophalangeal 41 Lateral ligaments 42 Plantar ligaments 41 of the ankle joint 35 Anterior, or anterior tibio-fibular ligament 35 External lateral ligament 36 Anterior fasciculus 36 Middle fasciculus 36 Posterior fasciculus 36 Internal lateral, or deltoid ligament 35 Deep layer 35 . Superficial layer 35 Posterior, or posterior tibio-fibular ligament 35 of the tarsus 37 Calcaneo-astragaloid ligament, External 37 Posterior 37 Calcaneo-cuboid ligament, Internal 39 Long 39 Short 40 Superior 38 Calcaneo-scaphoid ligament, Inferior 40 Superior 40 Dorsal ligaments 37 Interosseous ligaments 38 Plantar ligaments 38 Tarso-metatarsal 40 Dorsal ligaments 40 Interosseous ligaments 41 Plantar ligaments 41 Tibio-fibular ligaments 33 Inferior tibio-fibular ligaments 33 Anterior 34 Posterior 34 INDEX 383 Tibiofibular — Continued. Inferior osseous ligament 35 Transverse ligament 34 Middle 33 Superior or upper 33 Limb, Short 138 Limping, Intermittent 241 Locomotor Ataxia 138 Longitudinal arch, Inner 25 Outer 26 fracture 255 Long standing 136 Lumbricales 59 M Malleolar branch of the anterior tibial artery, External 68 Internal 68 Measurements of last 318 Standard shoe last 319 Measuring foot for fitting ready-to-wear shoes 324 Mechanical consideration of the foot 102 Medio-tarsal dislocation 271 Men's shoes, sizes and measurements 319, 323 Metals from which arch supports are made, Crystallization of. . . 186 Metatarsal bone, Subluxation of the head of a 272 bones 21 Dislocation of the tarsal and 272 Dislocation of the, from the tarsus and from one another. 272 Fractures of the 262 Metatarsal branch of the dorsalis pedis artery 70 Metatarsalgia 153 Fitting arch supports for ,. 184 Typical case of 167 Metatarso-phalangeal dislocations 272 ligaments 41 Metatarsus and phalanges 21 Method of fitting arch supports '. 168 Middle cuneiform bone 20 Minimi digiti, Abductor • • 59 Flexor brevis 62 384 THE HUMAN FOOT Misses' shoes, sizes and measurements 320, 323 Morton's toe 153 Fitting arch supports for 184 Movements of the foot 98 Abduction of the foot . 98 Adduction of the foot 98 Eversion of the foot 98 Extension of the foot. 98 Flexion of the foot ■. 98 Inversion of the foot ■ 98 Multiple fracture 257 Muscles 30 and tendons of the foot 54 Dorsal region 56 Extensor brevis digitorum 56 Plantar region 57 First layer 57 Abductor minimi digiti 59 pollicis 58 Flexor brevis digitorum 58 Second layer 59 Flexor accessorius 59 Lumbricales 59 Third layer 60 Adductor pollicis 62 Flexor brevis minimi digiti 62 pollicis 61 Transversus pedis 62 Fourth layer 62 Abductors ' 63 Adductors 64 Dorsal interossei 62 Extensors 65 Flexors 65 Plantar interossei 62 and tendons of the leg 43 Extensor muscles of the leg 44 Anterior group 44 Extensor longus digitorum 44 proprius pollicis •. 44 INDEX 385 Muscles^-Continued. Peroneus tertius 46 Tibialis anticus 44 Fibular group 52 Peroneus brevis 52 longus 52 Posterior group 46 Deep layer 49 Flexor longus digitorum 51 pollicis 51 Popliteus 51 Tibialis posticus 51 Superficial layer 46 Gastrocnemius 46 Plantaris 49 Soleus 48 Muscular branch, Deep or, of external plantar nerve 85 branches of the anterior tibial artery. 68 internal popliteal nerve 81 posterior tibial artery 73 Musculocutaneous nerve 87 External branch 87 Internal branch 87 Myasthenia (intermittent limping) 241 N Nail, Ingrowing toe 289 Nails 90 Skin and 88 Nerve, Great sciatic 81 Anterior tibial 86 Musculocutaneous 87 Plantar, External 85 Internal 84 Popliteal, External, or peroneal 85 Internal 81 Saphenous, Short 81 Tibial, Posterior • 81 Nerves 32 of the leg and foot 81 386 THE HUMAN FOOT Nervo- vascular corns 274, 283 Neuralgia, Plantar 251 Nutrient branch of the posterior tibial artery 73 Non-deforming club-foot 222 o Oblique fracture 258 Onychauxis 291 Onychia 291 Syphilitic 291 Os calcis 18 Dislocations of the 272 Fractures of the 261 Osseous ligament, Inferior 35 Osteoma 251 Osteophytes of the Os calcis 205 Outer longitudinal arch 26 Overlapping toes 211 P Padding, Felt 197 Pain 115 Painful great toe 201 heel 204 Fitting arch supports for 184 Palpation 112 Papulosquamous Syphilide 250 Paralysis, Infantile . 240 Patella and its ligaments, Accidents to the 233 Ankylosis of the 234 Fracture of the 257 Slipping 233 Tuberculosis of the 233 Pedis, Dorsalis, artery 70 Transversus 62 Perforating branch of external plantar artery, Anterior 76 Posterior 75 ulcer of the foot 247 Pernio 247 INDEX 387 Peroneal artery 73 Anterior j$ nerve, external 85 Peroneus brevis 52 longus 52 tertius 46 Perspiration, Excessive 248 Fetid 249 Scanty 249 Pes cavus, or hollow-foot 224 Phalanges 22 Dislocations of the 273 Fracture of the 262 Metatarsus and 21 Physiology 97 Pigeon toe 202 Pigmentosa, Keratosis 245 Plana, Verruca 245 Plantar artery, External 74 Internal 74 fascia 55 impression, Making cast of 344 interossei 62 ligaments (metatarso-phalangeal) 41 (tarsal) 38 (tarso-metatarsal) 41 nerve, External 85 Internal 84 neuralgia 251 Plantaris 49 Plaster of paris casts, Method of making 343 Bunion or enlarged toe joint 357 Entire foot 347 Plantar impression 344 Pollicis, Abductor 58 Adductor 62 Dorsalis 72 Extensor proprius 44 Flexor brevis 61 longus • • • • 51 388 THE HUMAN FOOT Polydactylism 246 Popliteal artery 66 nerve, external 85 internal 81 Popliteus muscle 51 Posterior calcaneo-astragaloid ligament 37 group (muscles of the leg) 46 inferior tibio-fibular ligament 34 ligament 35 perforating branches of the external plantar artery. 75 tibial artery 72 nerve 81 tibio-tarsal ligament • • 35 Posticus, Tibialis 51 Pott's fracture 259 Prepatellar bursitis, or housemaid's knee 232 Pretibial bursitis 233 Pretubercular bursitis 233 Proprius pollicis, Extensor 44 R Rapid growth 137 Raynaud's disease 242 Recurrent tibial branch of anterior tibial artery 68 Rheumatism 235 Gonorrheal 139 Joint affections simulating 237 Rickets 139, 243 Rigid flat-foot with adhesions, Fitting for 182 Rigidus, Hallux 201 Romans, Footwear of the 299 s Saphenous nerve, External or short 81 Vein, External or short 80 Internal or long 79 Scanty, perspiration 249 Scaphoid bone 19 Dislocations of the 272 INDEX 389 Sciatic nerve, Great 81 Sebaceous, glands 89 Seborrhoeica, Verruca 245 Secondary adjustment, How to make 185 Senilis, Verruca 245 Separation of the epiphysis 256 of a splinter of an epiphysis 255 Seventeenth century, Stuart period, Shoes of 307 Shoe last measurements, Standard 319 Shoes, Fitting of ' 318 History of 297 Short calcaneo-cuboid ligament 40 limb 138 Signs of fracture 262 Sixteenth century, Tudor period, Shoes of 307 Sizes and measurements 322 Skiagraphy 293 Skin and Nails 88 appendages of the 89 Slipping patella 233 Soft corns 274, 281 structures of the foot 29 Soleus 48 Spiral fracture 255 Splinter of an epiphysis, Separation of a 255 Splintered fracture 255 Sprained ankle 213 Squamous syphilide 250 Standard shoe last measurements 319 Standing, Long 136 Strain, foot. Fitting for 185 Strapping, Bandaging and 150 Structures of the foot, Soft 29 Stuart period, seventeenth century, Shoes of 307 Sub-astragaloid dislocations • 269 Subluxation of the head of a metatarsal bone 272 Sudoriferous glands . 89 Superficial branch of the external plantar nerve 85 Superior calcaneo-cuboid ligament • ■' 38 scaphoid ligament 40 390 THE HUMAN FOOT Supernumerary toes 246 Suppurated corns 274, 282 Sustentaculum tali, Fracture of 262 Sweat glands 89 Signs of fracture 262 Syphilitic Onychia 291 Syphilis 241, 250 T Talalgia 205 Talipes or club-foot 215 calcaneus 223 equinus 220 valgus 222 varus 222 Tarsal and metatarsal bones, Dislocations of the 272 branch of the dorsalis pedis artery 70 Tarso-metatarsal ligaments 40 Tarsus 18 Ligaments of the ^7 Tendo-achillis 49 Tendons 29 of the foot, Muscles and 54 of the leg, Muscles and 43 Tertius, Peroneus 46 Thirteenth century, Shoes worn in the 304 Tibia 22 Dislocation of the lower end of the, forward 267 and fibula, Fracture of the upper end of 257 Tibial artery, Anterior 66 Posterior 72 nerve, Anterior 86 Posterior 81 Tibialis, anticus 44 posticus 51 Tibio-fibular ligaments 33 Anterior 34 Inferior 34 Posterior ' 34 INDEX 391 Tibio-tarsal ligament, Anterior 35 Posterior 35 Toe, great, Dislocations of the 272 Painful 201 Hammer 208 joint, enlarged, Making plaster cast of 357 nail, Ingrowing '. 289 Pigeon 202 Toes, Bones of the 22 cramped, Fitting for 185 Dislocations of the 272, 273 Overlapping . . . . 211 Supernumerary 246 Webbed 246 Transverse arch 26 Weakened 153 fascia, Deep 49 fracture 255 ligament 34 Transversus pedis 62 Traumatic flat-foot 140 Tuberculosis of the ankle 214 of the patella 233 Tudor period, sixteenth century, Shoes of 307 u Ulcer, Perforating, of the foot 247 Upper end of tibia and fibula, Fracture of 257 V Valgum, Geru 227 Valgus, Hallux, and bunion 188 Talipes 222 Varicose veins 243 Varieties depending upon seat of fracture 256 Varum, Genu 229 Varus, Hallux, or pigeon toe 20- Talipes 222 Vascular corns 274, 284 392 THE HUMAN FOOT Vein, saphenous, External or short 80 Internal or long 79 Veins 31 of the leg and foot 77 Varicose 243 Venereal wart 245 Verruca or wart 245 acuminata 245 filiformis 245 plana 245 seborrhoeica 245 senilis 245 vulgaris 245 w Wart 245 Condyloma acuminatum 245 Keratosis pigmentosa 245 Venereal wart 245 Verruca acuminata 245 filiformis 245 plana 245 seborrhoeica 245 senilis 245 vulgaris 245 Weak ankle 212 and inward rotation, Fitting for 182 arch with enlargement at first metatarso-phalangeal joint, Fitting for 182 flexible foot 121 Fitting for 181 Weakened foot 117 Acute : 124 Fitting for 185 Webbed fingers and toes 246 Women's shoes, sizes and measurements 319, 323 Y Youth's shoes, sizes and measurements 321, 323 COLUMBIA UNF ry libraries This book is due on th/T datc^ndicated below, or at the expiration of a definite yfriodJttter the date of borrowing, as provided by the rules If thyLibrary or by special arrange- ment with the Librarian m charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE I lltlSi ^ 344 ¥ •' r — n ^ er in IO DEC1 ° 1J ipt. DEO B * 19 it fiF r« ' y j^q w OCT 5 194< \ ■'Oil > I D lOfi*? ■ y iv^A C28(l14l)M100