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.





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