COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD HX00079090 RECAP h^ CHoUf 9? of ptygHtnana anJi ^urgrnna Srfjer^nr^ ICtbrarg Diseases and Deformities OF THE FOOT BY JOHN JOSEPH NUTT, B.L., M.D. Surgeon-in-Chief, New York State Hospital for the Care of Crippled and Deformed Children; Surgeon, Sea Breeze Hospital; Assistant Attending Sur- geon, in Charge of Orthopedic Cases, Willard Parker Hospital; Mem- ber of the American Ortho- pedic Association. ILL USTRA TED NEW YORK E. B. TREAT & COMPANY 241-3 WEST 23 D ST. Copyright, 1913, By E. B. treat & CO. PREFACE This handbook is prepared for the use oi physicians who have not had the time or the opportunity for thor- ough study of this often neglected subject and who' feel keenly their inability to prescribe scientifically and suc- cessfully for the many who consult them regarding their pedal conditions. Textbooks on orthopedic surgery are rarely consulted by the general practitioner, as most of the diseases and deformities of the frame-work of the body demand such treatment as only orthopedic surgeons are prepared to give. With regard to the feet, however, much of the treat- ment is so simple that the general practitioner can and should assume the responsibility of preventing deform- ities, correcting abuses and those conditions which have already occurred and treating minor diseases of the bones and joints. Many painful and disagreeable conditions, such as chilblains, corns, ingrowing toe-nail, painful heel, excessive sweating of the feet, etc., may be cured by simple measures, and these, as well as the operations for severer complications, are herein fully described and amply illustrated. John Joseph Nutt, M. D. 2020 Broadway, New York. Septemiber lo, 1913. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diseasesdeformitOOnutt CONTENTS CHAPTER I ANATOMY PAGE Skeleton of the Foot — Bones — Ligaments — Muscles and Tendons — Nerves 13 CHAPTER II PHYSIOLOGY Distribution of Weight — Movements — The Foot at Rest — Standing — Work, Rest, Fatigue — ' Walk- ing 41 CHAPTER III EXAMINATION Inspection — History — Palpation — Pain . . . . 59 CHAPTER IV SHAFFER'S FOOT. WEAK-FOOT.. FLAT-FOOT Shaffer's Foot — Consequences — Symptoms — Eti- ology — ■ Treatment — Traction Shoes — Opera- tion — Weak-Foot — Characteristics — Results of Non-Treatment — Treatment — Fiat-Foot — Os- seous Fiat-Foot — Pathology — Treatment of Weak-Foot and Flat- Foot — Exercises — Arch Supporters — ' Whitman's Brace — Shaffer's Brace — Manipulations — Strapping — Severe Cases — Plaster-of-Paris Dressing — Tenotomy — Excision CONTENTS PAGE — Arthrodesis — Tarsectomy — Scaphoidectomy — Post-Operative Treatment — Liniments . . 64 CHAPTER V CONGENITAL CLUB-FOOT Varieties — Frequency — Etiology — General Appear- ance — Explanation of Appearance — Changes in the Bones — Changes in Ligaments and Muscles — Pathology After Use — Confirmation of Structural Changes . . .111 CHAPTER VI TREATMENT OF CONGENITAL CLUB-FOOT Early Treatment — Manipulation — Muslin Bandage — Adhesive Plaster — ■ Braces — Felt Splint — Wood Splint — Plaster-of-Paris — Willard's Shoe — Taylor's Brace — Deformity in the Long Bones — Therapeutics of Early Treatment — Treatment When the Child Begins to Stand — Congenital Tali- pes Equino- Valgus — Congenital Talipes Equinus — Congenital Talipes Valgus — Congenital Talipes Varus — Congenital Talipes Calcaneous — Congeni- tal Talipes Valgus and Varus — Congenital Talipes Planus — Congenital Talipes Cavus — Congenital Talipes Valgo-Cavus — Congenital Talipes Equino- Cavus — Operative Procedures in the Treatment of Congenital Club-Foot — Wolff's Law — Davis' Law — Tenotomy — History — Value — Tendo Achillis — Posterior Ligament — Tibialis Posticus — Astragalo-Scaphoid Capsule — Flexor Longus Digitorum — Tibialis Anticus — Peroneus Longus and Brevis — Plantar Fascia — Danger of Aneur- ism — Indications for Tenotomy — Phelps' Opera- tion — Bone Operations — Indications — Bones to be Attacked — Astragalectomy — Partial Excision — Ogston's Operation — Cuneiform Tarsectomy — I Multiple Cuneiform Osteotamies .... 125 CONTENTS PAGE CHAPTER VII POTTS' PARAPLEGIA. CEREBRAL PARALYSIS Paralysis Complicating Pott's Disease — Spastic Pa- ralysis — • Diagnosis — Examination — Treatment — Tenotomies — Neurotomy — ^Injections of Alco- hol — Stoeffel's Technique 178 CHAPTER VIII INFANTILE PARALYSIS Residual Paralysis — Diagnosis — Recent Cases — Apparatus — Active Movements — Massage — Electricity — Heat — Functional Use — Untreated Cases of Long Standing — Valgus — Varus — Equinus — Calcaneus — Cavus — Hollow Claw- Foot — ' Cases of Undoubtable Permanent Paraly- sis — Reduction of Deformity — Recovery of Muscles — ' Braces — Tendon Transplantation — Astragalectomy 183 CHAPTER IX TUBERCULOSIS AND GONORRHEAL DISEASE Tuberculous Disease of the Foot — Diagnosis — ^ Dif- ferential Diagnosis — Immobilization — Campbell Braces — Thomas Knee Brace — Bier's Treatment — Tuberculin Treatment — Heliotherapy — Sea- bathing — Constitutional Treatment — Operations — Sinuses — Injections — Gonorrheal Infection of the Foot — Treatment 217 CHAPTER X OTHER AILMENTS Painful Heel — Treatment — Operation — Metatarsal- gia — Treatment — Morton's Toe — Treatment — Hallux Valgus — Treatment — Operation — Ham- CONTENTS PAGE mer-Toe — Treatment — Operation — Raynaud's Disease — Treatment — Myasthenia Angio-Solero- tica (Intermittent Limping) — Treatment — Per- forating Ulcer of the Foot — Treatment — Pernio ( Chilblains ) — Treatment — Congelation ( Frost- Bite) — Treatment — Hyperidrosis (Excessive Sweating) — Treatment — Erythromelalgia — Plantar Neuralgia — Clavus (Corns) — Treatment — Paronychia (Ingrowing Toe-Nail) — Treat- ment — Callosities — Painful Soles .... 248 CHAPTER XI FOOT APPAREL Stockings — Shoes — Heels — Rocker Sole .... 2^]^ ILLUSTRATIONS PAGE Plate I Radiograph of a Practically Normal Forefoot i6 " II Unilateral Congenital Talipes Equino- Varus 120 " III Flail Ankle Supported by Silk Ligaments . 184 " IV Tuberculous Disease with Old Scars . . , 224 FIG. 1. Axis of Ankle-joint Movement 14 2. Trochlear Surface of Astragalus 15 3. Three Principal Axes of Movements of the Foot 25 4. Plantar Flexion in Walking 31 5. Tibial Flexion 44 6. Movements at the Ankle-joint 45 7. Movements at the Sub-Astragaloid Joint . . .46 8. Movements at the Medio-Tarsal Joint ... 47 9. Standing Positions 50 10. Heel-Walking 54 11. Toe- Walking 56 12-14. Effect of a Shortened Gastrocnemius ... 65 15-16. Effect of a Shortened Gastrocnemius . . . ^J 17-18. Illustrating Difficulty in Descending Stairs when Dorsal Flexion of Foot is Limited ... 69 19-20. Illustrating Difficulty in Descending Stairs when Dorsal Flexion of Foot is Limited ... 70 ILLUSTRATIONS FIG. PAGE 21. Author's Traction Shoe 73 22. Author's Traction Shoe in Detail 75 23. Lengthening the Tendo Achillis 'j'j 24-25. Adducted and Everted Feet 79 26. Abducted and Everted Feet Seen from Behind . 80 27. Abducted and Everted Feet Seen from in Front 80 28-29. Advancement of the External Malleolus . , 81 30-31. A Shoe Before and After the Insertion of Wedges 87 32-33. Inverting Heel 88 34. An Exercise for Weak Feet 90 35. The Feet at Rest 91 36. Forcible Correction of Abduction .... 98 37-38. Adhesive Plaster Strapping 99 39. Manipulation of Metatarsal Joints .... loi 40. Manipulation of the Toe- Joints 102 41-42. The Plaster-of-Paris Bandage 104 43. Congenital Talipes Equino-Varus .... 121 44. Manipulation of Congenital Club-Foot . . . 127 45-52. The Judson Club-Foot Brace 132 53. The Single Steel Bar Brace, First Position . .134 54. The Single Steel Bar Brace, Second Position . 135 55. The Single Steel Bar Brace, Third Position . . 136 56. The Taylor Club-Foot Brace 141 57. The Taylor Club-Foot Brace, Applied . . . 142 58. The Taylor Club-Foot Brace, Applied . . . 147 ILLUSTRATIONS FIG. PAGE 59. The Use of a Wedge in Adduction . . . .155 60. Relapsed Congenital Talipes Equino- Varus . . 159 61. Dangle-Foot 184 62. Paralytic Talipes Valgus 190 63-65. Examples of Equinus Deformity 191 66-68. Varieties of Calcaneus 193 69. Paralytic Calcaneus 194 70. Talipes Plantaris 195 71. Talipes Arcuatus 196 72. Paralysis of Anterior Muscles 198 y'i^. Paralysis of Tendo Achillis and Anterior Muscles 199 74. Paralysis of Posterior and Plantar Muscles . . 200 75. Paralysis of All Muscles Except Gastroc- Nemius and Soleus 201 "jd. Shaffer's Lateral Traction Shoe 204 'j'j. Right- Angle Stop at Ankle- Joint . . . . . 206 78. Reverse-Stop at Ankle-joint 207 79. A Stop-Joint Allowing a Few Degrees of Motion Only 207 80. Location of Ankle-Brace Joint . > . . . . 208 81. Night-Shoe 211 82. Tuberculous Foot 219 83. Campbell Brace 228 84. Thomas Knee-Brace 230 85-86. Transverse Section of the Forefoot . . . .251 87. Callus in Morton's Toe 256 ILLUSTRATIONS FIG. ■ PAGE 88. Hallux Valgus 258 89. Operation for Hallux Valgus 260 90. Conservative Treatment of Ingrowing Toe-Nail 273 91-92. The French and Cuban Heels 280 93. A Faulty Shoe-Toe 281 94-95. The Toe of the Shoe \ 282 96. An Excellent Shoe 282 97-98. Rocker-Sole and Flat-Sole Shoe 284 99-100. Alterations in Length of Foot During Rest and Weight-Bearing 285 loi. Alterations in Length of Foot During Tip- Toeing 286 DISEASES AND DEFORMITIES OF THE FOOT CHAPTER I ANATOMY THE BONES The bones entering into the formation of the foot are: the astragalus, the os calcis, the scaphoid, the cuboid, the internal, middle and external cuneiforms, the five metatar- sals, fourteen phalanges and two sesamoid bones under the head of the first metatarsal. Other sesamoid bones are inconstant : the interphalangeal one of the great toe is found in about 50 per cent, of cases according to Pfitz- ner, quoted by Dwight, and the peroneum, the sesamoid in the tendon of the peroneus longus, occurs in about 10 per cent. (Dwight). Variations in the conformation of the bones and in their numbers, changes which are not pathological but which may have important bearings on diagnosis and treatment, have been studied and the re- sults presented in book form by the late Professor Dwight of Harvard University. The Astragalus is the only bone of the foot entering into the ankle joint. It articulates with both bones of 13 "14 ■ DISEASES AND DEFORM'ITIES OF THE FOOT r n ^ • the leg. Its upper articular surface is convex antero- posteriorly. The axis of the chief movement in which this surface enters, that is to say, the axis of the most pronounced movement in the ankle joint, is close to the calcaneo-astragaloid joint. It passes considerably below the internal malleolus, but not more than an eighth of an inch below the external malleolus. The tip of the ex- ternal malleolus is a good guide to this axis. How- Fig. I. Axis of Ankle-Joint Movement The transverse axis of movement at the ankle-joint is represented by the line A-B. It is at the tip of the external malleolus and not through the joint surfaces of the tibio-tarsal joint. ever, this axis is not stationary ; its outer end moves for- ward during plantar flexion and backward during dorsal flexion. Thus the outer border of the superior articular surface of the astragalus has two movements : the one most marked of rotation about a transverse axis and an- other, forward and inward or backward and inward, about a vertical axis situated internal to the internal mal- leolar-astragaloid articulation. The cause of these two ANATOMY IS movements is seen in the shape of the trochlear surface: while the inner edge is almost completely in an antero- posterior plane, the outer edge is so curved that it lies in a plane extending downward and inward. The widest part of the trochlear surface is usually somewhat anterior to the center, the narrowest being at the posterior ex- tremity. B Fig. 2. Trochlear Surface of Astragalus Left astragalus, from above, demonstrating the arc, B-C, of a secondary movement at the ankle-joint about a vertical axis, A. The articular surface on the internal surface of the astragalus and that on the internal malleolus nearly cor- respond in size, showing that there is slight movement there other than that of rotation on a transverse axis. The articular surface on the external surface of the as- tragalus and that on the external malleolus, on the other hand, do not correspond in size, the former being ex- tended much further antero-posteriorly and thus permit- ting the secondary movement about the vertical axis above described. 1 6 DISEASES AND DEFORMITIES OF THE FOOT There is no lateral movement, no movement from side to side, at this joint except when the narrowest, the posterior, portion of the trochlear is presented in the mortice formed by the tibia and the fibula. When the widest part of the trochlear is brought directly between the malleoli they are slightly separated and the inferior tibio-fibular ligament is stretched. The head and neck of the astragalus incline inward toward the center of the foot; but it may be deformed and incline outward toward the other foot, as in con- genital club-foot. The head forms the ball of a ball- and-socket joint, the socket being formed by the scaphoid, by the sustentaculum tali of the os calcis, and by the cal- caneo-scaphoid ligament. Below, the astragalus articulates with the os calcis through both the body and neck, the two joints being separated by the interosseous ligament. The synovial membrane of the posterior joint is separate from that of any other, while that of the anterior communicates with the synovial membrane lining the astragalo-scaphoid joint. The movements permitted between the astragalus and the OS calcis are inversion and eversion on a longitudinal axis and slight rotation on a vertical axis. The move- ment on an antero-posterior axis, producing inversion and eversion, turns the sole of the foot inward and up- ward or outward and upward. The former movement, inversion, is the more pronounced. The axis of this movement, to be exact, is oblique; extending from the Plate I. — Radiograph of a Practically Normal Forefoot The slight deviation in the direction of the distal phalanges of the first, fourth and fifth toes from the long axes of their metatarsals shows that the foot-wear has not always been the best fitting. A properly fitting shoe should preserve the straight alignment of the bones of the toes and also the fan-like expansion of the outer metatarsals. ANATOMY 17 upper portion of the head of the astragalus downward, backward, and outward. The rotation through the vertical axis turns the heel inward or outward and the fore-foot in an opposite direction on an horizontal plane. The Scaphoid assists in forming the socket for the head of the astragalus. Anteriorly it articulates with the three cuneiform bones and, occasionally, externally with the cuboid. On its internal surface is a tuberosity to which is attached a part of the tibialis posticus muscle. This tuberosity is an important landmark in studying deformities. The Os Calais, or calcaneum, is the largest bone in the foot. Above, it articulates with the astragalus; an- teriorly, with the cuboid. Movement at the calcaneo- cuboid joint is almost entirely in a downward and inward and in an upward and outward direction. This joint has a synovial membrane separate from any other joint. On the inferior surface of the os calcis are two tubercles: an inner and an outer one. The former is the larger. When the bone is resting on a flat surface its long axis is directed forward, downward, and outward. A tuber- cle on the external surface, the peroneal tubercle, is sit- uated slightly below and in front of the center of this surface and separates two grooves, through the lower of which runs the tendon of the peroneus longus muscle and through the upper the tendon of the peroneus brevis. The Cuboid articulates with the os calcis pos- teriorly ; with the two outer metatarsals in front ; and, in- l8 DISEASES AND DEFORMITIES OF THE FOOT ternally, with the external cuneiform, and sometimes with the scaphoid. Externally it presents a tuberosity which is close to a groove on this bone for the tendon oi the peroneus longus. The Cuneiform Bones. — The three cuneiform bones articulate in front with the three inner metatarsals. The Metatarsal Bones. — Of the five metatarsal bones, the first is the strongest and the shortest, while the second is the longest. The Sesamoid Bones. — Under the metatarsal- phalangeal joint of the great toe are the two sesamoid bones. They are in the tendon of the flexor brevis hal- lucis and are united by a transverse ligament. These bones are not accidental formations due to pressure (Bell), but have been found in the still-bom baby (Cross). They are essential to the perfect physiology of the foot. The Phalanges. — There are two phalanges for the great toe and three for each of the others. Arches. — In most descriptions of the foot, the bones are divided into two rows and described as forming arches. Each foot is spoken of as forming three arches: an inner and an outer longitudinal arch and an anterior, or transverse, arch. None of these arches is a perfect arch and therefore can have no keystone. In fact, noth- ing is gained by trying to adopt the terms of an engineer of inanimate structures. Skeleton of the Foot. — If the articulated bones of a foot are placed upon the table, it will be seen that the ANATOMY 19 foot rests upon the os calcis, through its internal and ex- ternal tuberosities, and upon the heads of the five metatar- sals. The cuboid on the outer side is much nearer the table-top than is the scaphoid or the internal cuneiform on the inner side. Neither the scaphoid nor any of the cuneiforms nor the cuboid reach the plane on which rests the OS calcis and the heads oi the metatarsals. The lower edge of the tubercle of the scaphoid is slightly- above a line connecting the posterior edge of the internal malleolus and the inferior tubercle on the head of the first metatarsal. Attention has been drawn to this rela- tion by Feiss. Just back of the scaphoid is the head of the astragalus, with which it articulates, and below the head is the sus- tentaculum tali. On the outer side of the os calcis is seen the peroneal tubercle and on the outer side of the cuboid may be seen the groove for the tendon of the peroneus longus. The os calcis projects backward into what is called the tuberosity. It is this tuberosity which forms the projection of the heel, and therefore when the longitudinal axis of the os calcis is altered, as it is in a lowering of the dome of the foot, then the prominence of the heel is altered. Negroes are so frequently afflicted with the deformity of flat-foot, in which the axis of the OS calcis is changed from forward, downward, and out- ward to a direction of forward, horizontal, and inward, and in consequence have such prominent heels that it has been mistaken for a characteristic of the race, instead of a characteristic of an acquired deformity. 20 DISEASES AND DEFORMITIES OF THE FOOT It will be noted that the medio-tarsal joint is not trans- verse to the long axis of the foot: it lies in a plane which is oblique from within, outward and backward. There are only two bones in the foot back of this joint: the os calcis, articulating with the cuboid, and the astragalus, articulating with the scaphoid. In front of the medio- tarsal joint, the cuboid and the scaphoid are not side by side; the three cuneiforms articulate with the scaphoid anteriorly and the cuboid articulates with the external cuneiform. The five metatarsals, lying side by side, form a dome, convexity upward, much like that which is formed by the metacarpals when the hand is cupped. The two outer metatarsals articulate with the cuboid and the three inner ones with the cuneiforms. There is less movement be- tween the middle metatarsal and the ones on either side of it, than there is between the other metatarsal bones. It should be noticed that the joints between the heads of the metatarsals and the first phalanges are not in the same plane. The first two joints, those of the great toe and of the second toe, have their transverse axes in align- ment and the axes of the outer three form an almost straight line, but the axes of the outer three joints is di- rected obliquely outward and backward from the axis of movement of the two inner joints. The latter axis is nearly at a right angle to the longitudinal axis of the foot. The first metatarsal bone is conspicuously larger than any of the other metatarsals. In fact, there is reason for ANATOMY 21 considering it the first phalanx, but all we need to notice here is that it is a very strong, stout bone. The sesamoid bones under its head prevent pressure on the tendon of the flexor longus poUicis while the foot is weight-bearing, so that that tendon is always free to move. These bones also permit the head of the meta- tarsal to be moved under the same conditions. Upon assuming the position of tip-toe, abduction takes place at this joint, the large toe being moved away from the others. THE LIGAMENTS The ligaments are very numerous between the bones of the foot. Plantar Fascia. — Among these might be included the plantar fascia, as it has a ligamentous action among its other functions. No one can see this fascia without being impressed with its remarkable strength. It stretches from the tuberosities of the os calcis forward to the heads of the metatarsals and the first phalanges. It is made of white fibrous tissue containing many fat cells. To it is attached the plantar skin, which, there- fore, does not move upon it as does the palmar skin on its fascia. The upper or deep surface of this fascia sends layers to the bones to form compartments for the mus- cles, nerves, and vessels. Plantar Ligaments. — On the plantar surface, there are two true ligaments of large size : the long and the short plantar ligaments. They extend from the os calcis 22 DISEASES AND DEFORMITIES OF THE FOOT forward, the shorter to the part of the cuboid behind the obhque ridge, the longer to this ridge and, by some of its fibers, to the metatarsal bones. Thus this long plantar, the long inferior calcaneo-cuboid ligament, encloses the peroneal groove and forms a canal for the tendon of the peroneus longus. On the dorsum of the foot there are the dorsal liga- ments of each joint, but none of these demands our spe- cial attention. External Lateral Ligament. — On the outer side of the foot the lateral ligament of the ankle joint is strong and important. It may be divided into three slips : the one most anterior, extends from the anterior border of the malleolus forward and inward to the astragalus; the middle slip extends from the outer surface of the malleolus, close to its apex, to the tubercle on the outer surface of the os calcis, — this part of the ligament is crossed by the tendon of the peroneus brevis; the pos- terior slip arising from the posterior border of the mal- leolus and attached at its other end tO' the astragalus close to the articular facet for the fibula. Internal Lateral Ligament. — On the inner side of the foot are two ligaments of the greatest consequence in many deformities of the foot. They are the internal lateral ligament of the ankle and the inferior calcaneo- scaphoid ligament. The internal lateral ligament of the ankle, the deltoid ligament, is attached to the internal malleolus above, while below its attachments are: behind to the astragalus, in the middle to the astragalus and to ANATOMY 23 the sustentaculum tali, and in front to the calcaneo- scaphoid ligament and to the scaphoid bone. It is prob- ably this ligament which offers greater resistance to the correction of congenital club-foot than any other struc- ture exclusive of bone. Calcaneo-Scaphoid Ligament. — The calcaneo- scaphoid ligament is an exceedingly strong, thick liga- ment extending from the sustentaculum tali to the sca- phoid. As in some positions it supports the head of the astragalus, it has been called the suspensory ligament; but it is worthy of emphasis that this ligament must be less of a factor in supporting the astragalar head when the scaphoid is rotated downward, — as when the foot is on the ground and the toes are turned outward, — than when the foot is adducted, for the ligament is then re- laxed. Posterior Ligament. — The posterior ligament of the ankle joint, the posterior tibio-astragaloid ligament, may be an important factor in preventing full dorsal flexion at this joint. It lies in front of the narrowest part of the tendo Achillis, opposite the thickest part of the internal malleolus, and is easily divided through the same puncture made by the tenotome for division of the tendo AchiUis. MUSCLES AND TENDONS It is well to remember in studying muscles that though the name of the muscle will often indicate one action of which it is capable it is by no means its only action. Most 24 DISEASES AND DEFORMITIES OF THE FOOT of the muscles of the foot cross several joints and each one of these joints is affected by contractions of the mus- cles crossing it. Therefore a study of the physiology of these muscles is by no means a simple matter. Then, too, a muscle or a group of muscles, acting unopposed will produce one set of movements, while if opposed by the action of another muscle, or muscular group, a dif- ferent set of motions will be produced. It is an impos- sibility for any muscle of the foot to produce a movement confined to any one joint, unless its action is counteracted in part by one or more other muscles. Thus flexion or extension of the ankle is not a simple movement: some movement takes place in at least the sub-astragaloid joint. Under normal conditions almost every joint in the foot is affected by the movement in any one joint. It is this close association of joint movements which makes analysis of the movements difficult. For instance, rotation on a vertical axis takes place both in the sub- astragaloid and in the medio-tarsal joints, and so does rotation on an antero-posterior axis. However, it simplifies our study, if, with this in mind, we consider the chief axes of the movements of the foot to be three: one transverse, for flexion and extension through the ankle joint; one antero-posterior, passing through the sub-astragaloid joint, for inversion and ever- sion of the sole; and one vertical, through the medio- tarsal joint, for abduction and adduction of the fore- foot. Calf Muscles. — The calf muscles consist of the ANATOMY 25 gastrocnemius, the soleus, and the plantarus. The last is a small muscle, seldom inserted into the plantar fascia, but usually into the os calcis with the tendo Achillis. The gastrocnemius and the soleus have very large bellies which form the greater part of the calf. If the other muscles of the back of the leg are undeveloped, the lower Fig. 3. The Three Principal Axes of Movements of the Foot They are transverse, longitudinal and vertical. The transverse is shown in cross-section on the astragalus. It should be placed nearer the sub-astragaloid joint. It is here that the movements of the ankle, dorsal and plantar flexion take place. The longitudinal is parallel w^ith the long axis of the foot, through the sub-astragaloid joint. Motion here is in the direction of inversion and eversion of the sole. The vertical is through the medio-tarsal joint, vv^ith motion producing abduction and adduction of the fore-foot. third of the leg appears very small and the calf seems situated higher up than normally. The leg of the danc- ing girl, with the muscles all well developed, is much more graceful than the leg of the laborer, whose gas- trocnemius and soleus are out of all proportion to the development of the other muscles. 26 DISEASES AND DEFORMITIES OF THE FOOT The gastrocnemius is attached above to the femur and below to the os calcis through the tendo Achillis, com- mon to it and the soleus. Thus the influence of this muscle is felt in three joints: the knee, the ankle, and the sub-astragaloid. The muscle is stretched to its great- est extent when the knee is fully extended, the ankle dorsal flexed, and the foot inverted. If the knee is flexed, the dorsal flexion and the inversion can be increased. There- fore in testing the length of this muscle it is essential that the knee be in extension. The soleus is attached tO' both the leg bones and to the tendo Achillis. Tendo Achillis. — The tendo Achillis is not inserted directly into the posterior part of the os calcis, but its fibers should be considered as passing around the tuber- osity into the plantar surface, although these fibers are more or less ossified. Thus the force exerted through this tension is more of a lifting and a thrusting forward than of a direct pulling upward. The insertion of the tendon is not exactly in coincidence with the long axis of the OS calcis, but is slightly to the inside, so that it has a tendency to turn the ankle outward and to invert the sole of the foot when drawn on by contraction of the calf muscles. Thus it will be seen that the muscular action serves to emphasize that outward thrust of the ankle, when the weight-bearing foot is raised on tip-toe, which must take place on account of the shape of the trochlear surface of the astragalus and to which atten- tion has been called in discussing that bone. Between the tendo Achillis and the posterior part of ANATOMY 27 the tuberosity is a bursa which is subject to injury and disease. The narrowest part of the tendo Achillis is one and one-half inches above the heel, at a point about opposite the thickest part of the internal malleolus, and here it is not closely associated with important structures and is therefore the site of selection for subcutaneous tenotomy. Peronei.— The. two peroneal muscles have attach- ment to the fibula, their tendons passing downward be- hind and close to the external malleolus. The tendon of the brevis lies in front of the tendon of the longus in this location. On the outer surface of the calcaneum the brevis lies above the longus and here they are sep- arated by the peroneal tubercle. Here each tendon has its separate synovial sheath. The brevis is inserted into the fifth metatarsal. The longus, at the tubercle of the cuboid, enters the groove on that bone and runs diago- nally forward and inward to be inserted into the outer surface of the base of the first metatarsal and the cor- responding surface of the internal cuneiform close to the cuneiform-metatarsal joint. The action of these two muscles is to plantar-flex the ankle, to evert the foot on the longitudinal axis passing through the sub-astragaloid joint and to abduct the fore- foot on the vertical axis passing through the medio- tarsal joint. The brevis has a very weak abducting ac- tion, but greatly strengthens the calcaneo-cuboid joint and slightly flexes it. The longus draws the inner border of the foot toward the cuboid and heightens and greatly 28 DISEASES AND DEFORMITIES OF THE FOOT strengthens the dome of the foot. Furthermore, in this action it rotates the inner cuneiform and the first meta- tarsal inward, and thus crowds upward and outward the scaphoid, which in its turn brings a pressure to bear against the head of the astragalus. It should be noted well that the peroneus longus can act much better in holding down the forefoot and in strengthening the dome if the foot is in adduction rather than abduction. Structures at the Inner Ankle. — Behind the inner malleolus pass the tendons of three muscles together with the posterior tibial vessels and nerve. Just back of the thickest part of the malleolus these structures lie in the following order: close to the bone, the tendon of the tibialis posticus; next, that of the flexor longus digi- torum; then a vein, the artery, and the other vein; then the posterior tibial nerve; and finally the tendon of the flexor longus pollicis. The first letter in each word in the following sentence corresponds with the first letter in the name of each structure in its proper order, as is known to many students : Timothy doth vex all very nervous people. Flexor Longus Pollicis. — This muscle arises from the fibula. Passing downward, its tendon enters the outer groove on the back part of the tibia; then passes between two tubercles on the posterior surface of the astragalus and turning inward and forward passes under the sustentaculum tali; next crosses the tendon of the flexor longus digitorum, passing above it; and proceeds forward between the sesamoid bones under the head of ANATOMY 29 the first metatarsal to be attached to the base of the sec- ond phalanx. Action of this muscle produces at the ankle joint plantar flexion; at the subastragaloid, slight inver- sion; at the medio-tarsal, slight adduction; and flexion at the astragalo-scaphoid, the scapho-cuneiform, the cuneiform-metatarsal and the metatarsal-phalangeal joints. If the great toe is held rigid against the ground by the action of the short plantar muscles attached to it and by the weight of the body and the heel be raised, contraction of the flexor longus pollicis will throw the ankle outward and forward and, by flexion of the above- mentioned joints, will raise the vault and shorten the distance between the heel and the toe. In this position of the weight-bearing foot, the great toe is drawn away from the other toes and rotated upon its longitudinal axis. Under ordinary conditions flexion of the first phalanx is prevented by the action of the flexor brevis, the abductor, and the adductor pollicis. If the extreme tip-toe position is assumed and the last phalanx only is on the ground, the position habitually used in dancing the ballet, the metatarsal-phalangeal joint rides on the tendon of the flexor longus pollicis and the sesamoids are lifted from the supporting surface. Contraction of the flexor longus pollicis, therefore, does not flex the great toe unless it is desired to grasp something, and " grasping is not a function of the great toe when it is exerting its greatest strength." When the foot is at rest the metatarsal-phalangeal and the inter- 30 DISEASES AND DEFORMITIES OF THE FOOT phalangeal joints may easily be flexed, but the foot in action, or ready for action as in assuming a position for springing, has the first phalanx held securely against the metatarsal and the inter-phalangeal joint equally im- mobilized. In this respect the great toe is in strong con- trast to the other toes; under contraction of their com- mon flexor they flex at their first inter-phalangeal joints and extend at the distal joints, the flexor surface of the last phalanx being held against the ground, but the proxi- mal inter-phalangeal joint being raised, flexed. These toes may, however, for prehensile purposes be made to flex at all their points, but that is not their strongest nor their usual action. It will be seen from the foregoing that, in order that the flexor longus pollicis may act properly, it is necessary that the flexor brevis, the ab- ductor, and the adductor pollicis act normally. A pa- tient with paralysis of these small plantar muscles but with the other muscles of the foot and leg intact, will complain that in walking it is difficult to raise the heel, that he must bring the foot forward in its straight, right- angled position, and that when he attempts to rise on tip- toe his foot feels vei'y weak. He may not be able to^ do so at all. Upon examination it will be seen that when he rises on tip-toe, the great toe bends up and flexes at the inter-phalangeal joint. Holding this joint down by finger-pressure enables the patient to execute the tip-toe movement more easily. It is likewise essential for the normal functionating of this muscle, that the metatarsal- phalangeal joint of the great toe be normal. Deformity, ANATOMY 31 such as hallux valgus, or clothing of the foot which pre- vents normal movements, especially abduction, must in- terfere seriously with its actions. A word further is needed as to the thrusting out of the ankle during contraction of this muscle when the fore- foot is held immobile, as by the weight of the body in Fig. 4. Plantar Flexion in Walking Plantar flexion of the weight-bearing foot, in standing and walk- ing, thrusts the ankle upward, outward and forward as the fore- foot can not be moved downward, inward and backward — the direc- tion it takes when the free-foot is plantar flexed. walking: its power, together with that of the flexor longus digitorum and of the tibialis posticus, would tend to produce this movement, as they are all on the inner side of the joint; but the greatest factor in its produc- tion is the formation of the tibio-astragaloid joint. With the forefoot resting on the ground, the movement producing the adduction seen in extreme flexion of the 32 DISEASES AND DEFORMITIES OF THE FOOT free foot, produces the outward movement of the ankle. This turning outward of the ankle when the heel is raised can not take place unless the feet are parallel or adducted, and therefore the correct understanding of this move- ment and its mechanism is of the greatest importance in determining the proper positon of the feet in walking and standing. A common idea of the function of the flexor longus pollicis is expressed in Morris's Anatomy : " A strong flexor of the last phalanx of the great toe and of great importance in walking, as it presses the great toe firmly against the ground." As it is scarcely ever used as a flexor of the great toe, flexion should not be considered as one of its prime functions and though the muscle is of great importance in walking we do not believe it is used to press the great toe against the ground except, possibly, just before the heel is raised. The Flexor Longus Digitorum arises from the tibia and is inserted into the last phalanx of each of the four outer toes. As the tendon passes around the ankle, it is separated from the tendon of the flexor longus pol- licis by the nerve and the artery with its venae comities, and lies close to and on the outer side of the tendon of tibialis posticus. That is, the tendon of the tibialis pos- ticus lies between the tendon of the flexor longus digi- torum and the internal malleolus. From this point it runs forward, outward, and downward between the ab- ductor pollicis and the flexor brevis below and the ten- don of the flexor longus pollicis above. The action of ANATOMY 33 this muscle is to assist in moving the ankle upward, for- ward, and outward; to flex and to adduct the forefoot and to flex the metatarsal-phalangeal and the inter-phalangeal joints of the four outer toes. This action, however, is modified by the accessorius, the flexor brevis, and the lum- bricales. Accessorius. — -This small muscle from its origin at the tubercles of the os calcis, draws directly backward the tendon of the long flexor to which it is attached at its curved position in the plantar, thus altering the direc- tion of its force from one of marked adduction and in- ternal rotation to one more nearly in line with the long diameter of the foot. Flexor Brevis Digitorum. — By its insertion into the middle phalanges of the four outer toes, this muscle flexes the first inter-phalangeal joints and holds the sec- ond inter-phalangeal joints in extension when the foot is weight-bearing. Lumbricales. — They arise from the tendons of the flexor longus digitorum and are inserted into the tendons of the extensor longus digitorum upon the dorsum of the first phalanges of the four outer toes. Their action is to extend the phalanges and thus to assist in holding the plantar surfaces of the distal phalanges tO' the ground. They will also, by adducting the outer three toes and by abducting the second toe, tend to preserve the transverse arch. They also assist to a slight extent in flexing the metatarsal-phalangeal joints of these toes. Thus it will be seen that the usual action of the flexor longus digi- 34 DISEASES AND DEFORMITIES OF THE FOOT toruni is not to flex the toes as though about to grasp some object, — they are not dug into the ground as rep- resented by some sculptors, — but that its action is to flex the four smaller toes at their first inter-phalangeal joints while the distal phalanges are held flat against the ground. Tibialis Posticus. — This is stronger than either of the other muscles passing behind the inner malleolus. It arises from both the tibia and the fibula, its tendon pass- ing beneath that of the flexor longus digitorum and reaching the innermost groove on the back of the inter- nal malleolus. It then passes forward to be inserted into the tuberosity of the scaphoid. Expansions of this ten- don are inserted into the sustentaculum tali; the three cuneiform bones; the cuboid, and the second, third, and fourth metatarsals. In passing from the groove on the tibia the tendon passes beneath the inferior calcaneo-sca- phoid ligament from which it is separated only by the synovial sheath of the tendon. It is this ligamentous support to the astragalus which, according to some sur- geons (Hancock), is the influence whereby the tibialis posticus helps to preserve the normal dome of the foot. Undoubtedly, when one is standing, especially in the vicious position of abduction of the forefoot, this tendon does act as a more or less passive support; but in action, the adduction and inversion which it produces, together with flexion of the medio-tarsal joint, so opposes any descent of the head of the astragalus that no ligamentous action is present or necessary. By the wide extent of its insertion into the under surfaces of the other bones, and ANATOMY 35 especially into the second, third, and fourth metatarsals, its influence in preserving the transverse arch is also of importance. There are four muscles passing from the front of the leg across the ankle to the foot. They are the tibialis anticus, the extensor proprius pollicis, the extensor lon- gus digitorum, and the peroneus tertius. Tibialis Anticus. — This muscle arises from the upper two-thirds of the outer surface of the tibia. When well developed it may project in advance of the crest of that bone, but it never overlaps it. When it is atrophied a sulcus may be felt between the crest and the muscle's belly. Its tendon is inserted into the internal cuneiform on the lower part of its internal surface and into the ad- jacent part of the first metatarsal. The action of the tibialis anticus is usually described as being that of a dorsal flexor of the ankle and at the same time an elevator of the inner border of the foot. The chief cause of flat-foot has been ascribed to over- work and partial paralysis of this muscle (L. A. Sayre). The condition of this muscle is undoubtedly an etiologi- cal factor in some cases of flat-foot, but it would seem that the weakness in uncomplicated conditions is due to improper use of the muscle rather than primarily to the muscle itself, and the improper use is rather a lack of work than over-work. Its action at the ankle is to lessen the angle between the foot and the leg, but whether this action should be expressed as flexing the foot or as flex- ing the leg depends on which is the fixed and which is 36 DISEASES AND DEFORMITIES OF THE FOOT the movable attachment. This question will be referred to again in discussing the succeeding muscles. Acting from above this muscle has an adducting and an inward rotating force on the internal cuneiform and the first metatarsal and tends to cause an inversion of the sole. The changed position of the internal cuneiform and of the first metatarsal places them in the most advantageous position for supporting the weight of the body. The Extensor Proprius Pollicis arises from the fibula and is inserted into the first and second phalanges of the great toe. The Extensor Longus Digitorum arises from the fibula and partly from the tibia and is inserted into the three phalanges of the four outer toes and into the liga- ment over the metatarsal-phalangeal joints. The Peroneus Tertius arises from the fibula and is inserted into the fifth metatarsal. These muscles on the front of the leg have generally been considered as acting from their upper attachments only. The names of two of them imply that they are first of all useful as extensors of the digits. One of their functions is undoubtedly to hold the forefoot and the toes in extension and thus to give a firm support against which the posterior muscles may act, but of greater im- portance is their function of flexing the leg on the foot. It can not truthfully be said that barefooted people need these great extensors of the toes — and the same holds true for the long flexors — and that modern foot- ANATOMY 37 wear has done away with their usefulness. Those who have developed the prehensile power of the toes have done so mostly through the development of the plantar muscles. Of the plantar muscles, the accessorius and the lum- bricales have been described. The Abductor PoUicis is a strong muscle inserted into the inner part of the lower surface of the base of the first phalanx of the great toe and into the internal sesamoid bone. Its action is to flex the first phalanx and to abduct the great toe (toward the middle plane of the body). This action will draw the metatarsal inward toward the other foot into a position which supports the internal cuneiform and the scaphoid to the best advantage. Thus it produces flexion and abduction of the astragalo- scaphoid and of the cuneiform-metatarsal joints, but its action at the metatarsal-phalangeal joint is, normally, to support that joint by compressing the articular surfaces strongly together. The Flexor Brevis Digitorum is a comparatively weak muscle. It is inserted into the middle phalanx of each of the four outer toes and by flexing the first inter- phalangeal joint helps to hold the plantar surface of the last phalanx to the ground during action of the long flexor. The Abductor Minimi Digiti is inserted into the base of the fifth metatarsal and into the first phalanx of the little toe. Its action is probably to assist in altering 38 DISEASES AND DEFORMITIES OF THE FOOT the weight-bearing surface of the ball of the foot to ac- commodate it to uneven surfaces and to the changing po- sitions of the foot in walking and running. The Flexor Brevis PoUicis is inserted into the first phalanx of the great toe. It is not only a flexor of the metatarsal-phalangeal joint, but a slight adductor as well, as its origin from the cuboid is to the outer side of the middle line of the foot. Its tendons on either side of the head of the metatarsal are attached to the sesamoid bones and not the least important of its actions is to control these bones. The Adductor PoUicis is also attached to the first phalanx. The great toe, then, has three strong muscles to the first phalanx. Their action is more especially to support the joint strongly when the long flexor is con- tracted. The abductor is larger than the adductor and abduction is the more important of the two movements in altering the weight-bearing surface, in preserving the transverse arch, and in supporting the dome. The Transversus Pedis is a small muscle which as- sists the abductor minimi digiti in adjusting the ball of the foot to the varying pressures. The Interossei consist of three plantar and four dorsal muscles. Their common action is to flex the first phalanges and to extend the other two of the four outer toes. This they do by virtue of their insertions into the first phalanges and into the tendons of the extensor longus digitorum. It is mostly due to them, assisted by the lumbricales, that the toes are not flexed in walking. ANATOMY 39 The Extensor Brevis Digitorum is the only muscle on the dorsum of the foot. Of its four tendons, the innermost is attached tO' the first phalanx of the great toe and the outer three to the tendons of the extensor longus digitorum going to the second, third, and fourth toes. The obliquity of the direction of these three outer tendons assists in correcting the direction of pull by the tendons of the extensor longus digitorum. NERVES The nerve supply of all the muscles of the foot comes from two main trunks : the internal and the external popliteals. The internal popliteal, as such, or after it be- comes the posterior tibial or divides into the internal and external plantars, supphes all the muscles on the back of the leg and ah the plantar muscles. The external popliteal, after dividing into the anterior tibial and the musculo-cutaneous, supplies the muscles on the anterior and outer surfaces of the leg and on the dorsum of the foot. The cutaneous nerves of the foot are derived from the long saphenous, a branch of the anterior crural, which descends through Hunter's canal and becomes subcuta- neous in the upper part of the outer side of the leg; from the short saphenous, which is formed in the middle of the calf by branches from the popliteals, the communicans tibiahs, and the communicans fibularis; from the cutane- ous branch of the musculo-cutaneous; and by cutaneous branches from the anterior and posterior tibials. The 40 DISEASES AND DEFORMITIES OF THE FOOT outer border of the foot is supplied by the short saphen- ous ; the inner border by the long saphenous ; both ankles and the dorsum by the musculo-cutaneous, which also supplies the dorsum of the adjacent sides of the second, third, and fourth toes. The adjacent sides of the first and second toes are supplied by the anterior tibial. The sole is supplied by the internal plantar, as is also the inner border of the first toe and the adjacent borders of the second, third, and fourth toes and the structures about the nails. The external plantar supplies the adja- cent sides of the fourth and fifth and the outer side of the fifth toe. CHAPTER II PHYSIOLOGY Distribution of Weight. — A study of the structure of the bones, and especially of their striae, as indicating the direction in which nature is prepared to receive the stress of weight and power, shows that the greatest strength of the astragalus is in the body extending to the OS calcis, but that the head and neck are exceptionally strongly made. A comparison of the internal architec- ture of the head of the astragalus and the scaphoid with that of the bones about the calcaneo-cuboid joint demon- strates that the former are fitted to receive the greater stress. When the tibiae are in the transverse plane of the body containing the center of gravity, the amount of weight transmitted through the posterior tubercles of the os cal- cis and the amount transmitted through the astragalo- scaphoid articulation, will depend on the flexion of the foot. The greater the dorsal flexion, the greater will be the weight transmitted through the os calcis; and the greater the plantar flexion, the greater will be the weight transmitted through the scaphoid. However, it must be borne in mind that the position of the transverse plane containing the center of gravity will influence the share 41 42 DISEASES AND DEFORMITIES OF THE FOOT of the weight borne by any particular bone. This may be easily demonstrated by scales : if a stand is erected so as to be contingent to and level with the scale-platform, it will be readily seen that moving the transverse plane ever so slightly changes the proportion of the weight passing through the forefoot and the heel. With the subject so placed that the heels are on the stand and the forefoot rests upon the scale-platform, advancing an arm, nodding the head, contracting the abdominal muscles, raising the chest, will cause an alteration in the reading of the dial. It is hard to conceive of this plane remaining unchanged for any length of time. Though a man weighing 150 pounds and standing in low-heeled shoes may be said to transmit 100 pounds through the heels and 50 pounds through the forefoot, and this was the conclusion reached by Sampson after a careful mathematical calculation, it must not be supposed that even while one is standing the relation of these two weights is constant. One reaches forward, leans backward, bends the neck, makes a ges- ticulation, — and the ratio' between the weight borne by the forefoot and that borne by the heel must suffer al- teration. In short, no ligament, muscle, or bone is un- der a constant amount of strain while the body is in the upright position. The sense of balance will cause the plane of the center of gravity to be quickly returned when moved from its normal position; but changes in the amount of strain borne by individual bones, liga- ments, and muscles will have occurred, even if momen- tary, and that is of the greatest importance. PHYSIOLOGY 43 MOVEMENTS The arrangement of the bones of the foot and their pecuHar shapes have caused not a httle controversy as to their physiology. The only movement of the foot which is invariably examined, and usually imperfectly, is the movement at the ankle joint. Were the foot comparable to the rim of a wheel, as Dr, Holmes pictured it, the in- trinsic foot movements would be of slight value. But as every joint, with its every movement, is essential to the perfect usefulness of the foot and as knowledge of these structures is not widespread even among physi- cians, it is not a cause for astonishment that the pseudo- scientist has found the field of aching feet an especially profitable one. Ankle-joint. — The most marked movement at the ankle joint is that of flexion and extension. To avoid confusion they are frequently designated as dorsal and plantar flexion respectively. Dorsal flexion takes place normally to 20 degrees beyond a right-angle (18, Tubby: 15-20, Whitman). That is, with the foot upon the ground the leg can be flexed on the foot until it forms an angle of 75 or 70 degrees with the sole of the foot. If this dorsal flexion is limited, as when the tibia can be flexed only to a right-angle, an abnormal condition exists and proper functionating of the foot is interrupted. Plantar flexion of the foot is more free, extending to form an angle of about 150 degrees with the leg. As explained in the chapter on anatomy, these are not the 44 DISEASES AND DEFORMITIES OF THE FOOT only movements at the ankle. Owing to the convexity of the outer border of the trochlear of the astragalus, the anterior portion of that bone is turned slightly in- ward in full plantar flexion and less markedly outward in full dorsal flexion. This may be seen in the outward Fig. 5. Tibial Flexion Dorsal flexion of the weight-bearing foot may be termed tibial flexion. Normally the leg can be flexed on the foot to form an angle of 75 degrees with the ground. thrust of the ankle when one is rising on tip-toe; the weight of the body prevents the toes being carried in- wards, and therefore as plantar flexion progresses the ankle is forced outwards : — a most important fact to consider when studying the physiology of walking. PHYSIOLOGY 45 At the ankle joint, then, there is normally plantar flex- ion with adduction and dorsal flexion with slight abduc- tion. Fig. 6. Movements at the Ankle- Joint The axis of these movements is situated one-half an inch below the internal malleolus. Dorsal flexion is arrested at an angle of 75 degrees and plantar flexion at an angle of 150 degrees with the line of the leg, Sub-astragaloid Joint. — The chief movements at the calcaneo-astragaloid, the sub-astragaloid joint, are inversion and eversion, by which the sole is made to 46 DISEASES AND DEFORMITIES OF THE FOOT look inward and outward. With these movements there is some abduction and adduction, some rotation about a vertical axis. Fig. 7. Movements at the Sub-Astragaloid Joint Movements at this joint are on an antero-posterior axis, in the direction of inversion and eversion. The dotted line shows range of inversion and the dashed line the range of eversion. Medio-tarsal.— The medio-tarsal joint comprises two joints: the astragalo-scaphoid and the calcaneo-cu- boid. It is usually spoken of as one and is called the medio-tarsal or mid-tarsal joint. The chief movement here is about a vertical axis in the direction of abduction and adduction. With this there is some rotation on an antero-posterior axis, producing inversion and eversion, PHYSIOLOGY 47 and also some movement on a transverse axis producing flexion and extension. Anterior to the medio-tarsal joint, the arthrodial joints have only slight movements, but they are essential to the normal use of the foot. The metatarsal-phalangeal joints, especially the first, may, by an abnormality, cause serious loss of function. Fig. 8. Movements at the Medio-Tarsal Joint These movements are chiefly abduction and adduction about a vertical axis. The dotted line shovi^s range of abduction and the dashed line the range of adduction. There are, then, three principal axes of movement in the foot: one, transverse through the lower part of the astragalus, where most of the extension and flexion takes place; one horizontal, or nearly so, extending antero- posteriorly through the sub-astragaloid joint, where in- version and eversion are the most marked ; and the third 48 DISEASES AND DEFORMITIES OF THE FOOT axis, vertical through the medio-tarsal joint, where ab- duction and adduction of the forefoot are the most marked movements. Active abduction without eversion or active adduction without inversion is very limited, al- though passively they may be demonstrated. Great-toe Joint. — The first metatarsal-phalangeal joint is deserving of special notice. It is a condyloid joint, but motion is chiefly in a plane downward and in- ward, toward the middle line of the body, away from the other toes. At rest the toe is slightly dorsal-flexed and drawn toward the other toes. In the active position it is in a line with the foot, neither flexed nor extended, and is abducted, drawn away from the other toes. In the act- ing normal foot, therefore, there is a space, a separation, between the great toe and the second toe. This altera- tion in the position of this toe during rest and during activity has an important bearing upon the causes and cure of flat-foot and upon the designing of foot-wear. THE FOOT AT REST With all the muscles at rest the foot is plantar-flexed, adducted, and rotated slightly inward. This may be seen in the anesthetized patient, in the perfectly relaxed, supine position and in the crossed-leg position. During muscular rest there is ligamentous strain if the foot is not supported by some extraneous means. The plantar- flexed position will not cause strain of the plantar liga- ments, but of the dorsal ligaments; and the inward ro- tation, while relaxing the internal ligaments, will strain PHYSIOLOGY 49 the external. If this strain is allowed to continue for a prolonged period, the ligaments become weakened and more and more strain will be transferred to the muscles. Some changes may take place in the articulations, the most marked being the prominence on the dorsum of the trochlear surface of the astragalus, due to the exagger- ated plantar flexion of that bone. This passive strain may result in nothing more serious than a weak-foot; or a peripheral neuritis or even a paralysis may follow. During a protracted illness therefore it is incumbent on the physician to see that measures are taken to prevent this foot-drop and its possibly attending evils. In the weakened condition of all the body structures, including the muscles and ligaments, which accompanies protracted illness, such as typhoid fever, as well as when the muscles of the foot and leg are weakened from a partial or com- plete paralysis, some means should be taken to retain the foot at about a right-angle with the leg. A prolific cause of continued paralysis following anterior poliomyelitis is this passive stretching of muscles; this subject will be taken up more fully when that disease is discussed. STANDING Were the foot jointless except for the tibio-astrag- aloid joint, its physiology would be much simpler than it is with its no less than thirty-eight articulations. Many indeed use the foot as though it were one solid mass and more than one surgeon has described it as though its nor- mal movements were limited to flexion and extension at 50 DISEASES AND DEFORMITIES OF THE FOOT the ankle joint. Were this the case the question of the best standing position would be limited to the best geo- metrical figure to be formed by the two feet; their dis- tance apart, their relation to each other, and the angle the foot should form with the leg. There can be no doubt but that we should select the quadrilateral rather than the trapezoid figure for the feet. That is, we should have the centers of the balls of the feet and the centers of the heels form the corners of a square. If the heels are Fig. 9. Standing Positions Trapezoid and quadrilateral bases of support. The former is de- cidedly the weaker, not only mechanically but physiologically, on account of the weak position of the bones, ligaments and muscles. (After Ellis.) placed nearer together and the toes turned outward, a trapezoid figure is formed, which is a decidedly weaker base for support than the square (Ellis). To bring the transverse plane containing the center of gravity of the body over the strongest part of the bony structures of the foot and to preserve it there with the least muscular exertion, we should place the foot at about a right-angle with the leg. Thus the body of the astrag- alus would rest mostly on the os calcis. Even with the PHYSIOLOGY 51 most careful balancing, however, a condition of absolute equilibrium could be retained only by having the flexors and the extensors of the ankle in almost constant action, correcting the positions of the tibia as the gravity-plane was moved backward or forward. Work, Rest, Fatigue. — ■ It may be well to here dis- cuss work, rest, and fatigue. If the muscles as described above are in constant action, they are usually given credit for continuous work. The action, however, is not, strictly speaking, constant; it is intermittent. Normal growth of a healthy muscle, and in fact of every physi- ological tissue, demands both work and rest. With the former alone, fatigue must result; and with the latter alone, atrophy. Either condition may be produced to a serious extent, even beyond repair. Fatigue depends upon the relation of work to rest and is very variable. The corresponding muscle in different individuals varies in a wide range not only as to the work it can do without rest and without fatigue, but in the same individual this potentiality must be affected by a great many factors having to do with the functions of other tisues. In proper standing, no one muscle is in constant action. The amount of rest each muscle enjoys is or should be quite as definite as the amount of work, and in a healthy individual fatigue should not occur within a reasonable time. There are muscles in the body which undergo in- termittent contraction for most of the waking hours, and some muscles, the cardiac for instance, work and rest for the lifetime without any prolonged rest. 52 , DISEASES AND DEFORMITIES OF THE FOOT The foot can not be considered as a solid mass, as though it were composed of one bone. The modern clothing of the foot hides the more minute movements from view, but those movements are none the less made, and if they are prevented or even limited, the mechanics of the foot are altered and a weaker organ results. Whether or not such weakness becomes a serious disa- bility depends upon the extent of the interference and upon the amount the confined foot is used. If the foot is renting on the ground in a relaxed con- dition and is called into action by one's quickly rising to an upright position, certain changes in the positions of the bones take place. The most evident of these is the abduction; — toward the middle hne of the body, to- ward the other foot — of the great toe, the first metatarsal, the internal cuneiform, and the scaphoid. Whereas in rest all the toes are in contact, a space is now evident between the first and second toes. With this movement there also occurs a rotation of the same bones upward and inward, rotation downward on that side toward the middle line of the foot. There will also be an increa'se in the height of the scaphoid above the ground and an increase in the height of the dome, due mostly to the, abduction, rotation, and slight flexion of the joints already mentioned. The transverse arch will be increased, and the four outer toes will be flexed at their first inter-phalangeal joints and extended at their distal joints. The cuboid will be slightly flexed and addiicted and there will be some flexion at the two outer PHYSIOLOGY 53 scapho-cuneiform articulations. There will be some ro- tation inwards on a vertical axis at the subastragaloid joint. These movements will be produced, by the plantar muscles abducting the first phalanx of the great toe and holding it firmly against the metatarsal and the ground; by the long flexor of the great toe acting on all the joints over which it passes; by the tibialis anticus drawing up- ward and rotating inward the scaphoid and the internal cuneiform; by the tibialis posticus drawing backward, flexing the scaphoid; and also flexing and abducting — drawing away from the middle line of the foot — all the bones to which it is attached by the wide expansion of its insertion; by the long flexor of the toes, which, while pressing the distal phalanges to the ground, as- sists the tibialis posticus in rotating the foot inward at the sub-astragaloid joint; by the plantar muscles flexing the joints in the forefoot and thereby increasing the transverse arch, in which action the peroneus longus plays a very important part. The foot is not more in- verted, the forefoot more markedly adducted, and the toes crumpled up in complete flexion because the peronei, the small adductor of the great toe, the long extensors of the toes, the lumbricales and the interossei are acting at the same time. The importance of every one of these muscles is seen where one or more have been paralyzed. 54 DISEASES AND DEFORMITIES OF THE FOOT WALKING The question of what may be called the physiological way of walking can be determined by deciding whether the heel or the toe should be presented first to the ground. A few minutes' observation of the pedestrian in any large city will convince one that most people walk on their heels. On the other hand no runner would think of letting his heels touch first. The athletic trainer is continually cautioning his men to " keep up on your toes." Fig. io. Heel-Walking The feet are abducted; toes turned outward. This is conducive to awkwardness, fatigue, weakness, strain and deformity. Even a heel-walker presents his toes first if he steps down from any height, as from a high curb. No one would think of jumping from a height of a few feet and land- ing on his heels. Therefore it would seem to be quite evident that less concussion is felt and more spring is obtained by presenting the toes in advance of the heel. That all movements are more gracefully executed with the heels off the ground is known to dancing-masters. Many years ago, teachers of deportment are said to have PHYSIOLOGY 55 adopted a novel way of training young ladies not to walk on their heels; a rubber ball having a whistle at- tachment was so placed in the heel that if one did not walk on her toes in crossing the ballroom floor, the whistle sounded at each step. To the conclusion that for these reasons alone walking should be done on the toes, one might reply, however, that walking is not running, nor jumping, nor dancing. Yet why should the foot, which suffers less fatigue, trans- mits less shock, and gives more grace when the toes are brought to the ground in advance of the heel, be changed in its action so as to present the heel first when walking? As for the fatigue, the heel-and-toe walking is a far more fatiguing exercise than running, according to the witness of those who have entered these contests, which are rapidly being eliminated from athletic programmes. As for the shock, it may be very slight at each step ; but that there is a shock, which is felt in the cord and brain is quite evidenced by the toe-walking temporarily adopted by anyone suffering with a severe headache. It is for the lessening of this concussion, too, that rubber heels are worn. As for the grace, no comparison is necessary. Toe-walking is frowned on by some as being an ex- pression of affectation, but such a reason for ignoring physiological laws is too inane for discussion. Nevertheless many are convinced that the usual man- ner of walking is the correct one. They argue, that the heel presentation is by far the most common ; that people adopt it without being taught; and that in bringing the 5.6 DISEASES AND DEFORMITIES OF THE FOOT foot forward it seems to entail less effort to present the heel. Doctor Holmes represented walking by a wheel, the legs being the spokes and the feet representing seg- ments of the rim. Were this a true interpretation of the act, the heel would of course reach the ground be- fore the toes. The only one of the objections which is a true obstacle to the general adoption of toe-heel walk- ing is that heel-toe walking is so very common. It must ^_^_ PLANTAR r/ssa£:s Fig. 70. Talipes Plantaris The anterior muscles are weak and the plantar-flexors of the forefoot have raised the dome. The ball of the great toe is on a lower level than the heel. Cavus. — Aside from the condition of cavus which may accompany other paralytic deformities, there is one which is widely recognized; and although it is probably a result of other than infantile paralysis, being most common after the age of childhood, we shall take this opportunity to describe it. 196 DISEASES AND DEFORMITIES OF THE FOOT Hollow Claw-foot. — The arch is increased and the toes are in a position of dorsal-flexion at their metatarsal- phalangeal joints and of plantar-flexion at their first interphalangeal joints. Duchenne attributed it to a paralysis of the interossei and lumbricales, which plantar- flex the first phalanges on the metatarsals and dorsal- flex at the first interphalangeal joints ; and to a paralysis T.A. y E.LJ). Ta,.A PAAATTATf T/SSUES Fig. 71. Talipes Arcuatus The anterior muscles are weak and the dome is raised, but the forefoot can be dorsal-flexed to the level of the heel. of the short flexors and of the abductor of the great toe. Thus contraction of the long flexors and extensors pro- duces the clawed-toes. Golding-Bird, however, attrib- uted the condition tO' paralysis of the peronei; the un- resisted action of the adductors causing the hollow-foot, and the clawed-toes resulting from the ineffectuality of the action of the extensors on account of the fact that the INFANTILE PARALYSIS 197 proximal ends of the first phalanges are held down by the contracted plantar fascia. As this deformity is usually associated with a right-angled contraction of the tendo Achillis and as we have shown how this contrac- tion may cause a hollow-foot, we are inclined to believe that the shortened heel-cord may be a causative factor. In untreated cases of long standing those muscles which show no definite improvement after three or four months of treatment, may be condemned as permanently par- alyzed. CASES OF UNDOUBTABLE PERMANENT PARALYSIS All the muscles, ligaments, and fasciae which have been retained in one position for a protracted period, will have accommodated themselves to that position. If their points of attachment have been held nearer together than normally they will be contracted so that separation of the points of origin and insertion in their usual extent will be impossible without forcible stretching or division of the contracted tissues. The points of attachment of these tissues have been brought nearer together by forces, either intrinsic or extrinsic, by either muscular pull or external pressure. An illustration of the former in causing contractures is seen in the equinus produced when the anterior muscles of the leg are paralyzed and the action of the posterior muscles is unopposed. Vol- untary power of reducing the equinus position is lost and as the calf muscles are not stretched to the length they have in dorsal flexion they become contracted, to- 198 DISEASES AND DEFORMITIES OF THE FOOT gather with all the other soft structures which are held in a shortened position. Furthermore, the plantar muscles will hold the fore- foot flexed at the medio-tarsal joint since they are un- opposed by the anterior muscles, and a cavity deformity Tf^.A: Fig. 72, Paralysis of the Anterior Muscles The foot is drawn into the position of equinus. The dome is raised, owing to the unresisted action of the plantar-flexors of the forefoot and contraction of the plantar fascia. The toes are not more flexed because the interossei, inserted into the tendons of the long extensors, are intact. Walking also helps to keep the toes extended. will be added to the equinus. There will also be flexion deformity at the metatarsal-phalangeal joints; but the flexion deformity will not have taken place at the inter- phalangeal joints because the interossei muscles, through their attachments to the long extensor tendons over the INFANTILE PARALYSIS 1 99 first phalanges, will keep intact some power of extension at these joints. • Whether an external force, as weight-bearing, in- creases or decreases a deformity of the foot must depend on its direction, strength, and duration; so the amount of cavus deformity and of deformity of the toes in a F.LJ) Fig. t>). Paralysis of the Tendo Achilus and the Anterior Muscles The sound, long flexors flex the forefoot, contraction of the plantar tissues approximate the calcaneum and the metatarsals; thus a cavus is produced. case with the above mentioned paralysis, will be influ- enced by the amount and manner of the use to which the foot is put. If all the muscles passing over the ankle are paralyzed and only the plantar muscles are left intact, there will be added a rotation of the os calcis on a transverse axis, so that its tuberosity will be moved downward and for- 200 DISEASES AND DEFORMITIES OF THE FOOT ward; and its anterior extremity upward, and, at first, forward, and then backward. This is brought about through the absence of the calf -muscles' offering a point of resistance by holding the os calcis firm, when the plantar muscles contract; and consequently at each con- traction of these plantar muscles the force is not firmly resisted by the os calcis and the bone gives in the di- Fig. 74. Paralysis of the Posterior and the Plantar Muscles The foot is drawn into the position of dorsal flexion. In walk- ing the heel is presented tO' the ground in advance of the toes and as the impact of the calcaneum is received more and more, as de- formity progresses, on the posterior tuberosity of that bone, a cal- caneous results. rection of this rotation. Thus a calcaneus is produced which, added to the flexion of the forefoot, forms a marked cavus or hollow-foot. With this flail ankle, the foot, in walking, will take a position of eversion; and if much used will tend more and more to flatten the dome, but this force will not prevent, although it may delay, the calcaneo-cavus. INFANTILE PARALYSIS 201 If the posterior muscles are alone paralyzed, the os calcis will suffer the rotation as described above and the forefoot will be drawn up into exaggerated dorsal flexion. Flexion will not only be pronounced at the ankle joint, but there will be extension at the medio-tarsal joint, and the patient will walk upon the heel. If all the posterior muscles are paralyzed, and the Fig. 75. Paralysis of All the Muscles Except the Gastroc- nemius AND the SoLEUS With the tendo Achillis normal the heel is raised, but aii equinus of the foot is not produced because there are no muscles to flex the forefoot and because use of such a foot tends to lower the dome, to extend the medio-tarsal joint. plantar muscles as well, the os calcis will not be rotated and the toes will be held in extension. There will be dorsal flexion at the medio-tarsal joint and the dome will be flattened. When the tibialis anticus alone is paralyzed, the foot will be drawn into eversion whenever dorsal flexion takes place; and in standing, the inner border of the foot will fall into a position of valgus, especially marked if 202 DISEASES AND DEFORMITIES OF THE FOOT there is paralysis of the tibiaHs posticus accompany- ing it, TREATMENT Reduction o£ Deformities. — Whether our object is to discharge the patient wearing braces or whether we in- tend to attempt the restoration of power in the control of joints by muscle transplantation, or to support them by the use of artificial ligaments or by arthrodesis we plan to immobilize them, the first concern of the surgeon must be the reduction of deformities. Reduction of deformity may be undertaken by manual or instrumental force, or by open or subcutaneous cutting operations. Most contractures about the foot can be made to yield to stretching, without the use of an anesthetic, if the forces are correctly and repeatedly applied and the improvement constantly maintained. To be painless and at the same time efficient, the forces must be applied with such exacti- tude and perfect control that special apparatus is generally necessary. Instrumental Stretching. — In the hands of the ortho- pedic surgeon, Shaffer's antero-posterior and lateral traction shoes will give most satisfactory results. Special mechanical knowledge and an abundance of patience, to- gether with the absolute confidence and cooperation of the patient, are necessary; and therefore these appara- tuses have never been very popular with the general surgeon. A keen knowledge of mechanics is absolutely essential for the successful use of orthopedic apparatus. INFANTILE PARALYSIS 2O3 Without this knowledge the surgeon had better content himself with the knife and plaster-of-Paris. Therefore, I am persuaded that it is advisable for me to give but a short description of the lateral-traction-shoe and that is only for those who are or might become orthopedic surgeons. Lateral-Traction Shoe. — The lateral-traction ap- paratus is based upon the three varieties of rotation on the three axes of movements of the foot. It consists of a calf band, A, to which is attached a single upright, A'. This upright is always placed on the side toward which the deformity looks; in varus on the inside, in valgus on the outside of the leg, the instrument being a pusher. At a point just above the axis of motion of the ankle- joint, are placed a lateral joint, C, which is acted upon by a hinged lever and screw; and O, an arm, which pushes the lower part of the apparatus toward the de- formity to any desired extent. The distal end of this arm is free, and, as the arm is turned away from the deformity by key B', the foot part of the apparatus takes any lateral position required. This lateral hinge, with its lever and screw, is intended to meet especially the inversion of the os calcis. When traction is applied, it antagonizes the tibialis posticus muscle contraction as well as the shortening of the internal lateral ligament. Just below the hinged lever and screw is an antero-pos- terior joint, E, a worm and screw controlled by the key E'. With this any degree of flexion and extension may be obtained. Still lower and acting upon the an- 204 DISEASES AND DEFORMITIES OF THE FOOT terior part of the foot-plate (which is divided trans- versely at a point corresponding to the medio-tarsal joint) is the traction rod placed upon the inner side of the apparatus and moving in the cylinder F. It is con- FiG. 76. Shaffer's Lateral Traction Shoe The movements about the three chief axes of the foot are con- trolled by the three keys. A full description is given in the text. trolled by the key G'. H is the heel-cup, through the openings in which, X, are passed the ends of the as- tragalar strap. The outer part of the heel-plate is ex- tended quite well forward to form a resistance to the rotating movement imparted to the foot by the traction INFANTILE PARALYSIS 20$ rod G. The inner border of the foot-plate is curved over the dorsum of the foot, J, in order to grasp it as it moves from the center of motion at the outer border of the foot. The heel-plate part of the heel-cup has the semicircular opening to permit the descent of the heel when traction is applied, the same as in the antero-pos- terior shoe. Determination of Obstruction. — It is worthy of remark, that as exact a determination as is possible, as to what tissues are obstructing correction, should be made. The X-ray will assist in demonstrating the ex- tent of any bony obstruction, but the hands of the sur- geon are of the first importance. The resistance caused by bone is of a decidedly different " feel " from that due to ligament or muscle. It must be borne in mind that the movement allowed by the removal of one obstruction may be immediately blocked by another tissue which is shortened or otherwise abnormal. Thus an operator may be greatly disappointed at finding that a simple ten- otomy, while sufficient to remove all immediate obstruc- tion to correction, has simply served to bring into action other obstructions. It is worth while to spend much time and effort in trying to lengthen soft tissues by force, applied with the hand or wrench; but bony deformities will yield only to constant pressure and friction, and to the chisel. Recovery of Muscles. — After the restoration of the foot to its normal position, the bones being in their nor- mal relations to each other, it should be maintained thus 206 DISEASES AND DEFORMITIES OF THE FOOT for a sufficient length of time to assure the surgeon that all possible recovery of muscular power has taken place. Even though a muscle has been out of use for some years, it may yet enjoy a return of power if the oppor- tunity is given. That is to say, although the cells in the anterior horns, which supply the muscle, were attacked by the original disease, they may have recovered but are unable to cause contraction of the muscle because the muscle is so stretched. It is impossible to say in any given case, how long a time should be given to Nature to show a return of muscular power. As a rule, if a muscle is kept constantly in the best position for it to contract for five or six months, and if at the end of that time there is no apparent return of nervous control, it may be condemned as permanently paralyzed. Braces. — During this period of giving Nature an opportunity, braces should be applied. The design of Fig. •]•]. Right- Angle Stop at Ankle- Joint With this stop plantar flexion beyond a right angle is prevented. It is to be used in paralysis of the dorsal-flexors. the brace should be such as to protect the paralyzed mus- cles from being stretched by the sound muscles. If the anterior muscles are paralyzed the brace must be so con- structed as to prevent plantar flexion beyond a right INFANTILE PARALYSIS 207 angle. If the posterior muscles are paralyzed, dorsal flexion must be prevented beyond a right angle. The easiest way to make the joint of the brace meet these requirements, is to have a tongue extend beyond the joint with a peg to stop motion in the direction of the healthy muscles. Fig. 78. Reverse- Stop at Ankle- Joint With this stop dorsal-flexion is limited to a right angle with the leg. It is indicated in paralysis of the plantar-flexors. Fig. 'jg. A Stop- Joint Allowing a Few Degrees of Motion Only This is of use when extensive paralysis is present. It facilitates walking by permitting the body to be brought over the foot while it is flat upon the ground. If there is no movement at this joint, the heel must be raised as soon as the vertical is reached, which markedly embarrasses the walk. The brace may be secured to the outside of the shoe or it may be made with a foot-piece and be worn inside of the shoe. It will be found easier to fit the brace if it is made to go outside of the shoe and though that shoe will always have to be worn, unless other braces are made and fitted to other shoes, we should advise that 208 DISEASES AND DEFORMITIES OF THE FOOT the surgeon of little experience in such matters use the outside brace. The inside brace, if not accurately fitted, is likely to be uncomfortable; and many patients have discontinued treatment, when the principle of the brace was perfectly correct, because they despaired of ever being able to obtain an accurate fit. The joint of the brace must not be too high ; this fault Fig. 8o. Location of Ankle-Brace Joint Illustrating the necessity of the joint of a brace being below the ankle-joint: X represents the joint of the brace, if within the arc of movement at the ankle as in A, no interarticular pressure will be caused by motion, while if the joint of the brace is above the ankle-joint, as in B, motion in either dorsal or plantar flexion must cause interarticular pressure. is very frequently made by those unfamiliar with physi- ological mechanics. The center of the joint should be opposite the tip of the external malleolus, or even a little lower. The side bars should lie close to the leg and not stand away a quarter of an inch or so, and this fit should be just as accurate over the malleoli. If valgus is as- sumed upon weight-bearing, a pad should be placed on the outer side, low down, so as to hold the tarsal bones INFANTILE PARALYSIS 209 in their proper position. If varus is assumed under these circumstances, the pad should be placed on the inner side. The pad is not to push over the ankle, the prominent malleolus, as some seem to suppose. Wedge Sole. — When the paralysis is very slight and confined to one or two muscles, as the tibialis anticus or the peronei, it may be necessary only to apply a wedge to the shoe, such as was described under congenital club- foot; or a steel insole can sometimes be fitted to meet all requirements. When one is satisfied that the remaining paralysis is permanent, consideration may be given to the possibility of some operation relieving the patient from the neces- sity of wearing a brace for the rest of his life. Tendon Transplantation.- — This is very successful if correctly planned and properly executed. The plan- ning must provide for the substitution of sufficient new muscular force to take the place of the paralyzed mus- cles, without too great weakening of movements in other directions ; and the execution of the operation must be done with the most careful transposition of the tendon, providing as direct a line as possible to the new insertion, arranging the bed for the tendon so that it may move freely and not be held by adhesions, and exhibiting a perfect aseptic technique. The after treatment is of an importance second only to the operation itself : immobi- lization for four weeks followed by gentle massage and active and passive movements for several months. The condition in which the tibialis anticus is the only 2IO DISEASES AND DEFORMITIES OF THE FOOT muscle paralyzed, is the most promising for this oper- ation. The muscle to be transplanted is the extensor longus pollicis. Three very small incisions are all that are required, though one long curved incision may be used. The tendon of the long flexor is divided over the middle of the metatarsal, the distal end secured by silk or linen suture to the tendon of the flexor longus digi- torum going to the second toe, and the proximal end drawn out through an incision made over the ankle at the forward turn made by the tendon as it goes forward to the great toe. An incision is then made over the tuberosity of the scaphoid, a tunnel made to the incision above, and the tendon drawn down through this and sutured with silk to the periosteum or drawn through a hole drilled in the bone, and then sutured. The tendon should be drawn taut before it is sutured, with the foot in dorsal flexion to eighty-five degrees and in slight in- version. The position of the foot is retained in a plas- ter-of- Paris dressing for four weeks. A brace is then worn for six months to prevent the extremes of motion. A night shoe is also prescribed, and massage given daily. It may be necessary for the patient to wear a wedge on the inner side of the sole after the brace is discarded. This operation may sometimes be supplemented, when eversion is pronounced, by also transplanting a slip from the extensor longus digitorum to the scaphoid. If this is done the distal extremity of the extensor longus digi- torum is secured to the periosteum of the metatarsal. The tendon of the peroneus longus may also be used tO' INFANTILE PARALYSIS 211 reenforce the flexor longus pollicis. This is done by dividing it over the head of the os calcis, drawing- it out through an incision two inches above the tip of the ex- FiG. 8i. Night-Shoe An apparatus for retaining the foot in the right-angled position while the patient is in bed. The heel-strap, secured to buckles on the bottom of the foot-plate, passes over the bar at the toe and down the sides of the foot and around the heel. The astragalar strap passes over the instep to- hold the heel against the foot-plate. ternal malleolus, and then passing it through a tunnel downward and forward, across the inner surface of the tibia and above the internal malleolus, to the scaphoid. Where the condition presents a paralysis of the gas- 212 DISEASES AND DEFORMITIES OF THE FOOT trocnemius and the soleus, muscles from each side of the tendo AchilHs may be taken and secured either to the tendon itself or directly into the os calcis. Both pero- neals and the tibialis posticus and the flexor longus digi- torum are all accessible. My personal experience with this operation has not been successful. It is easy to ob- tain good active motion in plantar flexion at the ankle joint; but as soon as this motion is attempted while the foot is weight-bearing, the insufficiency even of all these muscles as compared to the two muscles they try to sup- plant, becomes evident, and instead of becoming stronger with use, as one might expect, they become weaker. Moreover, in this operation one is using muscles which can ill be spared from their normal functions. Others have made artificial tendons from the hamstring mus- cles to the OS calcis and have reported good results. This operation I have never tried. Silk Ligaments. — Where a flail joint exists, silk ligaments may be inserted to prevent foot-drop. This will prevent the dragging of the toes and greatly assist in walking. The operation is a simple one. Number i6 or 1 8 silk is used. It is best to boil it first in bichloride for an hour and then in plain water for fifteen minutes and dip in boiling paraffin shortly before it is used. Two ligaments are placed, each having two strands of the silk. One extends from the cuboid, under the annular ligament, to the tibia at a point two inches above its articular surface for the astragalus. The other passes from the scaphoid, also beneath the annular ligament, to INFANTILE PARALYSIS 213 the same point on the tibia. The bone insertions may be made through drill holes. By passing under the an- nular ligament, the new ligaments will not be raised up prominently at the ankle when attempts are made at dorsal flexion. All knots should be in positions where they can be well buried in subcutaneous tissue. ■ In the insertion of silk as ligaments, Ryerson was, I believe, the first to place them in the tendon-sheaths of the paralyzed muscles which they are to supplant. This is undoubtedly a great advance in the technique. Allison has added some ingenious details : in foot-drop he uses one continuous strand, passing it through a drilled chan- nel in the tarsus and running one end up the sheath of the peroneus tertius and the other up the sheath of the tibialis anticus, securing both ends high up on the tibia to its periosteum; to prevent calcaneous deformity in paralysis of the gastrocnemius and soleus, he drills two holes from the plantar surface of the calcaneum upward to either side of the tendo Achillis and threads the silk through them, bringing the loop taut around the heel and securing the ends to the tibia after passing them up through the sheath of the tendon. Astragalectomy. — Whitman's astragalectomy, which he devised for the treatment of calcaneus, is excellent also in cases of paralysis where all or nearly all the mus- cles crossing the ankle-joint are powerless. While this operation allows of some movement, it prevents the ex- tremes of either flexion or extension and thus facilitates walking, making it as easy as does an ankle brace which 214 DISEASES AND DEFORMITIES OF THE FOOT allows of slight motion. Moreover, it firmly holds the foot in the antero-posterior plane. It also increases the development of the foot, since it is used quite freely. Whether performed for calcaneus or for a flail ankle- joint, the operation is practically the same. The steps of the operation are as follows : " An Esmarc bandage ■having been applied, an incision is made from a point about one inch above the external malleolus midway be- tween it and the tendo Achillis, passing downward to the attachment of the tendo Achillis, forward below the ex- tremity of the malleolus and over the dorsum of the foot to the external surface of the head of the astragalus. The sheaths of the peroneal tendons which are exposed at once are opened, the tendons divided below the malleo- lus and drawn backward. One next divides the bands of the external lateral ligament, and the foot being some- what adducted, the interosseous ligament is divided. On further inversion, the tissues being retracted, one may with scissors free the head of the astragalus from its at- tachments to the navicular, and forcibly twisting it out- ward, break off the cartilaginous margin to which the internal and posterior ligaments that can not be reached are attached. One then prepares the new articulation. A thin section is removed from the lateral aspects of the adjoining os calcis and cuboid bones, and from the in- ternal surface of the external malleolus, which may be further shaped to secure accurate apposition. The same, but more difficult, procedure is undertaken on the inner side. One thoroughly separates the internal lateral liga- INFANTILE PARALYSIS 21 5 merit from the malleolus in order to permit complete backward displacement, then removes the cartilage from its inner surface. With a periosteal elevator the strong inferior calcaneo-navicular ligament is detached suffi- ciently to permit the malleolus to sink in behind or slightly to overlap the navicular. The two peroneal ten- dons, thoroughly freed from their attachments to the fibula, are then passed through the base of the tendo Achillis from within outward and are sutured to it and to the periosteum of the os calcis as well, at a sufficient tension to hold the foot in moderate plantar flexion. The tendo Achillis is sometimes overlapped and sutured as an aid in restraining deformity. The malleoli are then forced forward and accurately adjusted to the new articulation and the wound closed with catgut, reenforced with several silk sutures. The foot, carefully supported in its attitude of backward displacement and moderate plantar flexion, is thickly covered with sterilized sheet, wadding and fixed by a light plaster bandage, particular care being taken to exert only the slightest constriction. The leg is then brought to a right angle with the thigh and the plaster bandage is continued over the thigh, reen- forced by a band of steel in the popliteal region. The limb is suspended for several days or a week, the aim being to relax tension and to lessen the congestion. The plaster bandage fixing the limb in flexion at the knee remains for several weeks until immediate repair is com- plete, a section being removed over the wound to permit inspection at the end of a week. It is then replaced by 2l6 DISEASES AND DEFORMITIES OF THE FOOT one that reaches only to the knee, holding the foot in moderate plantar flexion, the sole being made level by the insertion of a piece of cork. The plaster support is worn for about six months, the longer the better, since the patient must bear weight on the front of the foot. Success in this treatment is directly dependent upon the accuracy with which its details are carried out. The most important of these is secure fixation in complete backward displacement." CHAPTER IX TUBERCULOUS AND GONORRHEAL DISEASE TUBERCULOUS DISEASE OF THE FOOT The primary focus may be in the tibia, fibula, one of the tarsal bones, or in the synovial membrane. Clinically it is usually found to be limited to one bone or to involve one or more joints together with the synovial membrane. The tendon sheaths may be infected, especially that of tibialis anticus, from their insertion into an infected bone. The order of frequency in which the bones were attacked in 1231 cases collected by Whitman, were: cal- caneum, astragalus, cuboid, scaphoid and metatarsals, cuneiform bones, malleoli, phalanges. The calcaneum and the astragalus are primarily infected much more than any of the other bones. The etiology and pathology are the same as bone tu- berculosis elsewhere. Diagnosis. — The history will be that of a limp with more or less pain, especially at night, alterations in the contour of the foot and sometimes sinus formation. In children it is usually the limp for which consultation is sought. Limp. — At the beginning this will be intermittent. The infected foot will unconsciously be favored in such a way as to relieve the infected areas from weigh t- 217 2l8 DISEASES AND DEFORMITIES OF THE FOOT bearing and from movement. Thus, if the focus is in the astragalus or in the os calcis, the foot will be used in the position of slight equinus; if the medio-tarsal joint is the location of the infection, the deformity will be that of abduction, resembling that of valgus ; and if the focus is in the forefoot, the child will walk on the heel. Pain will not be a prominent symptom during the early stages, but later, especially in adults, it may be severe. In children the pain may be enough to disturb sleep and to cause the patient to desist from romping as much as usual. There is little of value as a help in diagnosis, in the designated site of the pain. It may be along the inner or outer side of the foot. Sometimes pressure over the site of the infection will produce pain, but the absence of such a painful spot is of little or no value. The character of the pain is not distinctive of this disease. In adults, when the medio-tarsal joint is involved, the pain may resemble very closely that accompanying flat- foot ; a strained, sore, aching feeling rather than a sharp, severe, acute pain. Contour. — In the earliest stages even, a careful ob- server, on comparing the two feet, will note differences in them. Depressions in the normal foot will be filled in, partially or completely, in the other. If the synovial membrane is infected early, there will be a puffy appear- ance wherever the infected membrane is not confined securely by the over-lying structures; as on each side of the tendo Achillis, below and in front of the malleoli, over the calcaneo-cuboid joint, or the astragalo-scaphoid TUBERCULOUS AND GONORRHEAL DISEASE 219 joint, or in front of the ankle on either side of the ex- tensor tendons. The atrophy of the calf-muscles is an early sign, but in the early stages is not recognizable except by the use of the tape-measure. The consistence of the swelling will differentiate be- tween bony enlargement, induration of the soft parts, synovitis and abscess formation. That is to say an at- tempt should always be made to make such a differenti- ation, but experience alone can teach the comparative points in density, in fluctuation and in " feel." Fig. 82. Tuberculous Foot This drawing, from a photograph, shows the fusiform enlarge- ment, pointing of the toes and the equinus position. Deformity. — If the ankle joint is infected, there will gradually be assumed a position of equinus; if the cal- caneo-astragaloid joint, a position of eversion; and if the medio-tarsal point, especially the astragalo-scaphoid joint, a position of abduction. With the increase of the amount of tissue involved, the entire ankle and foot be- come involved, fusiform in shape, with toes pointed downward and slightly outward; and the possible ap- pearance of sinuses, in almost any location, will complete the picture. 220 DISEASES AND DEFORMITIES OF THE FOOT When one malleolus is attacked, it may be so enlarged as to give the foot the appearance of having been badly treated after a fracture. The foot seems to be dislo- cated at the ankle in the opposite direction. As long as the ankle joint is free of infection there will be no mus- cular spasm associated with its movements. Frequently pressure over the malleolus will give pain. Heat. — Heat will be present during the activity of the disease. It is best determined by first laying the hand on the sound foot until its temperature is determined, as compared with the temperature of the hand; and then placing the hand on the suspected foot and noting any difference in temperature. If one becomes adept in this examination for slight differences in the temperature of the two feet, he will have an excellent aid to the de- termination of the efficiency of any treatment being pur- sued. Redness is not present except at some point in advance of the opening of an abscess. The superficial veins may be much more marked than in the other foot. Muscular Spasm. — This will invariably be present whenever a joint becomes involved. Any movement, active or passive, of such a joint will elicit this spasm. Whether the spasm occurs at the beginning of move- ment, or not until the normal limitations of movement at that joint have been reached, will depend upon the exact location of the infected area and its extent. If this area is extensive, there will be no movement in the joint, it will be absolutely immobilized by the muscular spasm; if this area is very limited, movements may be TUBERCULOUS AND GONORRHEAL DISEASE 221 free until the limitations are approached, when they will be found to be halted before they are in the normal foot ; the range of motion is shortened. This spasm is the same involuntary protection of a diseased condition, or an injury, which is found in so many instances. The diagnostic value of this spasm was, I believe, not fully recognized until studied by the orthopedic surgeon. To-day the general surgeon, in a case of appendicitis for instance, is often guided more by the spasm than by any other one sign or symptom. In examining a joint for muscular spasm, it is neces- sary that the examiner be ready and able to recognize the slightest restriction to movement, its sharp, sudden ap- pearance, its muscular rather than bony " feel," and the invariableness with which this spasm always appears when that particular angle of movement is reached. There is no better indication of the progress, or the lack of progress, being made in the treatment of tuberculous arthritis, than the increase or decrease of the muscular spasm. In severe cases there will be no movement dis- cernible, the joint will seem to be ankylosed; but a pa- tient, careful examination will disclose the presence of a spasm while attempts at movement are being made ; and spasm once felt rules out bony ankylosis, regardless of whether every other test, even X-rays, seem to point toward bony ankylosis. When a muscle passes over two or more joints, and one of these joints is the site of a tuberculous infection, it will limit only the move- ment of the diseased joint and will not affect movement 222 DISEASES AND DEFORMITIES OF THE FOOT in the other joints, unless the movements in the healthy- joints tend to convey some movement to the diseased joint. Thus if the medio-tarsal joint is the subject of infection, the ankle joint may be freely moved if none of the movements is extended to the medio-tarsal. It is the failure to recognize this fact which sometimes leads to an erroneous diagnosis. After examining the sound foot, so as to become familiar with the range of movements it enjoys, each of the three axes of motions in the suspected foot should be examined separately. Early in the disease there is not likely to be absolute immobilization from the spasm, but only a limitation of movement. Later this muscular spasm may cause com- plete fixation. Mensuration. — This will disclose the atrophy of the leg, more marked in disease of the ankle joint and of the subastragaloid than of the medio-tarsal, and also the swelling of the foot. All measurements must be made at the same distance from corresponding points on each leg and foot. This atrophy is present early in the dis- ease, increases as the disease progresses, and is always greater than would accompany disuse alone. X-rays. — ■ The radiograph of a suspected foot will be of inestimable value and should always be had, if possible, before committing oneself to a positive diagnosis. In very early cases, however, if all the clinical signs and the history point to a tuberculous infection, even though the radiograph is negative, I should advise that the treat- ment be directed toward this disease. When the symp- TUBERCULOUS AND GONORRHEAL DISEASE 223 toms are pronounced, the absence of confirmation by the radiograph is, of course, of the greatest importance. Tuberculin Test. — The various tests with tuberculin may be used with the same advantage obtained in its use for diagnostic purposes in other suspected regions. A positive reaction may come from the presence of a focus in some other part of the body. Differential Diagnosis. — The following table for differential diagnosis is open to criticism in many re- spects, but it would manifestly be impossible to tabulate the many exceptions which may be taken to the state- ments as we have set them forth. Probably few phy- sicians of wide experience would agree in all respects with this or any other similar table. Flat-foot Tubercu- lous Arthritis Gonor- rheal Arthritis Rheuma- toid Arthritis Gout PyOGBNIC Infection Bilateral Unilateral Unilateral Unilateral Unilatera Unilateral Age 10-30 2-20 15-25 2-40 35-60 Any age Sex Male Either Male Female Male Either Previous attacks None None Likely Likely Likely None Onset Slow Slow Slow or rapid Slow Rapid Rapid Constitu- tional symptoms Absent Absent Slight Absent Slight Marked Location Astragalo- scaphoid joint Infected area " Tendon sheaths Bursae Plantar fascia Involved joints Great toe Infected joints 224 DISEASES AND DEFORMITIES OF THE FOOT Tubercu- Gonor- Rheuma- Flat-foot lous rheal toid Gout Pyogenic Arthritis Arthritis Arthritis Infection Position Everted Everted Everted About Extension Varies of foot abducted abducted plantar- flexed abducted normal great toe widely Swelling Inner border of foot Fusiform Diffuse May be absent Great toe Varies Color Purplish White Normal Normal Purplish Red Heat Absent Slight Absent Absent Slight Marked Tender- Slight, Over Over me- Inflamed ness Over over m- bursae Not tacarpal- area Hunter's fected tendon marked phalan- capsule area sheaths plantar fascia geal joint of large toe Pain Only after Slight but After use Continu- Worse at use contmu- Ache ous night Continu- Soreness ous Increased Constrict- ous Bruise Worse at night Sharp by use Dull ing char- acter throbbing Muscular Peroneus Peroneal May be Extensor spasm longus muscles absent of great Marked in and brevis Most marked: P. longus and brevis or gastroc- nemius toe any movement of involve joints Blood test Negative Tuber- culin reaction Compli- ment fixa- tion for gonococci Compli- ment fixa- tion for auto-infec- tious mi- cro-organ- ism from teeth or elsewhere Negative Negative Condi- None Atrophy Gonor- Results of tions to of leg rheal uri- attacks in be sought muscles thritis or other elsewhere ophthal- mia joints Tophi None Plate IV. — Tl'berculous Disease of the Foot The disease has extended so as to involve the tibia, astragalus, calcaneum and scaphoid. At the time this photograph was taken the equinus was practically overcome but valgus and aversion are still marked. The sinuses are discharging freely and spasm is evi- dent upon the least attempt at passive motion. An ankle-brace, crutches, and helio-therapy, with extra- urban hospital care, arrested the disease, healed the sinuses and reduced all deformities. TUBERCULOUS AND GONORRHEAL DISEASE 225 TREATMENT Immobilization. — It is impossible to obtain trac- tion in order to prevent inter-articular pressure; so that immobilization, with the removal of weight-bearing dur- ing the acute stage, is the object to be sought. Immo- bilization may be obtained by using plaster-of-Paris, a steel brace, molded leather, porous plastic felt, or silicate bandages. In the hands of those who are not expert orthopedic surgeons, the plaster-of-Paris is probably the most satisfactory to use, especially while the disease is active and while deformity and swelling exist. If the ankle joint or the subastragaloid is involved, the knee should be included in the bandage so as to insure con- trol over the gastrocnemius. Care must be tLken to put the foot up in the best position obtainable without using too much force. If some equinus and abduction are present, they need not be corrected at once, as these deformities will become less as the foot improves, and any violence to the diseased area is to be avoided. If sinuses exist, fenestra must be cut in the plaster to permit of their being dressed. The plaster should be changed about every two weeks if deformity and swelling are present, so as to allow further correction of the posi- tion and the better fitting of the bandage as the swelling subsides. When deformity and swelling are absent, the bandage needs to be changed but once a month. While the disease is active, the foot should not be allowed to hang down. Confinement in bed is not necessary nor 226 DISEASES AND DEFORMITIES OF THE FOOT advisable, but the foot should be kept elevated the greater part of the time. With the reduction of deformity, disappearance of swelling and lessening of spasm, and when these signs are not greatly marked at the first consultation, ambulatory treatment may be tried. It is at this stage that a brace is especially indicated: if properly fitted, it is not only more comfortable than plaster but better admits a close observation of the progress being made. The slightest increase of spasm is indication of insufficient protection. It should not be necessary to wait for the grosser signs, actual deformity or immobilization or swelling, to recog- nize Nature's assertion that we are not properly caring for the condition. At the first hint, an increase of spasm, a shorter range of motion, the treatment must be changed. Braces. — There are three braces which may be used in tuberculous disease of the foot: the ankle brace, the long leg brace of Shaffer's, and the Thomas knee brace. The ankle brace consists of a foot piece with two side bars extending to the knee and has no joints. Instead of a calf band it has a band connecting the tops of the leg-bars and passing in front of the tibia, with a strap passing around the calf and completing the circumfer- ence of the leg. The foot-piece must be made to fit accurately the bottom of the foot so that it will act as a perfect, immobilizing splint. It may be made over a plaster cast of the foot, or made from an outline of the foot and fitted, altered, and refitted until perfectly satis- TUBERCULOUS AND GONORRHEAL DISEASE 22/ factory. The use of a cast is recommended for the inexperienced surgeon, especially if the brace is to be made by a mechanic who is not an expert in this work. The side bars are formed to correspond to the outlines of the leg and are then welded to the foot-piece. They must not be riveted to the anterior cross-bar until they have been fitted to the leg after the welding, as it is im- possible to alter them after completion of the brace without freeing them from this cross-bar, because any change in their outline must be felt in other parts of the apparatus. The cross-bar should lie across the lower part of the tibial tubercle, should be well padded, and should fit snugly. The object of having this steel bar in front is to absolutely prevent any dorsal flexion, which is not possible with only a strap in this location. A strap to buckle over the ankle is riveted to the bottom of the foot-piece, just behind the line of the leg-bars. This strap, together with a laced shoe going on over the brace, will securely hold the foot against the foot-piece, and render immobilization complete. During the stage of convalescence, if the disease has been confined to the forefoot, an ankle brace may be applied permitting move- ment at the ankle. Campbell Brace. — The long leg brace which may be used for these cases is called the Campbell brace by Dr. Shaffer. The name is derived from that of the first patient for whom he devised it, just as he named the Condon brace after the first patient to wear one. The principle of this brace is to transfer the concussion of 228 DISEASES AND DEFORMITIES OF THE FOOT Fig. 83. Campbell Brace The pelvic band and the perineal straps are properly adjusted, the sole plate brought against the bottom of the foot and the shoe put on and laced up. Extension by means of the ratchet in the thigh-bar is then applied. This pushes the shoe away from, below, the foot. The thigh and calf bands are then laced. All weight- bearing is removed from the foot. The weight is transferred from the body through the tuberosities of the ischii, the perineal bands, the pelvic band, the long outside bar of the brace, to the foot- piece. The lock at the knee permits bending that joint when sitting; desirable not only for convenience, but as an important factor in preserving the health of the knee and the leg and thus a factor in curing the foot. TUBERCULOUS AND GONORRHEAL DISEASE 229 each step and the weight of the body, if desirable, from the foot to the tuberosity of the ischium. It consists of a long outside leg-bar, reaching from a foot-plate to a pelvic band and having a joint at the knee. A short inside bar reaches from the middle of the leg up to the inner side of the thigh at a point two and a half inches below the perineum, and is connected with the outside bar by a posterior calf and a thigh bar. In the outside bar, about opposite the middle of the thigh, is a ratchet, which permits of separation of the pelvic band and the foot-piece. The apparatus is applied with the patient lying on a couch : the pelvic band is adjusted, strapped, and the peroneals buckled into place; then by means of the ratchet, the foot-piece is brought up against the sole of the foot and the shoe is put on and laced up; with the leg straight, the ratchet is made to push the sole- plate, and with it the shoe, away from the sole of the foot; then the straps for the thigh and leg are buckled, and the patient allowed to get up. When properly ad- justed, there can be very little weight conveyed through the foot and none of the concussion of walking will be felt at the diseased area. The Thomas Knee Brace also transfers the weight- bearing and the concussion of walking to the tuberosity of the ischium. It consists of an iron ring, made from an outline obtained with a lead tape, so as to fit snugly around the thigh up against the ischeal tuberosity and at about the top of the great trochanter on the outer side. Provision must be made for covering the ring 230 DISEASES AND DEFORMITIES OF THE FOOT Fig. 84. Thomas Knee-Brace This simple and economical ambulatory brace is suitable for use in disease of the foot. It removes weight-bearing by transmitting the weight from the pelvis, through the tuberosity of the ischium^ to the padded iron ring encircling the thigh. From this ring the weight is taken by the upright bars, to the cross-piece below the foot. The length of the uprights may be adjusted by the screws in their lower part. Straps are placed about the thigh and leg, and a broad band supports the back of the knee. A high shoe is worn on the sound foot. TUBERCULOUS AND GONORRHEAL DISEASE 23 1 with leather and for padding it where it comes against the tuberosity. Extending down from the ring on each side is a steel rod having a crossbar connecting the lower ends. This crossbar should be about an inch and a half below the sole of the foot. The illustration shows how a leather " shoe " may be attached to the crossbar. Whether a brace, and what kind of brace, or whether plaster-of-Paris is to be used, must depend upon the exact site of the diseased process; its extent; the pres- ence of deformity; the condition of the patient, his age, weight, and general activity; and the control over the case which the surgeon can be sure of maintaining. With the Thomas brace a high shoe should be worn on the sound foot and sometimes crutches should be pro- vided. With Shaffer's brace crutches are frequently needed. With the ankle brace it is frequently necessary to interdict all walking and standing until convalescence is established. All of these matters must depend on the ability of the surgeon to recognize the slightest changes in the condition and on his promptness in making changes in treatment to meet the indications. Bier's Treatment. — Congestion, theoretically carry- ing to the diseased area an increased supply of blood with its bactericidal properties, should be of great value in the treatment of these cases. While some of the re- ports of cases treated by this method seem to be most encouraging, many surgeons have been disappointed in its use. Perhaps one great source of failure in using congestion, is to be found in the too great dependence 232 DISEASES AND DEFORMITIES OF THE FOOT which some have placed on it. Its use is sometimes ac- companied by a relaxation of the minute care which should always be given to the general and to the local treatment. If the bactericidal power of the blood is low, or is allowed to deteriorate, the increased supply of such blood may not be equal to the normal supply of blood which has been carefully built up by general treat- ment. So fixation and relief from functionating may be more powerful in preventing an increase in the local infection than congestion, and I do not believe they can be slighted without disastrous results. Bier's treatment should be regarded as an adjunct to other treatment. The object of this treatment is to obtain hyperemia; redness, heat, and swelling. Stasis is to be avoided as injurious. The bandage should be applied about the middle third of the thigh. It should not cause any dis- comfort. If a rubber bandage is used it should be ap- plied over a cotton or flannel bandage, so as to avoid any effect of the rubber on the skin. If an elastic band- age, not of pure rubber, is used, it should not have a selvage; it must be equally elastic throughout. Before applying the bandage, note the condition of the skin; its temperature and color, the superficial veins, the ap- pearance of any sinuses, and the pulse at the ankle. There are two distinct methods of proceeding. A degree of congestion may be obtained in which the veins are made more prominent, fuller, but they remain easily compressible by the finger, and the skin becomes just barely blue-red, not cyanotic. The bandage is worn for TUBERCULOUS AND GONORRHEAL DISEASE 233 five or six hours every day, the time being reduced to three hours after a week or ten days and after that to but one hour a day. In the other method, called the " intensification congestion method," the bandage is ap- plied more firmly and the skin becomes bluish-red. There is some swelling but no edema. A prickly sen- sation may be felt, but no pain, Cantile thinks this is the better method of treatment in experienced hands. Tuberculin Treatment. — The therapeutic value of injections of tuberculin, in the treatment of bone tubercu- losis, has been very widely tested during the past six years. The consensus of opinion, among American orthopedic surgeons at least, seems to be against its having any pronounced value. I have given it a careful trial at the New York State Hospital for Crippled and Deformed Children and also in private practice, having used it in over forty cases, in most of which the opsonic index was regularly ascertained, the clinical signs re- corded once a week or at least once a fortnight, and notes kept of the general condition, including weight, appetite, urinalysis, and general appearance. A report of over twenty of these cases was published in the Jour- nal of The American Orthopedic Association in 1909, in conjunction with Hastings, who undertook the labora- tory work. The opinion which I now hold regarding tuberculin in these cases is, that in most instances it is a valuable tonic; that it is not injurious in any way if constant watch is kept for the slightest reaction and any- thing more marked than a slight malaise avoided; that 234 DISEASES AND DEFORMITIES OF THE FOOT its influence on the local lesion is dependent on any im- provement in the general condition, appetite, etc. ; and that it in no wise warrants any less careful attention to details of other treatment. In some cases it seemed to shorten the time of treatment, but not so markedly that it could be highly recommended. It may be that this line of treatment will yet be perfected so that it may be used to greater advantage. It may be administered during any stage of the disease. The initial dose should be from .0001 to .0002 mg. or nx 3 of a solution, i c.c. of which equals .000001 gm. The next dose may be nx 5, and so on up until .001 mg. or "PX i^ of a solution, i c.c. of which equals .00001 gm. is reached. Until the dose of .001 mg. is given, the inoculations should be given every three or four days, twice a week. After that every five days, or once a week. When the dose has reached .01 mg. or nx 2 of a solution, i c.c. of which equals .0001 gm., the vaccinations should be made once in ten days and the greatest of care should be taken to guard against reactions. Larger doses are not ad- visable. The treatment should be interrupted for a month or two and the second series of inoculations should be begun with from .0001 to .0002 mg. A slight local reaction, whether simply an erythematous condition of the skin or an indurated mass at the site of injections is of no consequence, but injection should be made elsewhere until the part is again normal. The temperature should be taken every four hours, TUBERCULOUS AND GONORRHEAL DLSEASE 235 for forty-eight hours before and after each inoculation. A sudden or unusual rise in temperature had better be followed by a much reduced dosage or an omitted do- sage. Constitutional symptoms, such as nausea, chilly sen- sations and headache, occurring within forty-eight hours of a vaccination demand a cutting of the dosage by one- half, and a slower rate of progression. The opsonic index is not to be used as a guide to the removal of mechanical apparatus. Tuberculous individuals show variations in the indices which are more marked than in the normal individual. Inoculations are to be continued regardless of the indices ; the clinical symptoms alone to be the guide. Tuberculin can be safely given without ascertaining a single opsonic index. Heliotherapy. — The sun's rays may be used with decided advantage if the treatment is carried out in a con- scientious manner. The indifferent exposure of a tu- berculous foot to the sunlight cannot be of value. Probably the therapeutic value derived from the sun comes from a stimulation of metabolism and the diseased area is benefited more through a constitutional effect than through any direct local effect. Rollier's method is to begin with a short exposure of one part and then to increase at each treatment the time of exposure of that part and add a new area for a short original exposure. Thus at the third treatment the left leg may be exposed thirty minutes, the left thigh twenty minutes and the 236 DISEASES AND DEFORMITIES OF THE FOOT right leg ten minutes. This is continued until the entire body is exposed for one or two hours a day, or some- times longer. It would not be possible to follow out any set of rules in all cases nor in all localities. The object to be sought is a tanning of the skin. Rollier be- lieves that he can prognose with some certainty the value the treatment will have in any individual case by the appearance of this tanning. Not only will some skins tan easier than others and be less likely to be burned, but the condition of the atmosphere, effecting the pene- tration of the rays, the altitude of the sun, effecting the thickness of the layer of the atmosphere through which the rays must travel, and the surrounding conditions which effect the reflection of the rays must be factors of importance in determining the manner of prescribing. The head should be protected by a shade-hat or a para- sol. In dry climates the entire body may be exposed in low temperatures. The protection of the foot by a per- fectly fitting brace must not be interrupted during this treatment. Sea-bathing. — If one is treating a tuberculous foot at the sea shore, sea-bathing is generally to be recom- mended. Not only is it a wholesome stimulation to metabolism but I believe the exposure of a sinus to the sea water is in itself beneficial. The foot should be well protected by a brace which may be dried and reapplied after the bath or a brace may be used especially for bath- ing. Sinuses may be protected by one or two layers of gauze. TUBERCULOUS AND GONORRHEAL DISEASE 237 Constitutional Treatment. — In tuberculous disease of the bones of the foot, as in that disease of any of the bones and joints, the general condition of the patient is as essential as it is in tuberculosis of the lungs. The best of air and of food is essential for the preparation of the opsonins and other body-forces for the conquer- ing of the disease. The best air is always out-of-door air, preferably country air, and each inspiration is of benefit. Therefore an out-of-door life, night as well as day, is desirable. This is the treatment followed at the New York State Hospital for Crippled and De- formed Children for all of these cases. Regardless of weather conditions the children are out of doors night and day, protection, of course, being provided against severe winds, rain, and snow. Naturally, sufficient and proper clothing must be used to preserve the temperature of all parts of the body. Since this night and day fresh air treatment was adopted four years ago, there has been an undoubted improvement in the treatment of these cases of bone tuberculosis. Opinion seems to be divided as to the advantages of sea air over mountain air, some claiming superiority of one and some of the other. I do not believe there has been a sufficient amount of data collected, or sufficiently careful analysis made of the air in different localities, for the drawing up of positive statements. From my personal observations I am inclined to believe that with the same surgical treatment many cases do equally well in either environment, others do well at the sea shore 238 DISEASES AND DEFORMITIES OF THE FOOT but would do better at an altitude or vice versa, and yet others progress very poorly at one place who would be benefited at the other place. In other words, for many, perhaps most, of these cases, there is a choice between sea air and mountain air, but at present there is no method of determining that choice except by trial. Theoretically a meat diet might seem to be advisable, the carnivorous animals being less subject to tuberculous infection than the herbivorous; but experiments I have carried out have failed to prove anything positive and a mixed diet of nourishing food is all I can recommend. Operations. — In children this is so seldom indicated that it may be stated, as a rule, Do not operate. In adults new factors enter into the question, such as the probable duration of treatment and the final result of prolonged treatment as compared with operation. The length of time consumed by conservative treatment is never under eighteen months, seldom under two years, and more frequently three or more years. The amount of incapacity for work during treatment is not only fre- quently of grave importance in adults ; but complete idle- ness, of such long duration, is more or less demoralizing to most characters. The result of conservative treatment in the adult, must be dependent to a great extent, on the ability of the patient to follow the orders of the surgeon. If it is evident that the patient will not be able to follow the necessary instructions, including both local and general treatment, in their minutest details, then I believe it to TUBERCULOUS AND GONORRHEAL DISEASE 239 be wrong to enter upon them. The patient is too often allowed to " try " conservative treatment, when if he was given distinctly to understand that it would probably be years before he could discard all protection to the foot ; and that during these years it would be in a greater or less vulnerable condition, likely to become worse through some minor accident; and that most of the time he would have to pay special attention to his general health, he would probably elect to have some operative interference, even an amputation, were it offered him. In the early stages, when the pain may not be excessive, it is easy to persuade the patient that plaster-of-Paris will probably cure the condition, but must be worn for a " long time." Several months is a " long time " ; but if he must submit, he will. Tell him it will take three or four years, with the plaster or a brace, and offer him the alternative of an operation; and, I believe, most busy men, who have not much money and have some one or more persons dependent upon them, would not delay long in selecting the radical treatment. The mistake lies in undertaking to give a patient a " try " at conserva- tive treatment, when we know that he can not continue it in all its details for more than a year. When the patient has an abundance of means, will not be made " sick with worry," and is one to whom time is little object, the conditions are entirely different. With a single focus, and that limited to one bone, excision is indicated. Anything less, such as opening and curetting is inadvisable. If the disease is more 240 DISEASES AND DEFORMITIES OF THE FOOT extensive, then every bone which is surely infected should be excised. And with this excision, all possible infected soft tissue should be cut away. The incisions should be made through healthy tissue. It is of less importance to follow the procedure of any classical operation for the excision of this or that bone or part of the foot, than it is to accomplish that for which the operation is per- formed, the eradication of all diseased tissue. The more thorough the operation, the less the danger of compli- cations, such as meningitis, and the shorter will be the convalescence. During the early stage, operation need produce but little mutilization of the foot, while during the latter stages amputation may be necessary. Sinuses. — Abscesses and sinuses are to be treated according to the symptoms they excite and the line of treatment being followed. Where conservative treat- ment is being followed, the appearance of an abscess, some time after the patient has been under observation, usually points to some fault in treatment. The foot is not receiving sufficient protection or the general health is not improving. Under efficient treatment most of these abscesses will become absorbed. It is seldom that they need to be opened or aspirated on account of their being the source of pain. Sinuses should be kept scrupu- lously clean so as to prevent a mixed infection. It is the mixed infection of sinuses from bone tuberculosis which is the greatest cause of amaloid changes in the internal organs. When the sinus becomes nearly dry bismuth paste may be tried to hasten its closing. I give TUBERCULOUS AND GONORRHEAL DISEASE 24I Beck's formula for its composition, but would not recom- mend it to be used unless a very small quantity will fill the sinus and that should be injected without much pressure. At the beginning, until all discharge of pus has ceased, the formula used is : Bismuth subnitrate (arsenic free) 30.0 gms. Vaseline 60.0 Mix while boiling. Afterward, the formula used is: Bismuth subnitrate 30.0 grns. White wax 5.0 Soft paraffin 5.0 Vaseline 60.0 Mix while boiling. " Care must be taken that no water should accidentally be spilled into the paste during the process of boiling, and the glass syringes must likewise be sterilized by the dry process and the plunger dipped in sterile vaseline instead of water, before charging the syringe." The fistula tract must be dried out, if possible, by packing with dry gauze before the injection. If a case to be operated has sinuses they should be cut out, the cutting being done through healthy tissue, so as to include their entire wall. Abscesses must be emptied and their walls cut entirely out with scissors. 242 DISEASES AND DEFORMITIES OF THE FOOT and then the surfaces left free swabbed with pure car- bolic followed by swabbing with alcohol. Injections. — Injections of iodoform and glycerine, ten per cent., are frequently used in treating tubercu- lous disease of joints, especially after abscess formation. Instead of glycerine, ether, olive oil, and other vehicles are also used. Glycerine may be rendered sterile by adding one per cent, of carbolic acid ; and the iodoform, by being steeped in a carbolic solution, one in twenty. The skin may be prepared with tincture of iodine and then frozen with ethel chloride. The needle is intro- duced in such a way as to avoid important structures or areas which appear to be breaking down. Any pus is first aspirated. The syringe, holding two or three ounces is then screwed on the trochar, and the injection made slowly and with considerable pressure. Upon withdrawal of the trochar, a pledget of cotton dipped in a fifty per cent, solution of alcohol is pressed against the puncture for several minutes. Then a pad is ap- plied and firmly bound on with a bandage. Considerable pain may result, lasting in some instances for several days; but this will vary greatly in individual cases. If it seems to be advisable, the injection may be repeated in about four weeks. A combination of iodoform and glycerine is also used in the treatment of sinuses. It should be injected through an olive pointed tube, and the injections repeated at about every dressing. Kirmisson prefers a one in ten solution of iodoform in ether. He injects only that amount which he feels TUBERCULOUS AND GONORRHEAL DISEASE 243 can be safely left in the cavity; five to twenty grams. The trochar he uses has a cock which he closes at the completion of the injection and which thus allows the confined ether to coat thoroughly with the iodoform all the tissues with which it comes into contact as it expands. After a few moments, he opens the cock and the ether escapes, thus removing all pain from pressure. Camphorated-thymol as an injection is recommended by some, on account of its liquefying action, if the con- tents of the abscess are caseous (Calve and Gauvain, quoted by Tubby). It is prepared by mixing two parts of camphor to one of thymol, the formula determined by Menard. GONORRHEAL INFECTION OF THE FOOT Next to the knee, the foot is the most frequently in- volved in this form of arthritis. Most writers agree that men are more often attacked than women. " Women possess a strange immunity" (Keys). But of fifty-six cases observed by C. F. Marshall, quoted by Tubby, eighteen were men and thirty-eight women. It usually appears after the first week of the infection and may come on any time during the later stages. There are several forms in which the disease presents itself : it may include several joints and be ushered in with symptoms resembling those attending an attack of acute articular rheumatism or it may be confined to one foot and cause but slight constitutional disturbance. The differential diagnosis of the former rests on the arthritis 244 DISEASES AND DEFORMITIES OF THE FOOT remaining in the joints primarily infected and, if a new- joint is attacked, in its not immediately subsiding in those first attacked; on the disproportion between the local and the general condition, the temperature, pulse, and sweating being less severe in the gonorrheal arthritis and more quickly subsiding; on the absence of effect from the use of salicylates ; on the presence of a uri- thritis, and on the finding of gonococci in the flakes aspirated from the joint. If but one joint is involved, and the constitutional symptoms are not pronounced, it may easily be mistaken for a tuberculous infection. The rapidity of the onset should put one on his guard, although it must be remem- bered that a gonorrheal arthritis may be a chronic con- dition. Persistent search should be made in every doubtful case for a possible origin of a gonorrheal infection. The brunt of the attack may be on the synovial mem- brane, causing an exudation of fibrin, which, if not interfered with, may form bands of adhesions interfering with joint-movement and finally eroding the cartilage and causing complete ankylosis; or the periarticular structures may be the most involved, causing pronounced swelling, with marked tenosynovitis, and heat and red- ness. Signs of inflammation are, however, frequently absent even when the swelling is pronounced and abscess formation does not take place unless a mixed infection is present. The plantar fascia and the bursae between the tendo Achillis and the os calcis and underneath the TUBERCULOUS AND GONORRHEAL DISEASE 245 posterior tubercle of the os calcis, are frequently involved. The pain may be as severe as that accompanying articu- lar rheumatism, but rest and immobilization are much more effective in allaying it. A number of cases of gonorrheal arthritis have been reported in infants, complicating the same infection elsew^here. The prognosis must depend to a great extent on the tissues involved, on the virulence of the invading organ- ism, and on w^hether or not there is a mixture of other bacteria. In the mildest cases, six weeks or two months may produce a cure; while in the severer forms, six months may be necessary, and a perfect restoration may not then have been made. Treatment. — To relieve the pain the foot should be put at rest in the most comfortable position. A posterior splint made of plaster-of-Paris, reaching from the toes to the middle of the thigh, is very satisfactory. The foot should be dressed in a thick layer of cotton-wool before the splint is applied. It may be well during the first few days to keep the patient in bed with the foot elevated. These are considered ideal cases for the ap- plication of Bier's treatment and those who have had the greatest experience with it, are enthusiastic in its power to relieve the pain and to hasten a cure. No in- ternal medicine is indicated other than general tonics, if deemed necessary, or possibly alkalies for the urine. The font of the infection should be attacked immedi- ately. If the surgeon is not greatly experienced in 246 DISEASES AND DEFORMITIES OF THE FOOT genito-urinary work he had much better call in one who is, if such a one is available, rather than attempt to treat this factor himself. Aspiration through a large-bore needle, or a small incision, a puncture, had better be performed early if there is much deposit in the joint. This relieves pain, hastens resolution, and renders material available for a bacteriological examination. The joint may be washed out with a sterile salt solution, a carbolic solution, i in 40, or a bichloride solution i in 5000. In a mixed in- fection this is absolutely necessary. If the ankle and foot are boggy and tense and much tenosynovitis exists, several long incisions may be made and the foot placed in an antiseptic bath or put up in a wet dressing which should be kept wet. Usually, however, in this disease of the foot, immobilization and Bier's band will be all the local treatment necessary. The danger of a resulting ankylosis and of flat-foot is always very imminent, and therefore immobilization must be interrupted by passive movements after the first few days. When the acuteness has subsided, the espe- cially painful spots remaining, the bursae and the tenosyn- ovitis, may be greatly relieved by the Paquelin cautery. Bier's treatment, hot air baths, and douching with hot and cold water will often render supple, joints which seemed to be permanently limited in motion. Vaccine treatment should be reserved for the later stages. Stock vaccine, which is put up by the large pharmaceutical houses, is quite efficient. In case of a TUBERCULOUS AND GONORRHEAL DISEASE 247 mixed infection, however, it is much better to use an autogenous vaccine. A brace which permits movements within the range of comfort is advisable, as it permits of ambulatory- treatment, protects the foot from deformity, flat-foot, and preserves the movements which are not already limited. CHAPTER X OTHER AILMENTS PAINFUL HEEL METATARSALGIA MORTON's TOE HALLUX VALGUS HAMMER TOE RAYNAUD'S DIS- EASE INTERMITTENT LIMPING CHILBLAINS FROST BITE HYPERIDROSIS CORNS INGROW- ING TOE NAIL. PAINFUL HEEL This is a condition in which the greatest pain, per- haps the only pain, is described as being in the bottom of the heel. It is most frequently found in people who have to be on their feet a great deal, as policemen, and has in consequence been called " policeman's heel." It is aggravated by use of the foot and may be entirely absent during rest, but the painful spot can always be found by digital pressure. Examination. — In appearance the foot may be nearly, if not quite normal. Upon the patient's stand- ing there may be slight evidence of weakness, some bulging along the inner border, and some deflection out- ward of the tendo Achillis; but usually any apparent abnormality is not sufficient to account for the symptoms. The dome may appear normal and, sometimes, even somewhat exaggerated. OTHER AILMENTS 249 Palpation. — Abduction and adduction may be nor- mal and also inversion and eversion. It is necessary to say " may be " as painful heel may exist with oncoming flat-foot. Dorsal flexion will almost always be limited to a right angle; and, in my opinion, this is the primary cause of the condition. Etiology. — According to my theory, the painful spot or spots (there may be two) are caused by a trau- matic periostitis set up by the pulling and tearing of the periosteum by the plantar tissues. From his experience, Konig is convinced that " calcaneum spur " in itself does not cause pain; the pain develops when the spur is injured by some trauma or becomes involved in an infectious process originating in an adjoining bursa and frequently of gonorrheal origin. The strain of a shortened heel- cord, especially one not limiting dorsal flexion to more than a right angle, is felt mostly in these plantar tissues, as explained under non-deforming club-foot. Whereas this strain may result in a giving- way or stretching of these tissues, in these cases under discussion the greatest effect is in the traumatism to the periosteum at the at- tachment of the plantar fascia and other plantar tissues to the tubercles of the os calcis, and in a resulting chronic inflammation, a chronic periostitis. A further result, if it continues, is an excess of bony growth which may be clearly apparent in the radiograph. Pathology. — The examination of these exostoses, when they have been removed by operation, has shown a large number to be infected with gonococci, and quite 250 DISEASES AND DEFORMITIES OF THE FOOT reasonably, these exostoses, and therefore painful heel, have been considered by many surgeons as a complica- tion of gonorrhea. My only quarrel with this classi- fication is that it seems to be probable that the cocci have made a nidus at these spots only after the chronic periostitis has been set up by the strain due to the short- ened heel-cord. Whether or not there is a simple traumatic, or a gonorrheal infectious periostitis, the history, and especially a complement-fixation test, will help in deciding. Treatment. — The condition of a shortened heel- cord should be relieved and if a weak- foot exists it should receive appropriate treatment. The acute symptoms may sometimes be ameliorated by providing a lift to the heel which is so formed as to relieve the painful spots from direct pressure. As such a lift will also, by rais- ing the heel, relieve some of the strain on the plantar tissues, as the range of flexion of the tibia on the plane of the ground in walking is thereby increased, further relief may be obtained. Operation. — In the hands of some surgeons, ex- cision of the exostoses gives splendid results. They shpuld be reached from a lateral, longitudinal incision on the external aspect, so as to avoid a scar in the tread of the heel. Doubtless the rest in the plaster-of-Paris dressing after the operation is of material benefit, too. Vaccine treatment in cases where a complement-fixa- tion test has been positive may be tried. OTHER AILMENTS 251 METATARSALGIA Metatarsalgia is a painful condition in which the part of the dome formed by the metatarsal bones, the trans- verse arch, is weakened, lowered, and sometimes obliter- ated. Normally this part of the foot is very flexible, although any one direction of movement is greatly lim- ited. This flexibility is essential to proper poise and ( Figs. 85-86. Transverse Section of the Forefoot Fig. 85 shows the normal position of the metatarsals and Fig. 86 their abnormal position when their arch is flattened. balance. If for any reason the muscles controlling the metatarsals become weak, the ligaments will stretch, the arch be lowered, and movement between these bones be lost, together with the finer movements of the toes. Etiology. — Although severe traumatism may de- stroy this arch, as from falls from a height or by the falling of heavy weights upon this part of the foot, the 252 DISEASES AND DEFORMITIES OF THE FOOT condition under consideration is the result of weakness. Usually it is the effect of non-use. Many shoes are made so as effectually to immobilize the forefoot. Metatarsalgia is more common among women than men. It is rare during childhood. Pain. — The pain is of an aching character, brought on by use of the foot and sometimes remaining indefi- nitely during rest. When great weakness exists, the pain will be excited whether the patient walks in a broad-toe shoe or even bare- footed. The pain is usu- ally confined to the forefoot. Examination. — If the condition is of long standing, calluses will be found under each of the metatarsal heads, as a rule; although they may be only under the second, third, and fourth. In the former case, a right angled contraction of the heel-cord will be present. The forefoot is broader than normal and usually appears thinner, depressions sometimes being present between the metatarsals, as it is seen between the metacarpals in muscular atrophy of the hand. On the other hand, the forefoot may be swollen and somewhat inflamed and, according to Tubby, lead to a diagnosis of gout or rheumatism. In examining the shoes, it may be found, as pointed out by Goldthwait, that the sole is concave from side to side so that the first and fifth metatarsals are held on a higher plane than the others, and may also be concave antero-posteriorly so that the phalanges are held extended in a position to force down the heads of the metatarsals. The shape of the sides of the shoes OTHER AILMENTS 253 will have a very great determining influence on the position which the bones will take when the arch is materially weakened. Treatment. — This is sometimes so easy and so successful that one case will bring renown to the surgeon among the patient's friends. In others the greatest ' patience is demanded and many therapeutic measures will be tried before a cure is obtained. The object is to strengthen the arch, and to keep it in the position of strength while this is being accomplished. When a shortened gastrocnemius or a weak- foot exists, appro- priate measures must be taken for their treatment. Ex- ercises which will strengthen the small muscles of the forefoot are indicated: picking up objects, as a marble (Osgood) ; and voluntary attempts at abducting, flex- ing, and extending the toes. It is best to be very spe- cific in prescribing the time for these exercises, as five minutes every morning and evening, with instructions to move the toes, while the shoes are on, at the stroke of each hour throughout the day. Support may be had in a number of ways : if a brace is to be made for the antero-posterior arch, it can be extended forward and a convexity made on its upper surface beneath the anterior arch. If the bases of the metatarsal bones are grasped in the hand and slightly compressed, their heads slightly separate and they may be easily made to assume the arched position : a piece of adhesive strapping about this part, acting as does the hand, may frequently be sufficient support. A piece 254 DISEASES AND DEFORMITIES OF THE FOOT of felt, varying in size according to necessity, may be placed under this arch and retained by adhesive plaster. A leather insole, exactly fitting in the shoe so that it can not vary its position, may have secured to it a piece of felt or soft rubber, which will support this arch when the foot is weight-bearing. When the exact location for this pad, on the insole, has been determined, a cot may be secured, opened at one end; and this will admit of fresh padding being inserted as may become necessary. The amount of padding which can be tolerated and which will afford relief, varies to a remarkable extent. I have had patients made quite comfortable, and able to travel abroad, visiting art galleries and being on their feet a great deal, with a piece of soft rubber the size of their own forefinger supporting this arch ; while in other cases of apparently the same degree of weakness and deformity, a piece of soft felt the size of a small pencil, could not be tolerated. Sometimes, by having the shank of the sole of the shoe made very narrow, the lacing over the waist can be drawn so snugly as to effect what strapping accomplishes. MORTON^S TOE Morton, of Philadelphia, was the first one to describe this condition. It is often confused with anterior meta- tarsalgia, but has a distinct pathology. The two con- ditions may be present at the same time. Etiology. — Morton's toe is a neuritis, caused by nerve pressure by the head of the fourth metatarsal. OTHER AILMENTS 255 It may be pressure on one of the larger branches of the external plantar nerve or on the nerve formed by communicating branches of the external and internal, or on some one of the filaments from the plantar, or from the anterior tibial. The pressure is usually between the head of the fourth metatarsal and the base of the first phalanx of the fifth toe, or it is an intermetatarsal pressure between the third and the fourth. Whitman has drawn attention to the similarity in the character of this pain to that elicited in the hand by compressing laterally the metacarpals while they are held in the same plane, and are not allowed to form the carpal arch. Tubby has twice found evidence of true nerve inflamma- tion. Diagnosis. — The pain in this condition is charac- teristic: it comes on suddenly, sometimes from a slight traumatism ; is sharp, lancinating, and defined to the fourth toe, extending down to its tip and also, fre- quently, up the leg, following the nerve's course. The sufferer may be compelled to remove the shoe immedi- ately, and will instinctively rub the forefoot, compress and relax it, and flex and extend the toes. It may be possible to replace the shoe in a few moments and be comfortable until another traumatism, perhaps some particular poise or step, excites it again. When the at- tacks become frequent, and a chronic neuritis results, the slightest pressure causes pain so that walking, espe- cially with a shoe, is almost impossible. Examination. — A callus may be found beneath the 256 DISEASES AND DEFORMITIES OF THE FOOT fourth metatarsal and its head may be distinctly beneath its normal plane. The base of the fifth metatarsal may be prominent and its shaft incline inwards toward the fourth, while the little toe is directed outward, so that the base of the first phalanx is directed inward toward the head of the fourth metatarsal. Fig, 87. Callus in Morton's Toe The situation of this callus is very characteristic. It lies beneath the head of the fourth metatarsal bone. _ The calluses resulting from a shortened heel-cord are usually five in number, lying beneath the heads of the five metatarsals. There is present in the above illustration a hallux valgus and also a hammer toe. Treatment. — Sometimes a pad, carefully shaped and applied to restore the transverse arch, and strapping to separate the bones may be successful. When the radio- graph shows an undoubted impinging on the head of OTHER AILMENTS 257 the fourth metatarsal by the third metatarsal or by the first phalanx of the little toe, an excision of the fourth metatarsal head may be undertaken. It is a simple operation and, aside from a slight retraction of the fourth toe, is not followed by any bad results. Re- section has been done of other metatarsal heads with reported cures. On the other hand it is easy to be de- ceived by the radiograph and to give an excellent prog- nosis, only to reap disappointment, an unfortunate experience which I once had. It is now my custom to withhold operation until all other means of cure have been exhausted. An operation has been devised and practiced by Forbes which consists of a transplantation of the extensor tendon of the fourth toe into the head of the metatarsal. HALLUX VALGUS This is a condition in which the great toe is directed in toward the middle line of the foot and toward the other toes, and the first metatarsal-phalangeal joint is made prominent on the foot's inner border. Etiology. — Its most frequent cause is the crowding together of the toes in a narrow-toed shoe. After the deformity has started, a short shoe will increase it by pressing backward against the tip of the toe and crowd- ing the head of the first metatarsal outward from the middle line of the foot. The extent of the deformity may vary from a slightly abnormal inclination to al- most a right angle with the other toes, so ^that the great 258 DISEASES AND DEFORMITIES OF THE FOOT toe may lie upon and across the others. A bursa, called here a bunion, develops on the side \oi the joint where it presses against the side of the shoe. The loss of the normal function of this toe precludes proper walking and the prevention and cure of this deformity is therefore of great importance. Shoes likely to cause it should be unhesitatingly condemned even if otherwise perfect. Fig. 88. Hallux Valgus The great-toe is turned inward toward the middle line of the foot. The cause in this case was paralysis. When due to faulty foot-wear the deformed toe usually lies above the other toes and the metatarsal head is made very prominent by pressure outward, toward the other foot, through the phalanges. Treatment. — ^ When the deformity is slight and the toe can easily be brought by passive movement to its normal position, exercises, manipulations, and correct foot-wear may be all that is needed. But the detail of such treatment must receive conscientious attention to be effective. At night a brace may be worn to retain the toe in a straight position. A piece of steel spring, secured along the inner border of the foot by straps and having a strap to hold the toe against it, will be all that is demanded. OTHER AILM'ENTS 259 Various braces have been made designed for wear in the shoe. Perhaps the most popular device is a stall made by inserting a small piece of steel through an in- sole so that it will press against the side of the toe and hold it in a straight position. An insole is obtained which fits the shoe accurately, the foot is placed upon it, and the cleft marked between the first and second toes. A piece of light steel (tin is satisfactory) is cut so as to be one-half inch longer than double the depth of the toe, the height of the top of the toe from the ground, and of a width equal to the length of the first phalanx. This is doubled upon itself, on its long di- ameter, and the ends for the last quarter of their lengths bent at right angles to make flanges. The end of the contrivance will now have the shape of an inverted T with the stem having two layers and the flanges one each. This stall is then pressed through a slot made in the sole at the place marked as the site of the cleft, the flanges coming against the bottom of the inner-sole and holding the stall in place. The stall had better be covered with a little padding which may be secured by adhesive plaster. If the stall is not high enough the toe will at times get above it and cause severe pain. This method is only practical in moderately deformed cases, where the deformity is easily corrected by manipu- lation. Wedges made of cotton may be used to separate the first and second toes and together with other treatment, especially exercises, will be of assistance. 26o DISEASES AND DEFORMITIES OF THE FOOT Operation. — When the deformity is of long stand- ing, bony changes and shortening of the soft structures on the inner side of the joint will make an operation imperative. This is best done by a curved incision around the bursa with the base downward; careful dissection of the flap off from the bursa, a second in- FiG. 89. Operation for Hallux Valgus The solid line represents the skin incision, the interrupted line the incision for the flap containing the bursa, which is turned in between the metatarsal and the phalanx, after removal of the head of the former. cision, forming a flap with its base forward and includ- ing the bursa ; removal of the head of the metatarsal in a line not directly at right angles to the long axis of the bone, but extending outward and slightly forward; making the end of the bone smooth with the rongeur: placing the bursa in the resected joints and securing with OTHER AILMENTS 261 a suture; closing the wound and applying a plaster-of- Paris dressing with the great toe in the straight or slightly abducted position. A movable joint may be expected as a result. Objection to the operation has been made on the score that removal of the head of the first metatarsal takes away an important support of the forefoot. How- ever, no unfavorable results have been reported, and, on the other hand, C. H. Mayo reports (Annals of Surgery) sixty-five operations, all of which were most satisfactory. HAMMER-TOE When one of the smaller toes has become flexed at its first inter-phalangeal joint, so that this joint stands up prominently above the plane of the other toes, and is not extensible even by passive movement, it is called a hammer-toe. Etiology. — It is caused, in the last instance at least, by the toe's being retained in this position continuously by the crowding together of the other. The chief reason for its exciting any complaint is that the summit of the flexed joint is subject to pressure against the shoe leather and a painful corn is usually the result. Treatment. — If not of too long standing, the pre- scribing of proper foot-wear and of exercises for the toes, may relieve the condition. The upper of the shoe over the toes should be of sufficient room to avoid pres- sure on the joint; a soft leather will be less irritating than a stiff leather. A simple arrangement may be 262 DISEASES AND DEFORMITIES OF THE FOOT made to hold the toe extended by strapping it down to an inner sole, the straps running through slots opposite the cleft on either side of the deformed toe. Operation. — In cases of long standing, however, success is not likely to be achieved by any means short of an operation. Simple division of the contracted soft tissues, followed by retention of the toe in the straight position for two weeks, will be all that is needed, unless there have been marked bony changes. The contracted structures are usually the lateral ligaments and some- times the plantar ligament. All three may be divided through a small puncture on one side. If the joint is much altered in shape the extension made possible by dividing the tissues on the flexor side can not be expected to remain permanent. Under such circum- stances a resection of the joint is better when an opera- tion has been undertaken. Raynaud's disease Usually a symptom of some disease affecting the nervous system, Raynaud's disease may, rarely, exist without any such connection. It may affect any of the extremities or even other parts of the body. It is most frequently seen in middle life, attacking women more often than men. It is not always symmetrical, although this was at one time considered one of its characteristics. If symmetry is present it is the more easily diagnosed. There are three stages, the first and second coming in paroxysms; local syncopy, local cyanosis, and local OTHER AILMENTS 263 gangrene. The disease may present the symptoms of the second stage without those of the first having been present or at least without the symptoms having been recognized. In the stage of syncopy, caused by spasm of the arterioles, the part, usually the plantar surface of the toes, becomes white and cold and there is present a disturbance of sensation. It may be brought on by exposure to a low temperature, not necessarily a very cold temperature, or by walking or standing. It is attended with pain which may not be severe, but is, in some cases, excruciating. Warmth and rest may restore the part to its normal condition. The disease may ex- press itself only in these attacks of the first stage and may not progress to the second stage. At any time it may be arrested and not return for months or even years. The second stage, that of local asphyxia, usually fol- lows the first. It is caused by spasm of the, venules. The part becomes blue or purple, cold and edematous. Pain may vary as in the first stage. The third stage, which does not follow in every case, is that of gangrene. This results in a mummification of the part. Treatment. — Anything which will help to correct the condition of the vasomotor system will help to prevent the attacks and to produce a cure. General hygienic treatment, tonics, and equable temperature are of great value. When gangrene is present, care should 264 DISEASES AND DEFORMITIES OF THE FOOT be taken against infection. The line of demarkation should be awaited before active interference is under- taken. MYASTHENIA ANGIO-SCLEROTICA. INTERMITTENT CLAUDICATIO. INTERMITTENT LIMPING This is a rare condition in which a severe, spon- taneous, cramp-like pain occurs in the calf while walk- ing. A moment's halt relieves the pain, walking is resumed, and the attack returns. There is present a circulatory disturbance which causes a feeling of cold- ness in the foot accompanied by a blanching of the skin. Lovett reports the absence of pulse in the dorsalis pedis and in the posterior tibial arteries in two of his cases. Treatment. — Codein, given in small doses three times a day, has been highly reported. If syphilis, dia- betes, or chronic alcoholism exists appropriate treatment may alleviate the local condition. PERFORATING ULCER OF THE FOOT This is a neuropathic ulcer occurring in the sole, usually in the metatarsal region, painless, and showing no tend- ency to heal. Other stigmata of the nervous condition underlying the ulcer may be also found in other parts of the body, such as the condition of the skin and nails of the hands. It may be associated with either a periph- eral neuritis or with some central lesion. The ulcer is usually neglected on account of its analgesic condition OTHER AILMENTS 265 and may be an eighth or a quarter of an inch in diameter before treatment is sought and may reach to and involve the bonel The callous formation about the ulcer may lead to the diagnosis of an infected corn. Treatment. — The underlying condition should be sought for and appropriately treated. Local treatment consists in thoroughly cleansing the v^ound, using the curette freely, and lightly packing and dressing. A mildly stimulating antiseptic may be of value. Balsam of Peru mixed with castor oil is to be recommended. PERNIO. CHILBLAINS This is a condition of disturbance of the circulation to a part and results from prolonged exposure to moderate cold. The skin assumes a purplish color and there may be edema. The subjective symptoms are a burning pain with itching. A foot which is partly or completely paralyzed is very subject to chilblains. Anemia is a predisposing factor. According to Wright there is present in people who suffer from this condition a de- ficiency of the calcium salts. Treatment. — This consists in the prevention of exposure to cold. Woolen stockings should be worn in cold weather. The burning and itching may be re- lieved by the application of cooling lotions, as a fifty per cent, solution of alcohol. If the skin becomes broken from scratching, infection must be guarded against. Internal treatment should be directed against anemia if such exists. Calcium is reported to be a specific and 266 DISEASES AND DEFORMITIES OF THE FOOT may be given as the lactate or the chloride. It has been recommended that its administration be commenced at the beginning of cold weather and continued for several weeks in cases of recurring chilblains. CONGELATION. FROST-BITE This is the effect of a prolonged exposure to a severe cold. The diagnosis is not difficult. Treatment. — The generally accepted plan of treat- ment is the gradual restoration of the circulation by massage with snow or cold water. It is the opinion of some surgeons that a too sudden raising of the temperature results in a paralysis of the muscular coats of the vessels. Doubtless the slow restoration of the circulation is much less painful, but it is not satisfactorily proved that gangrene is any the less likely to occur. The foot should not be kept continually moist for days, but after thirty-six or forty-eight hours should be dried, powdered with boric acid, wrapped in wool, and placed in an elevated position. If gangrene sets in, the line of demarkation should be awaited before the knife is used. Bullse should be treated as they are in burns. HYPERIDROSIS. EXCESSIVE SWEATING When this condition attacks the feet it may prove to be a most disagreeable and troublesome affection. Not only the stockings but the shoe-leather as well become damp and a pungent and penetrating odor, " bromid- rosis," is created, due to bacterial growth. There is OTHER AILMENTS 267 present a functional disease of the sweat glands of the feet, the cause of which, except that it is' probably of nervous origin, has not been determined. Treatment. — Mild cases may demand nothing more than a change of stockings twice a day and the applica- tion of a powder made up of equal parts of boric acid and salicylic acid. If the shoes are damp when the stockings are changed another pair should be put on. When only the soles of the shoes are damp, the use of cork insoles may answer the purpose, a fresh pair being inserted whenever the stockings are changed. It will generally be found that these patients are in the habit of frequently bathing their feet in very hot water, their object being to keep their feet odorless. It is much better to bathe the feet in cold water or better still to douche them with alternately hot and cold water, then dry, rub with alcohol and powder. In severe cases Hebra used an ointment made of lead plaster and olive oil. This he applied on strips of linen after the feet had been thoroughly washed. This dressing is not dis- turbed for twenty-four hours when fresh ointment is applied without, however, again washing the feet. If necessary this procedure is kept up for a week or even two when the epidermis comes off in large plates. The feet are then washed and treated with boric acid powder. Careful strapping of the feet with zinc oxid plaster is much easier to apply and is very gratifying in its re- sults. The general condition of the patient should receive 268 DISEASES AND DEFORMITIES OF THE FOOT attention at the same time as the feet, as most of these patients will be found to be run down and more or less anemic and nervous. ERYT H RO M ELALGI A A chronic disease in which there is a painful conges- tion of the feet and to a less extent of the hands. It is at first limited to the heel, or perhaps to the forefoot and occurs only at night but finally extends over the entire plantar surface and is present night and day. When it has progressed to this stage walking or even standing becomes very painful. PLANTAR NEURALGIA Erythromelalgia is considered by Dana as a form of plantar neuralgia. He states that in rare cases the pain of sciatica is limited to the plantar nerves and is ac- companied by anesthesia and paresthesia of this region. It may be present in insular sclerosis, tabes dorsalis, and myelitis. CLAVUS. CORNS The skin is being constantly renewed by the multi- plication of its deeper cells and the shedding of its external ones. The new cells push the older ones up- ward into the outermost layer of the epidermis, the horny layer or stratum corneum, whence they are cast off. If pressure is exerted against an area, these cells are not only prevented from escaping ahead of those pushing OTHER AILMENTS 269 them outward; but, if the pressure continues, they are crowded back into a compact mass. The cells pile up and spread out beneath the point of pressure; and in consequence a cone-shaped mass is fonned, the apex being in the deep layer and the base on the external surface. It is thus that a corn is formed. Its apex, pressed in among the papillae which are extremely abun- dant in nerves, causes the pain which is an accompani- ment of all corns. When this external pressure is made by an adjoining toe the outer layer of the corn is kept moist and thus a " soft corn " is formed. If the pres- sure is intermittent as is more frequently the case in the sole of the foot, calluses are produced. These, while causing the piling up of the outer layer, do not so confine the cells as to form the distinct hard cone seen in the veritable corn. In the formation, therefore, a corn is first a callus and later, as the pressure continues, the cells become more and more compact so that a dense center column, the core, is formed. A corn is always the result of pressure and much valuable information in the diagnosing of foot-deformi- ties can be obtained by noting the location of a corn. It is quite essential to bear in mind that although the patient's foot may be in otherwise perfect physical con- dition, and the pressure may be caused by an ill-designed shoe; on the other hand the shoe may be designed for a perfect foot and be of a correct size; but owing to some faulty condition of the foot, as will be the case if it is held in abduction, the skin will be pressed un- 270 DISEASES AND DEFORMITIES OF THE FOOT duly against the leather. Spasm of the peronei will SO abduct the fore-foot that pressure will be exerted opposite the head of the fifth metatarsal regardless of what shape shoe is worn. A short shoe with a narrow toe cannot fail to crowd one or more of the toes into flexion causing the skin over the proximal interpha- langeal joint to press against the leather and produce a corn. Thus a hammer-toe frequently has a corn over this joint. If a hallux valgus is present a short toe will press the toe backward and outward so as to crowd the head of the first metatarsal against the leather of the shoe. As a hallux valgus interrupts the symmetry of the inner line of the foot and shoes are not usually made to accommodate this bulging joint, there is pres- sure here even in a shoe of ample length and a corn in this condition is almost invariably present. In some cases it may be noted that the skin seems to produce corns with extraordinary facility and will not tolerate pressure which would cause no disturbance in other cases. In pityriasis rubra pilaris corns are easily formed. Diagnosis. — A small perforating ulcer has a callus about it and may easily be mistaken for a corn, a mis- take which can be avoided if this fact is kept in mind during the examination. Treatment. — It hardly need be pointed out that the removal of the cause is essential. We know that the cause is the pressure of the skin against the leather and the removal of pressure may be obtained by stretch- OTHER AILMENTS 2/1 ing the leather or cutting it away, proceedings fre- quently resorted to by the patients themselves. The rings of felt sold in the drug-stores for this purpose are generally efficient. Some shoe-makers, when hallux valgus is present, make a ring of leather with wings or extensions extending forward and backward, which when placed in the shoe not only prevent pressure but hide the deformity quite effectually. All of these meas- ures are but palliative: they recognize pressure as the cause, but do not remove the cause of the pressure. If an on-coming deformity, such as a beginning flat- foot or hallux valgus, is found or if a deformity al- ready exists, appropriate treatment should be directed toward the correction of such. The shoes must be changed if they are too short or too narrow or if they hold the forefoot abnormally abducted or adducted. To remove the corn, it should first be softened. This may be done by soaking the foot in a hot bath for twenty minutes and then drying the foot and applying salicylic acid. Salicylic acid acts chemically upon the callus, softening it so as to facilitate its removal. It may be put up in flexible collodion, five grains to the ounce, and painted on with a camel's hair brush; or it may be applied in the form of an ointment made up of lanoline and vaseline, five parts of each and one part of salicylic acid. In ten or twelve hours the softened callus appears as a white mass and can be picked off. It may be neces- sary to repeat the treatment, perhaps two or three times before the last vestige of the corn is removed. Naturally, 272 DISEASES AND DEFORMITIES OF THE FOOT if the original pressure is operative after each treat- ment, the corn will return and the above procedure will have to be repeated indefinitely. There are two corns which deserve special mention: the soft corn and the corn over an hallux valgus. The soft corn can be effectually treated by the process as above described and then by placing a pledget of cotton between the toes. A broad-toed shoe is essential for a cure. The corn accompanying a hallux valgus will often have a bursa developed beneath it. This corn is more subject to inflammation than any other and it is frequently called a bunion. The treatment quite commonly resorted to, of paring it with a knife, may result in an infection and a serious condition thereby be produced. When infection is present half-way meas- ures must not be tolerated. The patient must remain indoors to the end that appropriate treatment can be carried out. It may be sufficient to apply hot boric acid dressings, under oiled silk, the dressing being large enough to cover the entire forefoot; or more radical pro- cedure may be demanded, such as opening and draining. As the bursa beneath this corn communicates with the metatarsal-phalangeal joint, neglect or improper treat- ment may prove to be a rather serious matter. ONYCHIA. PARONYCHIA. INGROWING TOE-NAIL This is an inflammation of the matrix and the soft parts about the nail. Paronychia of the toes is most frequently found on the large toe and is commonly called OTHER AILMENTS 273 ingrowing toe nail. It is caused by the pressure of the shoe against the side of the toe, forcing the soft parts against the nail which may have an abnormally sharp edge, usually from careless trimming. The soft parts become inflamed and swollen and a painful con- dition exists. Treatment. — This must depend upon the severity Fig. go. Conservative Treatment of Ingrovv^ing Toe-Nail The irritation from the nail is relieved by a pledget of cotton and the exuberant tissue is drawn away by a strip of adhesive plaster. of the case and the control one can expect to have over the patient. In dispensary patients radical measures are the most satisfactory. When time is not of importance, operation is seldom necessary. Moreover, in private practice this condition is apt to be called to the surgeon's attention in its early stages. Conservative treatment consists first in removing all pressure such as may be caused by a pointed or narrow shoe or even by a narrow or short-toed stocking, and then in removing the irrita- 274 DISEASES AND DEFORMITIES OF THE FOOT tion caused by the pressure of the side of the nail. This last may be done by pressing a little piece of cotton with a probe or an orange wood stick or a pointed match under the edge of the nail and between it and the swollen parts. The soft parts may be further relieved by draw- ing them away from the nail with a narrow strip of adhesive plaster encircling the toe. When conservative treatment is undertaken the patient should be instructed to trim the nail straight across and not to cut down the corner or inner edge. Radical treatment consists in the removal of the sharp edge of the nail. About a third of the nail should be taken off together with that part of the matrix and the swollen soft part. It can readily be done under a local anesthetic. A rubber tube is first fastened about the base of the toe and cocaine, if that is used, is injected around the nail. The first thrust of the needle should, cause all the pain there is to bear. The incision should be elliptical, including all that is to be removed. Horse hair sutures are the best for closing the wound. The edges will not be brought close together; but there will be less surface to granulate, the time of healing will be shortened; and the co-aptation of the V-shaped de- pression left in the soft parts by the removal of the exuberant tissue will the better insure a rapid cure. Should the toe be acutely inflamed and very painful it may be better to defer operation until the condition has been rendered less acute by a few days' treatment with rest and wet dressings. OTHER AILMENTS 275 CALLUS. CALLOSITES Callus will appear wherever the skin is subjected to constant irritation. When on the feet it is due to de- formities, faulty mechanism in the use of the feet, ir- ritation from foot-wear, or the presence of one of two diseases. If the callus is of long standing, a bursa may be developed beneath it, as is frequently found beneath the callus over the cuboid in a much used talipes equinus varus. Frequently the location of the callus and its extent and hardness are guides to the condition of the foot. Calluses under the heads of the five metatarsals are evi- dence of a complete lowering of the transverse arch and will be found in non-deforming club-foot of long standing and also in cases of anterior metatarsalgia. If the callus is under the head of only one metatarsal, usu- ally the fourth or third, the condition found in Morton^s toe is present. There are two diseases which may be accompanied by calluses of the soles; ichthyosis and pityriasis rubra pilaris. Treatment. — The cause of the irritation must be de- termined and dealt with accordingly. The callus may be removed by the treatment laid down for corns, or it may be left to desquamate, as it will if the cause of its inception is eradicated. 276 DISEASES AND DEFORMITIES OF THE FOOT PAINFUL SOLES Pain in the sole of the foot may be present with any of the following conditions : deformities, new growths, contractions, scar tissue, absorption of fat from pres- sure or following prolonged illness, gout, rheumatism, arthritis deformans, inflammatory arthritis, as tubercu- lous or gonorrheal, Raynaud's disease, erythromelalgia, plantar neuralgia. CHAPTER XI FOOT-APPAREL It is quite generally admitted that many deformities of the foot are due to faulty clothing. Some French surgeons, to be sure, have recently taken pains to dis- count this opinion, claiming that some pathological con- dition of muscles, nerve, or joint is the primary etio- logical factor and that the shape of the foot-clothing is of but secondary importance. " Without wishing to ignore the role played by mal- constructed shoes in the production of deformities of the toes, it seems to us that such causes ought to be considered as accessories; the role by far the most im- portant, it seems to us, appertains to general causes, among which chronic rheumatism ought to have first place." * While this may be true in some cases, we do not believe that most surgeons agree that it is so in the majority of the deformities of the foot. Stockings. — A stocking so short as to prevent full extension of the toes or so pointed as to cause adduction of the great toe and of the two outer toes, would not * Les Difformites des Orteils. Kirmisson et Baillene. Revue D'Orthopedie. ler Mars, 1913. 277 -278 DISEASES AND DEFORMITIES OF THE FOOT cause a permanent deformity were it worn but a few hours and the muscles and joints properly exercised when freed of the restraining influence of the stocking. The gravity of the restraint of a confining shoe or stocking is due to the prolonged time of its effect. Improper walking and standing have so trained many people to use the foot as though it were one solid mass that upon removing the shoes and stockings they will walk the little that is necessary, bare- footed or in bed-room slip- pers, go to bed, and dress in the morning without having moved the toes or the smaller joints of the foot to even the smallest extent. As stockings and socks are made of flexible and elastic material, their influence is limited to that of compressing the more movable joints, especially the toes. Digitated stockings have been made but were never very popular. " Rights and lefts " are on the market and are to be recommended if one does not try to get too good a fit and thereby get a stocking that is too short. The ordi- nary stocking, as long as it is not too pointed and not too short, is beyond criticism. Whether it should be made of silk, wool, or cotton will depend upon the circu- lation of the foot. Shoes. — A great many attempts have been made to produce a perfect shoe. Shoemakers have been at no little pains to turn out a confection of their art which would meet the scientific requirements as they have under- stood them. The results have been encouraging al- though they have been far from perfect. As soon as FOOT-APPAREL 279 it has been definitely decided just what constitutes a perfect shoe, a long step ahead will have been taken. When the surgeons are finally in accord on this subject it is not probable that Dame Fashion will be able to ig- nore the dicta as to shoe-construction as laid down by Master Science. She has been forced to bow to so many laws of hygiene that we hope she will allow her toes to be stepped on. As it is, we should feel pleased at the advance that has been made in the styles of shoes sold in the markets to-day. Orthopedic, Common Sense, and various other named shoes have a constantly increasing sale, showing the desire of the laity to treat their feet with becoming respect and not to be too much the slaves of the passing whims of fashion. Some of these shoes have the fore- foot so adducted that the outer border of the soles form almost a quadrant of a circle ; some have simply a broad, square toe; some an extension or Thomas heel; some a wedge-shaped heel; and some have stiffening of one sort or another under the dome. Most of these modifications have their therapeutic value, but, for the normal foot, some of them are likely to prove to be in- jurious. The first requirement of a shoe for a normal foot is that it must permit the free functionating of the foot. This is of less importance if the foot is not to function- ate while in the shoe; but as most shoes are used for standing and walking, we need not consider the shoe worn only while the foot is at rest. 28o DISEASES AND DEFORMITIES OF THE FOOT Heels. — First as to the heel; a high-heel is injurious only when being used. The greatest objection to the high-heel is that it makes it so difficult to walk on the toes. Most of them are found on narrow, pointed shoes which are of themselves objectionable. If high-heels are worn constantly they may also be a contributing factor to non-deforming club-foot. Of the two most popular forms of high-heels, that which has its supporting surface the more anterior is the better, the French, rather than Figs. 91-92. The French and Cuban Heels The heel of a shoe should have its base in the plane of gravity to give the greatest support. If it is behind this plane it may be a contributing cause of vi^eakness of the ligaments and muscles. the Cuban heel. The ideal heel is not higher than the sole, has straight sides and extends well forward, to the plane of the anterior border of the internal malleolus, thus giving a firm and extensive support. Toe. — The main features to be sought in the toe of the shoe are, that the toes have room to extend and to flex ; that the great toe has room for abduction and rota- tion; that the metatarsals are not cramped; and that the forefoot as a whole is not held in abduction. FOOT-APPAREL 28 1 As a cross section through the heads of the meta- tarsals has its thickest part over the head of the first, the leather covering the toe of the shoe should not offer the most room, to the center of the foot, to the middle metatarsal, as is so often the case; but the highest part of the toe of the shoe should be over the great toe. A last which does not take this into consideration will exert Fig. 93. A Faulty Shoe-Toe Illustrating the evil effect of the inner border of the shoe, at the toe, turning inward too sharply. This shoe does not increase the deformity of the great toe by pressing it directly inward, but by pressing against the tip in a direction backward and inward. This force is felt at the first metatarsal-phalangeal joint in a direction outward and backward; the direction best calculated to produce a marked hallux valgus, an adducting force on the large toe and prevent its ab- duction and rotation, its normal movements. In the normal foot, the line connecting the middle of the tip of the great toe with the center of the first meta- tarsal-phalangeal joint will, if continued backwards, pass over the center of the heel. If the inner side of the great toe, when in the shoe, can for its entire length form a 282 DISEASES AND DEFORMITIES OF THE FOOT straight line with the inner border of the heel, this re- quirement is met. As the anterior part of the heel of the shoe is frequently not at a right angle to the long diameter of the shoe, care must be taken that one is not thereby deceived. Figs. 94-95. The Toe of the Shoe The sole should be sufficiently stout to prevent its being curled up at the sides. The space within should be ample for the free functionating of the metatarsals and the phalanges. The figure on the right shows a badly fashioned shoe-toe: the sole curls up and the greatest depth of the inside measurement is in the center, thus crowding the bones together and forcing the third metatarsal onto a lower level. Fig. 96. An Excellent Shoe The heel extends forward on the inner side and also further in- wards than is usual. Secure support is thus given in the plane of gravity and eversion is prevented. There is ample room to permit of abduction of the great-toe and also to provide for the alterations in the shape of the dome of the foot while the foot is function- ating. It is not unsightly. The breadth of the toe should be such that the toes can be fully extended and flexed as easily as they could be were one wearing sandals. The interference with this movement is the greatest cause of anterior metatarsal- gia. Shank. — The waist of the shoe should fit snugly and FOOT-APPAREL 283 should not be so far forward, there should not be so short a vamp, as to limit movement at the medio-tarsal joint. The shank must be narrow, for if wide it will prevent the leather along the inner side from being laced snugly up against the longitudinal arch. The shank usually contains a steel spring which undoubtedly aids in pre- serving the shape of the shoe; but if walking is properly done and if the heel is not too high, it is unnecessary. Providing it is not so long as to obstruct movement at the medio-tarsal joint, however, there can be but little objection to it. The importance of the distance of the part of the sole beneath the first metatarsal-phalangeal joint and the cen- ter of the heel, has been pointed out by Sampson. If the inner border of the sole begins to curve too soon toward the shank, the upper at this point will unduly press against the head of the first metatarsal and will not only operate against the normal movement of the great toe, abduction (away from the middle line of the foot) and rotation, but will exert an abducting force on the forefoot. Upper. — • The uppers may be low, the " shoe " of the English, or high, the English "boot." The low shoe offers more freedom to ankle movements and the close fitting high tops may be the cause of a certain amount of weakness. If high shoes are worn we should advise that under ordinary circumstances the uppers be soft, not too stiff and unyielding, and never reen forced with whale- bone or other material unless assuredly indicated by some 284 DISEASES AND DEFORMITIES OF THE FOOT abnormal condition. A lace fastening is always prefer- able to any other kind. Rocker-sole. — It remains to say a word regarding the rocker-sole. It is the claim of shoemakers that if the sole is made to lie flat on the ground, especially with a low heel, it will be turned up at the toe after it has been worn a short while and not be so presentable as a shoe which was made that way in the first place. To a great extent this is true, due to the habit of heel-and-toe walk- ing. If walking consisted in rolling onto the heel and Figs. 97-98. Rocker-Sole and Flat-Sole Shoe The former is the shape assumed by any shoe, with a low heel, which is worn by a heel-walker. With such a shoe it is impossible to walk properly. off the toe, the rocker-sole would be our choice; but for the normal manner of walking as we conceive it, the toes should bear the same relation to the rest of the foot while the shoe is on that they do in the normal barefoot, whether walking, standing, or resting. Fit. — In the consideration of shoes, it is well to re- member not only that the distance across the metatarsals increases during standing, due to the abduction of the first metatarsal and to a slight lowering of the metatarsal arch; but that there is a lowering of the dome as a whole. FOOT-APPAREL 285 This may be demonstrated by marking the position of the tubercle o£ the scaphoid and observing its changed Figs. 99-100. Alterations in the Length of the Foot During Rest and Weight-Bearing During rest: the foot is represented as 7 inches long and the scaphoid-tubercle (imperfectly marked) as 2^ inches above the ground. Weight-bearing: the arch is lowered as shown by the lowering of the tubercle of the scaphoid, and the foot is elongated as evi- denced by the toe reaching beyond the o of the tape. relation to the plane of the sole during rest and during weight-bearing. With this lowering of the dome there 286 DISEASES AND DEFORMITIES OF THE FOOT is a lengthening of the foot, which may be read on a tape measure by placing it under the weight-bearing foot, taking the length from heel to tip of great toe, and then with the foot still on the ground, removing the weight by having the subject sit. If instead of removing the weight, the subject rises on tip-toe, and the tape is brought up to the heel, it will be found that the foot has shortened. Fig. ioi. Alterations in the Length of the Foot During Tip- Toeing Tip-toeing : the foot is shortened as shown by reading of the tape, due to the elevation of the arch. The tubercle of the scaphoid is, of course, raised. The slight flexion of the great-toe during rest and its position in activity, are also shown in these illustrations. These changes in the length of the foot during rest, weight-bearing, and tip-toeing, are only what would be expected from the lowering and raising of the dome. A slipper which fits snugly the relaxed foot, will be too tight when standing and too loose when on tip-toe. A comfortable slipper usually flips-flaps up and down at the heel when used for walking; a slipper perfect for dancing is uncomfortable for walking. INDEX Abductor minimi digiti, 37- poUicis, 37- Abscesses, tuberculous, 240. Accessorius, the, 33. Adams, on "club-foot," 64. Adams on etiology of congeni- tal club-foot, 115. Adductor poUicis, 38. Allison's treatment of spastic paralysis, 181. Ankle brace for tuberculous feet, 226. Ankle-joint movement, 14, 43' _ Apparatus for treating congeni- tal club-foot, 130. for treatment of infantile par- alysis, 186. Arch supporters, 92. Arthrodesis of astragalo-sca- phoid joints, 107. Aspiration for gonorrheal infec- tion of the foot, 246. Astragalo-scaphoid capsule, ten- otomy of, 168. Astragalectomy for congenital club-foot, 174- in paralysis of foot, 213. Astragalus, the, 13-16. Beely shoe-heel, 88. Berg on causes of congenital club-foot, 116. Bessel-Hagen on frequency of club-foot, 113. Bier's treatment of tuberculous disease of the foot, 231. Bone operations for congenital club-foot, 172. Bones, changes in, in talipes equino-varus, 118. of the foot, 13. Bonnet's classification of club- foot, 112. Brace, Taylor's, 140. Braces for congenital club-foot, 131- for foot paralysis, 206. for hallux valgus, 259. for tuberculous feet, 226. for weak-foot, 94r-96. Broadhurst on tenotomy, 171. Broca on astragalectomy, 175. Calcaneo-astragaloid joint, move- ments at, 45. Calcaneo-scaphoid ligament, 23. Calcaneum, the, 17. Calf muscles, 24. Callosities, 275. Campbell long leg brace, 227. Cavus, accompanying infantile paralysis, 195. Chilblains, 265. Clavus, 268. Claw-foot, 196. Club-foot, Bonnet's classification, 112. causes, bone theory, 115. characteristics, etiology and treatment, 64-73. congenital, iii-i77- causes, germ theory, 115. 287 INDEX Club-foot — Continued. causes, nerve theory, 115. causes, pressure theory, 115. causes, theory of abnormal fe- tal movements, 116. etiology of, 114. frequency of, 113. non-deforming, 64-110. pathology after use, 121. Congelation, 266. Congenital club-foot, adhesive plaster for, 131. astragalectomy for, 174. bone operations for, 174. braces for, 131. felt splints for, 133. muslin bandages for, 130. pathology after use, 121. theories of causes, 114. varieties, iii. wood splint for, 136. Congenital deformities, 113, in the tibia and femur, 143. Coote, Holmes, on "Joint Dis- ease," 64. Corns, 268. Cuboid, the, 17. Cuneiform bones, the, 18. Davis's physiological lavir, 157. Detmould on subcutaneous ten- otomy, 161. Diagnosis of case, 59-63. of tuberculous foot, 217. of w^eak-foot, 79. Diet, for tuberculous foot, 238. Differential diagnosis of tubercu- lous foot, 223. Dorsal flexion at ankle joint, 43. Douching in post-operative treat- ment, 108. Duval, E., on tenotomy, 171 Early treatment of congenital club-foot, 125. Erythromelalgia, 268. Etiology of congenital club-foot, 114. Eschricht on causes of congeni- tal club-foot, 116. Exercises for flat-foot, 89. Extensor brevis digitorum, 39. longus digitorum, 36. proprius poUicis, 36. External lateral ligament, 22. Fallen arch, 251. Felt splint for congenital club- foot, 133. Flat-foot — arthrodesis operation, 107. diagnosis, 83. osseous, 84. pathology of, 85. Plaster of Paris dressing for, 103. post-operative treatment, 108. tarsectomy for, 107. tenotomy for, 106. treatment of, 86. Flexor brevis digitorum, 33, 37. brevis pollicis, 38. longus digitorum, 32. longus digitorum, tenotomy of, 168. longus pollicis, 28. Foot at rest, 48. bones of, 13. ligaments of, 21. muscles and tendons of, 23. nerves of, 39. standing, 49. Frequency of club-foot, 113. Frost-bite, 266. Galen on causes of congenital club-foot, 116. Gastrocnemius, contraction of, 65. INDEX 289 Golding-Bird, on hollow-foot, 196. Golding-Bird's scaphoidectomy, 108. Gonorrheal infection of foot, 243. Great-toe joint, 48. Guerin, J,, on etiology of con- genital club-foot, 115. Hallux valgus, 257. Hammer-toe, 261. Heel-and-toe walking, 55. Heel-cord, shortened, treatment, 250. Heliotherapy, 235. Hippocrates on causes of con- genital club-foot, 116. History of case, 59. Hoffa on causes of congenital club-foot, 116. Hollow claw-foot, 196. Hyperidrosis, 266. Infantile paralysis, treatment, 202. Ingrowing toe-nail, 272. Injections for tuberculous joints, 242. Inspection of patient, 59. Intermittent limping, 264. Internal lateral ligament, 22. Interossei, the, 38. Ketch on congenital deformities, 113. Kirmisson on frequency of club- foot, 113. on injections for tuberculous joints, 242. on treatment of congenital club-foot, 146. Kocker on causes of congenital club-foot, 116. Lannelongue on frequency of club-foot, 113. Lateral traction shoe, 203. Lechiberder on congenital de- formities, 113. Ligaments, changes in, in talipes equino-varus, 120. of the foot, 21. Liniments, 109. Little on etiology of congenital club-foot, 115. on subcutaneous tenotomy, 161. Lumbricales, the, 33. Lund, on astragalectomy, 174. Manipulations for weak-foot and flat-foot, 97. Manipulative treatment of con- genital club-foot, 126. Mayo, C. H., on treatment of hallux valgus, 261. Medio-tarsal joint, movements at, 46. Mensuration of tuberculous foot, 222. Metatarsal bones, the, 18. joints, manipulation of, loi. Metatarsalgia, 251. Morton's toe, 253. Movements of the foot, 43. Murphy, J. K., on congenital de- formities of the tibia and fe- mur, 143. Muscles, changes in, in talipes equino-varus, 120. of the calf, 24. of the foot, 23. Muscular spasms in tuberculous foot, 221, Myasthenia angio-sclerotica, 264. Myers wrench, 154. Nerves of the foot, 39. Neurotomy for spastic paralysis, 180. Nutt's traction shoe, 73. 290 INDEX Ogston'6 operation — arthrodesis of the astragalo-sca- phoid joint, 107, 176. Onychia, 272. Operation for hallux valgus, 260. hammer-toe, 262. shortened heel-cord, 250. tuberculous foot, 238. Ogston's arthrodesis, 107. tenotomy for flat-foot, 106. tenotomy of tendo Achillis, 'j^. Operative treatment of congeni- tal club-foot, 153. Os calcis, the, 17. Osseous flat-foot, 84. Osteoclasis for congenital club- foot, 144. Osteotomies, multiple cuneiform, 176. Osteotomy for congenital club- foot, 144. Pain, significance of in diagnosis, 62. Painful heel, 248. soles, 276. Palpation, 61. Paralysis, infantile, 183-216. of plantar muscles, 198. of tibialis anticus, 201. residual, 183 spastic, 178. Allison's treatment, i8r. Schwab's treatment, 181. Stoefifel's treatment, 181. treatment, 180. Paralytic talipes calcaneus, 193. equinus, 192. valgus, 191. varus, 191. Pare on causes of congenital club-foot, 116. Parker on causes of congenital club-foot, 116. Parker on tenotomy of the as- tragalo-scaphoid capsule, 168. Paronychia, 272. Peroneal muscles, 27. Pernio (chilblains), 265. Peroneus brevis, tenotomy of, 168. longus, tenotomy of, 168. tertius, 36. Phalanges, the, 18. Phelps' operation for congenital club-foot, 172. Physiological laws, Wolff's and Davis', 157. Plantar fascia, 21. fascia, tenotomy of, 169. flexion, 30-32. of the foot, 43. ligaments, 21. muscles, paralysis of, 198. neuralgia, 268. Plaster-of-Paris dressing for flat-foot, 103. for congenital club-foot, 137. Policeman's heel, 248. Post-operative treatment of flat- foot, 108. Posterior ligament, 22,. Pott's disease, complicated by paralysis, 178. Radiography of tuberculous foot, 222. Raynaud's disease, 262. Residual paralysis, 183. Scaphoid, the, 17. Scaphoidectomy for flat-foot, 108. Scarpa on causes of congenital club-foot, 116. Schwab's treatment of spastic paralysis, 181. Sea-bathing for tuberculous foot, 236. INDEX 291 Sesamoid bones, the, 18. Shattock on causes of congenital club-foot, 116. Shaffer's brace, 96. Shaffer's foot, 65-77. etiology, ^2. characteristics, 65-67. symptoms, 68. treatment, 72. Shaffer's liniment, no. traction shoes, 72, 202, Shoe, lateral traction, 203. Nutt's traction, 73. Shaffer's traction, 72. the Beely-heel, 88, Willard's, 139. Shoes, the heels, 280. importance of proper fitting, 284. the toes, 280. the uppers, 283. the shank, 281. the rocker-sole, 284. Silk ligaments, use of in paralysis of foot, 212. Sinuses, tuberculous, 240. Skeleton of the foot, 18. Soles, painful, 276. Spastic paralysis, 178. Standing, proper position, 57. Stockings, 277. Stoeffel's treatment of spastic paralysis, 181, Strapping weak-foot with ad- hesive plaster, 100. Stromeyer on subcutaneous ten- otomy, 161. Sub-astragaloid joint, move- ments at, 45. Subcutaneous tenotomy, 161. Sun-bath for tuberculous foot, 235- Sweating feet, 266. Symptoms of Shaffer's foot, 68. Talipes calcaneo-valgus, defini- tion of, III. calcaneo-varus, definition of, III. calcaneus, congenital, treat- ment, 151. definition of, in. paralytic, 193. cavus, congenital, 153. comparative frequency of va- rieties, 114. equino-cavus, congenital, 153. equino-valgus, congenital, treat- ment, 150. definition of, iii. equino-varus, changes in bones in, 118. changes in muscles and liga- ments in, 120. confirmation of structural changes in, 123. definition of, in. early treatment, 125-145. general appearance, 116. pathological changes in, 148. treatment when child begins to stand, 146-150. equinus, congenital, treatment, ISO. definition of, iix. paralytic, 192. planus, congenital, 153. varus, congenital, treatment, 151. definition of, in. paralytic, 191. valgo-cavus, congenital, 153. valgus, congenital, treatment, 150. valgus and varus, congenital, treatment, 152. valgus, definition of, in. paralytic, 191. 292 INDEX Tamplin on frequency of club- foot, 113. Tarsectomy, cuneiform, 176. for fiat-foot, 107. Taylor's club-foot brace, 140. Tendo Achillis, 26. contraction of, 64. tenotomy of, 76, 163. transplantation, 209. Tendons of the foot, 23. Tenotomy for flat-foot, 106. for spastic paralysis, 180. indications for, 170. of astragalo-scaphoid capsule, 168. of flexor longus digitorum, 168. of peroneus longus and brevis, 168. of plantar fascia, 169. of tendo Achillis, 76, 163. of tibialis anticus, 168. of tibialis posticus, 166. subcutaneous, 161. Therapeutics of early treatment of congenital club-foot, 145. Thomas knee brace, 229. wrench, 154. Tibialis anticus, 35. paralysis of, 201. tenotomy of, 168. posticus, 34. tenotomy of, 166. Toe-walking, 55. Traction shoes, Shaffer's, 72. Transversus pedis, the, 38. Treatment, Bier's, for tubercu- lous foot, 231. constitutional, for tuberculous foot, 237. callosities, 275. chilblains, 265. congenital club-foot, 125-177. early, 125, manipulation, 126. Treatment, congenital club-foot apparatus, 130. muslin bandages, 130. adhesive plaster, 131. braces, 131. felt splint, 133. wood splint, 136. plaster-of-Paris, 137. Willard's shoe, 139. Taylor's brace, 140. osteotomy, 144. osteoclasis, 144. therapeutics of, 145. when child begins to stand, 146. operative procedure, 153-172. wrenching, 153. tenotomy, 1 61-172. indications for, 170. Phelps' operation, 172. bone operations, 172. astragalectomy, 174. Ogston's operation, 176. cuneiform tarsectomy, 176. multiple cuneiform osteo- tomies, 176. congenital talipes calcaneus, 151. congenital talipes equino-val- gus, 150. congenital talipes equinus, 150. congenital talipes valgus, 150. congenital talipes varus, 151. corns, 270. fallen arch, 253. flat-foot, 86. frost-bite, 266. hallux valgus, 257. hammer-toe, 261. gonorrheal infection of the foot, 245. infantile paralysis, 202. instrumental stretching, 202. lateral traction shoe, 203. INDEX 293 Treatment of infantile paralysis, braces, 206. wedge sole, 20Q. tendon transplantation, 209. silk ligaments, 212. astragalectomy, 213. ingrowing toe-nail, 273. intermittent limping, 264. metatarsalgia, 253. Morton's toe, 256. painful heel, 249. perforating ulcer of the foot, 264. Raynaud's disease, 263. Shaffer's foot, 72. shortened heel-cord, 250. sinuses, 240. spastic paralysis, 179. sweating feet, 267. tuberculous abscesses, 240. tuberculous disease of the foot, 225. tuberculous joints, 242. tuberculin, for tuberculous foot, 233. weak-foot, 86. Tubby on astragalectomy, 174. Tubbyj on talipes equino-varus, 148. Tuberculin test for tuberculous foot, 223. Tuberculin treatment for tuber- culous disease of the foot, 233. Tuberculous foot, diagnosis, 217, mensuration, 222. Tuberculous foot — Continued. muscular spasms in, 220. primary focus, 217. joints, 242. Ulcers of the foot, 264. Vaccine treatment for gonorrheal infection of the foot, 246. Volkman, on causes of congeni- tal club-foot, 116. Walking, 54. Weak-foot, adhesive plaster strapping, 100. characteristics, 78. diagnosis, 79. exercises for, 89. manipulations for, 97. treatment, 83. Wedge sole, 209. Weight, distribution of on the feet, 41. Whitman on congenital deformi- ties, 113. Whitman's astragalectomy, 213. brace, 94. Willard, on early treatment of club-foot, 125. Willard's shoe, 139. Wolff's physiological law, 157. Wood splint for congenital club- foot, 136. Work, rest and fatigue, 51. Wrenching in operative treat- ment of club-foot, 153. Practical Monographs DISEASES AND DEFORMITIE-S OF THE FOOT By John Joseph NuTT, M.D., Orthopedic Sur- geon, Willard Parker Hospital, New York, etc. 8vo, over 300 pages, 105 illustrations, prepaid. . .$2.75 This treatise is prepared for the use of those physicians who have not had the time or the opportunity for thorough study of this often neglected subject and who feel keenly their inability to prescribe scientifically and successfully for the many who consult them regarding their pedal conditions. The illustrations will be found an especially valuable feature. DIAGNOSIS OF NERVOUS DISEASES By PURVES Stewart, M.D., F.R.C.P. 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Svo, diagrams and tables, cloth, prepaid |1.50 The author's experience, during the past seven years, with over 2,000 cases of diabetes in his clinic and sana- torium, forms the basis of these American lectures. E. B. TREAT & CO., Medical Publishers 241-243 Weat 23d Street :: :: NEW YORK COLUMBIA UNIVERSITY LIBRARIES ' This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE 'J _U .1., V .'^Tf^: J/ \n 8 1949 C2S (747/ MlOO i (