Shoes for infants should be distinctly right and left; the front of the shoe should be adducted, the inner edge tr a ic:11 t, and there should be room along the straight inner edge for the front of the foot and the big toe to assume their positions of greatest strength. Adults should wear right and left stockings, preferably with a separate apartment for the big toe. J. A. Simpson (Amer. Medicine, Jan. 1S, 1902).
To relieve the strain on the arch the weight of the body should be thrown on the outer edge of the foot. This is ac complished by raising the heel and sole on the inner side a quarter of an inch or more, also by using some additional me chanical support. This mechanical sup port may be given either by a separate insole or plate which is inserted into an ordinary walking-shoe or by a shoe which is specially constructed for the patient.
In some cases metal plates or insoles work well, but they are often unsatisfac tory, and on that account in all serious cases and in many others I prefer a specially-constructed shoe. The plate usually used consists of a sheet of metal, of the shape of the foot, which has been worked up on its inner edge so as to sup port the arch. In order to support the outer side of the foot and prevent it from sliding outward away from the plate Royal Whitman has added a pro jection on the outer side. A leathern insole braced with a metal strip can also be bought of instrument-makers. The objection to metal sole-plates are that they are hard to fit and be made com fortable, they require the use of a spe cially loose shoe, and many of them are liable to rust and break. Practically the only way of preventing the latter is to have them coated with hard rubber after being specially fitted to the patient, or to use some special, non-corroding metal. The shoe which I prefer is made on these lines: a steel shank is inserted between the layers of the sole, over this at the part of the foot which it is desired to support is placed a small pad so shaped as just to fill the hollow of the restored arch. The counter of the shoe is made extra strong, the inner edge of the sole and heel are raised a quarter of an inch, and if the case is an exceptionally bad one a small side-plate is riveted on the sole-plate and goes up on the inner side of the foot for an inch or two. This is covered by sewing over it a piece of leather. The shoe is to be a laced one, and not buttoned. In severe cases a side-iron may be added to this shoe, or an inside plate with side-iron and joint at ankle may be used.
Tenotomy of the peronei tendons may be performed, but rarely for cases in which spasm is quite marked.
Celluloid plates advocated for flat-foot soles. The thickness of the sole varies from one and a half to four millimetres. For men this should be strengthened by portions of celluloid dissolved in acetone. Kirsch (Centralb. f. Chir., No. 35, '90).
Pes Valgus.
Diagnosis and Treatment.—In valgus the foot is turned out instead of in. It is almost always an acquired affection and associated with calcaneus, as in cases of pes cavus already referred to. Its treatment is a combination of that used for pes cavus and pes planes. The tendency for the foot to turn out is overcome by using an apparatus with a steel sole-plate, and any tendency to too much flexion or extension is counter acted by a stop-joint. The brace can either be fastened to and incorporated with the sole-plate or the brace can be separate from the shoe and used inside of it. An advantage of the latter is that it may be used with different shoes, but it is not so efficacious as the former.
Knock-knees.
In knock-knees the legs, instead of being straight in line with the thighs, are inclined outward from the knee joints. This causes the feet to be wider apart than natural and the knees closer together, so that in walking they knock against one another and interfere in walking; whence the name.
t is caused by an increased obliquity of the lower articular surface of the femur, together, usually, with an in creased laxity of the ligaments of the knee-joint. The internal condyle of the femur projects downward farther than does the external. The increase in the internal condyle is on its lower, and not on its posterior, surface; so that the formity manifests itself when the legs are extended. When they are flexed they assume their normal position and nothing unusual is to be seen except, in marked cases, the projection of the in ternal condyle. The increased length of the internal condyle is not caused by a more rapid growth of the extremity of the condyle itself as of the whole sub stance of the inner side of the femur, for the epiphyseal cartilage is not transverse to the long axis of the femur, but is tilted so as to be almost parallel to the joint-surface. Associated with this con dition of the bones is also a laxity of the ligaments of the joint, particularly those on the inner side.