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Foot Troubles





The more physicians see of affections of the feet and of painful
conditions of the legs due to foot troubles the more they realize that
the human faculty of the erect position becomes the source of many
discomforts unless care is taken of the muscular apparatus of the
legs. There are few people engaged in standing occupations who do not
suffer from their feet. These achy sensations are especially
bothersome if the patient is run down in health, or is in the midst of
worry or irritation from physical or mental stress. Even under
favorable conditions there are few who reach old age without serious
foot troubles or without, at least, some deformity of the feet, which,
by preventing or limiting exercise, have an important influence upon
the general health. Careful analysis of the conditions that develop
will convince an observer that yielding of the joints of the foot has
much to do with the deformities and that the wearing of unsuitable
shoes rather than any internal pathological condition is responsible
for the foot troubles that are so common.


Foot Deformities in All Classes.--An Englishman who visited this
country, and who had ample opportunity to observe our people, declared
after seeing the bathers at Newport, that there were two interesting
peculiarities of American masculine anatomy--the deformity in their
feet and the appearance of having swallowed a watermelon whole and
retained it within them. The latter condition has doubtless much to do
with the causation of the former. Inactive lives, overeating, and the
overweighting of flaccid limbs that are not capable of bearing even
their normal burden, complicated by tight and ill-fitting shoes, give
rise to the deformities of the toes that are so common--hammer toes,
over-riding toes, bunched toes, twisted toes, bent toes. Examples of
most of these are sure to be seen wherever we observe our men and
women bathing. The Englishman's observation was of our so-called
better class--at least, our leisure class. Ordinarily, it is assumed
that clerks, waiters, and others, who have to stand upon their feet
are the principal sufferers from foot deformities. They are, but they
are not alone, and a goodly proportion of the population suffers in
this way.


Mechanical Factors.--The most important deformity in these cases is a
yielding of the arch of the foot with consequent flattening of the
instep and lengthening of the foot. This overstretches especially the
flexer tendons which run underneath the arch, produces bunions, and
gives occasion for the development of corns. The pull upon the flexor
longus hallucis which runs along the inside border of the foot, gives
rise to the bunion by pulling the big toe outward--in the direction of
least resistance. The pressure upon the tendons of the flexor longus
digitorum pedis causes the smaller toes to bend somewhat, and this
gives rise to projecting angular points on which corns readily form.
Besides, the imperfect action of the muscles of the foot consequent
upon the fall of the arch gives rise to plantar corns and callouses
that are often painful. The living cushion of muscle which is the best
protection against injury, while walking or running, has its vitality
interfered with by the fall of the arch and the consequent
blocking of the return circulation through the thin walled veins. This
gives rise to cold feet and, in those who stand much, to the tender
feet that are now so much complained of and for which so many foot
powders and appliances are advertised.


Confusion of Rheumatism and Foot Troubles.--Most foot troubles are
reflected up the leg because muscles have to be overused or used at a
serious mechanical disadvantage. This combined discomfort of foot and
leg is readily referred to rheumatism. Some of the pains produced by
yielding of the arch are in the ankle, some are in the calf, some in
the tissues around the knee, and some even in the muscles and tendons
above the knee. It is much easier to say "rheumatism" than to
investigate carefully and differentiate the conditions that may be
present. Out of forty successive patients who came to the dispensary
of the Polyclinic Hospital of New York complaining of rheumatism,
eighteen were suffering from flatfoot. Out of twenty-four who thought
they had rheumatism in the feet or legs eighteen proved to be cases of
flatfoot. Of the others, one was suffering from that rare disease
meralgia paresthetica, two were suffering from sciatic neuritis, one
was suffering with sub-acute joint trouble consequent upon pinching of
a cartilage within the knee joint, and one had a painful condition
consequent upon an old dislocation of the ankle due to a fall,
accompanied by considerable laceration of the soft tissues. Analyses
of the cases left no room for the so-called chronic rheumatism which
had so easily covered all the cases at the beginning.

It was not unusual to see patients who had consulted many physicians
and taken all sorts of internal and external remedies for the
rheumatism that they supposed was causing their discomfort, yet who
had nothing more than flatfoot. Their condition had become so bad that
some of them had actually given up occupations that required them to
stand. Merely following the advice to wear flatfoot braces in their
shoes relieved these patients almost as if by magic. There was no need
to measure them particularly; all they needed was an ordinary set of
flatfoot braces. Some of them needed only a pair of good shoes, but
the metal braces were advised to make sure that there would be a firm
support for the arch of the foot. No wonder the "magic shoe-maker" had
such success in New York a few years ago.

Nearly always the shoes worn by dispensary patients are of the worst
kind, considering the condition. The patients' feet are often cold,
and they think this is nature's demand for heavy shoes, so they buy
heavy shoes and large sizes so as to be sure they will not hurt their
feet. This clumsy footgear allows the arch to drop still further
because no proper support is furnished, and the foot-trouble becomes
more poignant. Then working people nearly always wear older shoes on
rainy days, and this makes two elements for discomfort instead of one.
The yielding arch is already a source of discomfort which is more
noticeable in rainy weather because any affection around a joint is
more bothersome at such times. The support that a new pair of shoes
affords to the arch is lacking when what are so aptly termed "sloppy
weather shoes" are worn, and the consequence is that the patient is
particularly miserable in damp weather.


Unfavorable Disease Suggestions.--Of the cases in my experience of
so-called rheumatism in the legs, over one-half are due either to
flatfoot or to the incipient yielding of the arch which is called weak
foot. Rheumatism is most commonly held accountable for the
condition, though gout comes in for its share of blame with quite as
little justification. Occasionally some even more serious pathological
condition is appealed to. I have seen the tendency to passive
congestion in the feet with slight swelling around the ankle
consequent upon the yielding of the arch called kidney trouble in
spite of the fact that there was nothing in the urine to justify any
such diagnosis. I have even known the coldness of the feet, which is
likely to be a symptom of the disturbed circulation consequent upon
the yielding of the arch, attributed to heart disease. As we shall
see, most of the curious deformities of the old that make locomotion
so difficult and so painful are due to a breaking down of the arch
just after middle life and then to a progressive deformity of the
foot. The mechanics of the support of the body are sadly interfered
with when the arch yields, for bones are pushed out of place and
ligaments and tendons are lengthened in order that the foot may
accommodate itself to the new conditions. In nearly all these cases
the patients are prone to say that they are sufferers from rheumatism.
This diffuses and inveterates the notion which is a source of many
unfavorable suggestions, that rheumatism is a curious progressive
crippling disease which begins insidiously but advances remorselessly
and eventually leaves its victim a prey to deformity.


Gout and Flatfoot.--Bunions consist originally of an enlargement of a
bursa over the proximal end and the inner side of the big toe in order
to protect the bone and joint from friction. If the irritation is
continued, the proximal end of the first phalanx may enlarge, though
usually this is preceded by a series of attacks of more or less acute
inflammation of the bursa, when the bunion is said to "become
sensitive." I have seen these attacks called gout so often that I feel
sure that much of the gout reported in this country is nothing more
than bunions. There is true gout, and it is probably almost as
frequent with us as it is in England, but many of the so-called cases
are really flatfoot associated with development of the bunion that so
commonly occurs as the arch yields.

I was once asked to see a physician's wife who was thought to be a
sufferer from gout. Long ago Oliver Wendell Holmes said that, as the
shoemaker's children are likely to wear the worst shoes of the
village, so the doctor's family is likely to take the least medicine,
that is, be subjected to the least formal medication. The physician
had seen the more or less acutely swollen and red enlargement of the
base of the big toe, and heard his wife complain of the severe pain
associated with it, and had suggested the possibility of gout. After
rest in bed and the administration of salicylates and colchicum, the
pain subsided and the redness and much of the swelling disappeared.
This was a typical illustration of one event following another without
causal relation. The succession of events was taken as a therapeutic
test of the diagnosis of gout, and the patient was advised to regulate
her diet so as to prevent the further accumulation of urates or uric
acid in her blood. She was warned about eating red meat, about taking
acid fruits, and about the acid fermentation of starchy vegetables.
The main result of eating only white meat is apt to be simply a
limitation in the amount of meat eaten, because white meat is less
savory and after a time palls on the appetite. In the same way fruit
was largely eliminated and sweets were taken out of the diet and
vegetables were limited.



As she did not escape recurrent attacks of soreness in her bunion,
while at the same time there were achy feelings in her foot, she took
up the careful study of the dietary for gouty patients which she found
in the books in her husband's library. So many things have seemed
possibly deleterious for gouty people that it is not surprising that
after a time nearly everything worth eating except a few cereals and
milk and eggs had to be eliminated and she began to suffer from
inanition. Then, after a time, came constipation, due to the
insufficient amount of residue in her intestines, and this, partly by
physical action but largely by mental suggestion, still further
diminished the appetite for food, and a loss of over twenty pounds in
weight was the result. The weakening of the general muscular system
consequent upon this loss emphasized the trouble with the foot and the
painful condition at the base of the big toe became more marked.

The supposed necessity for more exercise in the open air led her to
walk long distances and in order to prevent her feet from hurting her,
as she thought, she wore roomy shoes, distinctly too large. This is
one of the common mistakes of people whose feet bother them, and it is
just the wrong thing to do, since a snug, well-fitting shoe provides
both support and protection. It is not surprising that the attacks of
sub-acute bursitis became more frequent and more painful.

It was then that I saw her, and, as I feared to disturb the family
harmony by suggesting that the whole trouble was a bunion and
flatfoot, I compromised by saying that, while there might be some
gout, there was undoubtedly flatfoot, and if she would wear the proper
sort of shoe and stop limiting her diet so strenuously, and cease
suggesting to herself that she had a progressive gouty affection that
would lead to deformity and decrepitude, she would soon be much
better.

It required tact to make her look favorably on this advice, after all
that she had gone through during months of limited diet and enforced
exercise. Though not quite convinced, she was ready to try the new
method. She began to be better as soon as she was fitted with a pair
of shoes that supported her arch and as soon as her increased
nutrition began to make itself felt. At the end of two weeks she was
able to give up the remedies for constipation that she had been using
for nearly a year, while at the end of four weeks she had regained ten
pounds of weight and felt much better.

Several years have passed since I saw her professionally and
occasionally I hear from her only to be told what a great measure of
relief it afforded her and how much better she has been as a
consequence of a few simple directions with regard to her feet. I have
seen at least a dozen of cases of so-called gout in educated people
which followed almost exactly the same course and yielded promptly to
the same treatment. The hardest symptom about these cases to cure is
the cherished mental conviction that they are the victims of
constitutional disease, either gout or rheumatism, to which all their
symptoms are attributed. They are cases for psychotherapy more than
any other form of therapeutics and need for a considerable period to
have repeated assurances of the entirely local character of their
affection.


Bunions and Flatfoot.--The etiology and preventive treatment of a
bunion has always seemed to me to bear a closer relation to a flat
foot than to anything else. The flatfooted man has nearly always a
tendency to bunions. The explanation of this is not difficult if
one traces the relation between the tendons that run around the arch
to the big toe. The usual etiological explanation, however, is that in
youth short shoes were worn which initiated a tendency to divert the
big toe inward toward the other toes. But there are many reasons
against this explanation. Anyone who tries will find that it is
practically impossible to wear shoes that are so short that the big
toe is crowded back. Women are more apt to shorten their shoes than
men, yet women suffer both from flat feet and from bunions much less
than men. The reason for this seems to be that the forward position
with the elevation of the heel of the shoe supports the arch and gives
the shoe a shape more fitted to the normal foot than is found in the
masculine flat-heeled shoe. Besides, this form of shoe maintains its
shape better, and then, too, women are not so prone to wear old
so-called comfortable shoes as are men.

The mechanism of the formation of the bunion in many cases seems to
be, that the large toe, instead of lying straight along the inner edge
of the foot, is pushed or pulled toward the other toes. If this
process began from the wearing of pointed shoes, especially if such
shoes did not have a straight line on the inside, conditions within
the foot would soon tend to emphasize it. If the adductor hallicis
once gets the habit of contracting rather strongly, as it is likely to
do through the irritation set up by the yielding of the arch, it will
be hard for its opposing muscles to counteract it. More important than
this, however, is the fact that the tendon of the flexor longus
hallucis runs along the inner border of the foot and is particularly
affected by the yielding of the arch. For it works at a decided
mechanical disadvantage under the new conditions and is stretched in
such a way as to pull forcibly and constantly upon the big toe,
necessarily turning it more and more outward as the arch continues to
yield. The dropping of the arch makes the distance from the heel to
the toe longer than before and the tendon pulls the toe as far outward
as possible to compensate for this, as the distance to its insertion
is thus made somewhat shorter.

The yielding of the arch lengthens the foot and puts the tendons of
all the flexors on the stretch. All of them have a tendency to bend
the toes, and as this action is constant, gradually the tendons of the
extensors become over-stretched and these muscles are not capable of
exerting their full force in overcoming the action of the flexors. The
flexor longus digitorum has a tendency to cause a bending of the small
toes, and as it also runs across the foot it pulls the toes somewhat
inward, that is, toward the big toe. This crowding leads to hammer
toes and over-riding. The big toe, however, is maintained in a state
of extension by its firm, full contact with the sole of the shoe and
with the floor when walking barefoot. The one direction in which it
can yield rather readily is outward toward the other toes because this
shortens the distance between the end of the toe and the heel. The
pressure put upon the flexor longus hallucis will have a tendency to
cause this, for it is over-stretched by the yielding of the arch and
keeps constantly pulling on the big toe until that member has a
distinct flexion outwards.

This makes the metacarpo-phalangeal joint prominent and then nature
proceeds to protect it by a water cushion, a special bursa due to the
formation between layers of connective tissue of a pocket in which
some serum is constantly present. One can scarcely admire enough this
provision of nature by which she protects prominent bony points
whenever they are subject to much irritation or to such use as would
cause injury to important structures below. If continued pressure
continues to be irritating, however, the water cushion proves
unavailing and an inflammation of the overlying skin occurs with
occasionally a spreading of infectious agents from the surface into
the serum pocket below. This serum is such a good culture medium that
an acute abscess is likely to form--the acute bursitis of the
surgeons.


Rarer Foot Troubles.--Besides bunions, a number of other deformities
of the feet occur as a consequence of the yielding of the arch. All
the toes are likely to bend rather acutely, and the points of them are
pressed against the shoe, while the knuckles, so to speak, are made
prominent and are more likely to be subject to corns than would
otherwise be the case. Besides, the displacement of the big toe toward
the little toes leads to a crowding of the toes together, and this
gives rise to soft interdigital corns and to a lowered resistive
vitality which may be the predisposing factor to slight infections of
various kinds that will make the patients miserable. Such affections
may appear negligible, a matter for the chiropodist, and not deserving
the physician's attention; but they mean so much for the comfort of
the patient and the prevention of exercise through sore feet reacts so
deleteriously on the general health that these minor ailments become
important and merit careful attention. Dr. Emmet tells the story of
the old family servant, always grumpy and complaining, who, when he
had the many blessings of life pointed out to him, confessed that the
Lord had been very good to him, but said, "The Lord knows He takes it
out of me in soft corns."


Hammer Toes--Clam Toes.--Nature has provided a wonderful mechanism
in the arch of the foot and the anatomical relations of the toes to
support the weight of the body firmly, gracefully, and comfortably;
yet any yielding of any part of it leads to a disturbance of its
delicate mechanical relations and, consequently, to ever-increasing
deformity. Hammer toes are typical examples of what such a disturbance
may lead to. One of the toes becomes pressed downward between two
others. This over-stretches the extensor muscles and tempts the
unbalanced flexors to contract. As the extensor muscles become, after
a time, unable to work in the constantly bent toes, they atrophy to
some extent and then the flexor muscles pull the toe farther and
farther down until there is no possibility of its being straightened
at all. Now, if the flexor tendons are cut and the toe straightened
the atrophic extensor muscles will not hold it in that position, and
when the flexors grow together the old condition will reassert itself.
In the meantime, muscle changes in the neighboring toes have also
taken place. With no resistance on one side of them, they become bent
sidewise over the hammer toe, and so their muscles on one side are
overstretched and on the other side become contracted. After a time it
is impossible to correct this series of deformities which are being
constantly increased and emphasized by the weight of the body above.


Present-day Shoes.--In recent years we have heard much more than
heretofore about foot troubles. As the old-fashioned shoes were
carefully made by skilled shoemakers to fit the feet of one individual
and not to conform to some supposed ideal pedal extremity, they
supported the feet much better than do the modern cheap machine-made
shoes. These custom shoes lasted a long time, and, after they were
once molded to the foot, the wearer was not disturbed for many
months by the process of having to become accustomed to another shoe.
The many advertisements in quite recent times of foot powders and
other artificial relief for the foot show that people are suffering
much more than before, or, at least, are less able to bear the
discomfort. These powders, however, are not likely to do good in the
long run, since they tempt the wearers to stand the discomfort against
which they do furnish a certain amount of soothing. It is much better,
however, for the sufferer to find the cause of the discomfort and to
remove it if possible, for otherwise it will lead to constantly
growing displacement of bones and muscles and may eventually even
bring on actual and ever-increasing deformity. [Footnote 35]

[Footnote 35: How much deterioration of the tissues of the foot may
be brought about by improper footwear and, above all, by sedentary
life and the substitution of the trolley car for the exercise of
walking, is well illustrated by the functions that are lost. The
child can use its adductor and abductor muscles for the toes quite
as well as for the fingers. Those who go barefooted retain those
muscular powers. Some time we will be able to influence young folks'
minds enough to keep them from sacrificing all the more delicate
muscular powers of their feet to the fashion of small or curiously
shaped shoes. Armless men learn to use their feet almost as hands,
they write, pick up small articles, oven play musical instruments.

Some people have special muscular faculties, as, for instance, the
power to displace certain tendons and bring them back with a snap
which makes a distinct sound. The Fox sisters, to whom we owe the
origin of modern spiritism, confessed that this was the way they
produced their spirit rapping. Some mediums can, it is said,
dislocate the tendon of the flexor longus hallucis onto the edge of
its grove and then bring it back with a snap. Others can produce
partial toe dislocations which by muscular power are suddenly
reduced with a dull noise like the sound of a gloved hand rapping
beneath the table.]


Prophylaxis.--The most important means of prophylaxis in these cases
is to have patients who must assume the standing position for some
hours each day, exercise their legs rather vigorously. If teachers,
lecturers, and the like, have to stand for a long time, it is
important that on the way to and from their occupations they should
not have to stand up in cars nor assume cramped and uncomfortable
positions. It would be better for them to walk rapidly for several
miles rather than ride in a standing or a constrained position. If
they are convinced of the necessity for exercise, there is much less
likelihood of the development of the severer discomfort that is
sometimes very discouraging. It is particularly difficult to make
women understand this; yet, once they have found how much relief is
afforded by vigorous exercise, they are likely to overdo it and thus
run the risk of incurring ills quite as serious as those consequent
upon not taking enough. In nervous people the nagging discomfort of a
yielding arch will sometimes (just as eye strain does) produce reflex
headaches, constipation, lack of appetite, and apparently predispose
to the frequent recurrence of migrainous headaches. I have, in not a
few cases, seen these conditions relieved by rational treatment of the
foot condition.


Circulatory Disturbances Due to Flatfoot.--An interesting direct
consequence of flatfoot is the disturbance of the venous circulation,
which is likely to bring about some swelling of the feet and nearly
always considerable coldness and numbness, particularly in the winter
and, above all, on damp days during cold weather. The swelling of the
feet makes the patient think--sometimes at the suggestion of his
physician--of kidney trouble or heart trouble, and sometimes it is
hard to persuade him that there is nothing serious the matter with
these important organs. The disturbance of the circulation further
leads to numbness, to some anesthesia, and to paresthesia. Corns and
especially callouses grow more readily between the toes, and patients
who are prone to read about such ailments may conclude that they are
suffering from hypesthesia and hyperesthesia due to some serious
progressive organic nervous disease. I once had a woman patient
discourse learnedly to me about these things who was sure that she had
the beginning of some incurable spinal disease. Locomotor ataxia was
the least she might expect from her description of her feelings. What
I found was flatfoot. Raising her arch cured her.

The cold feet and the numbness, to call them by simple Saxon names
which will not disturb patients, may sometimes keep them awake. In the
chapter on Insomnia we suggest that the best thing for this is to
secure a return of the circulation either by exercises, or by wearing
a flatfoot brace during the day, or by putting the feet in water as
hot as can be comfortably borne and keeping them there for a quarter
of an hour. Of these means exercise is the best. Raising up on the
toes after the shoes are off and coming down on the outside of the
foot strengthens the muscles, pulls the bones of the arch firmly
together and encourages the circulation. For beginning flatfoot this
is a curative measure and it is the natural mode of treatment for the
coldness and numbness of the feet. Rubbing, also, is good for the feet
in order to restore the circulation, but patients are inclined to rub
downwards while they should rub upwards in order to help the hampered
venous circulation. The thin-walled veins are more likely to be
compressed by any disturbance of tissues than are the firm-walled
arteries, and it is to help the veins that our remedial measures must
be directed.


Secondary Consequences.--The secondary consequences of flatfoot are
interesting. It is surprising how many people who frequently suffer
from sprains of the ankle have some yielding of the arch as a
predisposing factor to that condition. Two classes seem to suffer
frequently from sprained ankle--those with yielding arches and those
with high insteps. Apparently there is weakness in the excess in both
directions. Very flatfooted people apparently do not suffer so
frequently from sprained ankles as those in whom there is only an
incipient yielding of the arch. They seem to have learned to walk more
circumspectly. Perhaps, too, their well-known tendency to toe outward
lessens their liability to turning on their ankle. The effects of
sprains of the ankle in people with weak foot last, as a rule, longer
and leave more weakness after them than they do in ordinary cases.
This, of course, might be expected, but it is surprising how often the
significance of beginning flatfoot fails to be noticed even by the
physician. I have seen rather frequently cases of so-called chronic
rheumatism in which there is a series of stories of sprained ankle
because of the assumed weakness of the ankle from supposed rheumatism,
when the whole case can be summed up in a yielding arch.


Exercises.--If the arch has not yielded much, it is often unnecessary
to prescribe flatfoot braces or arch supports of any kind, unless
perhaps at first. After the first soreness has passed off, exercises
may be employed to strengthen the muscles. As we have said, the
patient should rise on his toes and then come down slowly on the
outside of his feet. He may be instructed to sit with his feet--not
his legs--crossed, the feet resting on their outer edges. He may be
shown how even various slight movements of his toes, almost without
moving his shoes at all, will strengthen the muscles that pass around
the arch, which, thus strengthened, will hold the bones of the arch
firmly together and prevent further yielding. There is, at the present
day, a tendency to recommend too freely the wearing of flatfoot braces
or arches. After all, these are only crutches and should not be
worn unless absolutely necessary. If the arch can be strengthened--as
it can be in many cases--so as to bear the body weight without
discomfort, then this is much the better treatment. If the arch is
restored the feet are in a more natural condition, while artificial
support leaves the muscles without that exercise which will preserve
their functions. Flatfoot braces may be necessary, but only if
absolutely necessary should they be advised, and palliative measures,
such as exercise, manipulations, and rubbings, should be given a fair
trial after the unfavorable suggestions as to his foot condition have
been removed from the patient's mind.


Significance of Foot Troubles.--We have devoted much space to foot
troubles--more, perhaps, than will seem justified to the minds of many
physicians. We have done so, however, because of the firm conviction
that the feet are the source of more discouragement and depression of
mind than any other part of the body. Life very often takes on another
aspect when foot troubles are relieved. In the old, progressive
deformities of the feet consequent upon mechanical disturbance are
probably the source of more discomfort, and by their interference with
exercise and outing, the cause of more ill-feeling and even
disturbance of health than any other single factor. Even life may be
shortened by the confinement or limitation of movement consequent upon
bad feet. Above all, the idea that any constitutional trouble, or
hereditary disease, is at the bottom of their affliction must be
removed, and then these patients are encouraged to live their lives
more fully and with more happiness for themselves and others. Hence
this long chapter.





Next: Arthritis Deformans

Previous: Painful Knee Conditions



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