Chapter V · THE CARE OF THE FOOT

The Naked Foot. For many centuries the human foot was allowed to go naked, and our aboriginal ancestors never knew what foot clothing of any type meant. Much the same as with the rest of his body, unaided nature was allowed to minister to the needs of his pedal extremities. Research has shown that primitive man was very strong and able to withstand the abuses of the elements to a marked degree. The body adapted itself to nature and the elements, so that it could bear extreme heat or cold, wind or rain, or any condition of the weather, without giving way before these nature forces.

So it was with the foot of man during this period. The skin of the soles became thickened so that even the roughest surfaces caused no discomfort when borne upon by his bare feet. Even to this day, savage tribes that still go barefoot have skin on the soles of the feet that is tough and hardened. The author has seen natives of Central America, who are of this class, step on objects such as glass, lighted cigars, etc., without experiencing any appreciable discomfort.

In aboriginal man, muscular action of the entire foot was developed to its maximum. The muscles of the toes were under perfect control so that objects could be felt and lifted with them, much the same as with the fingers of man today. The leg muscles were well developed so that the position of the body in walking could be altered quickly and the body weight could be rapidly changed from one foot to another, so as to avoid contact with sharp pointed objects, such as burrs, sharp twigs, pointed stones, etc.

Nature was primitive man’s physician. Being continuously exposed to the air, skin exfoliation, evaporation of moisture and other normal functions were never interfered with. The objects with which the body came in contact in wading through small streams, or in walking through the wet grass and dewy underbrush, acted much the same as the bath brush of modern times. Further, man of that period, living on nature’s foods, was never subject to the various conditions brought about by improper diet and which in turn manifest themselves in the feet as well as in other parts of the body.

Advent of Foot Clothing. As time went on and man became more and more civilized, clothing for the foot was gradually adopted, and from that time to the present the foot has undergone changes that make it necessary for the human race to resort to treatment for lesions that could not have developed if nature had had her way, and man had never adopted covering for the foot.

The first style of foot covering was the sandal. This caused no special trouble, but when man began to depend upon them for protection for the soles of the feet, nature consequently no longer required the tough, protecting, heavy skin, and gradually the integument of that region became thinner. The result has been, that today, slight trauma or irritation causes many disturbances on the soles, among which are the common helomata dura and verrucæ.

An evolution of footgear followed the use of the sandal, and with civilization came vanity in foot dress and finally the modern shoe, completely at variance with nature’s demands and causing so many disturbances that specialists in treating foot lesions became requisite to care for them.

Modern Footgear. The modern shoe, as compared to the normal foot, is worthy of special consideration. As a rule, the men who build shoes have from time immemorial been pure commercialists. Their purpose in engaging in the manufacture of footwear always has been and is to do business. They have attempted to create styles that would sell. They have produced wares that would be popular and therefore saleable. The question of the niceties of the anatomy and physiology of the foot and leg played no part in their calculations because they knew nothing about these features as factors in gaining results. The foot was treated as a whole, much as the hat manufacturer considers the human head when building a head covering. No consideration was given the natural beauties of the foot, so much appreciated by the ancient Greeks. The need for conserving the functions of the small bones of the foot so that their articulations would not be disturbed, caused them no pause. The necessity for allowing free play to all of the muscles which abduct, adduct, evert, invert, flex and extend the foot was and is a negligible quantity with the shoe-builder. There are few exceptions to this rule.

Suppose the dentist were to make sets of teeth to be fitted to the jaws of those who had become toothless, basing their manufacture of these dental adjuvants on the prevailing needs of groups of these tooth-defectives, and tooth-shops were to be instituted to fit these sufferers from wares in stock! The public would deride such an innovation. And still it is almost as ridiculous to suppose that our shoe-shops can properly clothe the feet of the public as they should be clothed from a stock of shoes which are made without careful relevancy to the anatomy and physiology of the foot. Let us take one feature of the modern shoe as a sample of this pandering to style: the high heel, so common on women’s shoes, is a pure conceit. It is responsible for many of the foot lesions of today, and in addition causes systemic disturbances of a serious nature. When the body in standing is erect, the foot should be at right angles to the leg. When the heels are raised, however, it would be necessary to tilt the body forward to still maintain the right angular posture. It therefore becomes necessary in maintaining the erect position to allow for the malalignment of the body, due to the high heels, and this is accomplished in the knees, hips and spine. The knees are flexed, the hips rotated and the abdomen thrust forward. This latter interferes with the normal position of the abdominal organs, and thus arise many diseases common to women. The high heel is the etiologic factor. Locally, the calf muscles become contracted and an inward lateral displacement of some of the tarsal bones results. Gradually the other bones of the foot are displaced, and weak and flat foot result. Further, the high heel causes the foot to slip forward in the shoe and the toes are thus crowded. When the body weight is brought to bear upon the ball of the foot in walking, this crowding prevents the normal spreading of the metatarsal bones, and there is distortion of the bones, causing anterior displacement, or dropping of the anterior arch with resulting metatarsalgia.

Another illustration: the function of the sudoriferous glands, namely, the elimination of liquid waste, in the form of sweat or perspiration, is going on continuously. As the fluids are brought to the surface by the gland ducts, evaporation takes place immediately, except under unusual circumstances, such as mental excitement, increased temperature, etc., in which instances the production may be very rapid or may be retarded. When the foot is encased in a shoe, or in a stocking that does not absorb moisture, such as silk or lisle, this evaporation is retarded to a greater or lesser degree, depending upon the leather of which the shoe is made. Such interference with normal functions is productive of many foot ills elsewhere noted in these pages. In this connection the podiatrist should be familiar with these facts: Vici kid is the most porous of all the leathers used in shoe manufacture, so that most if not all of the moisture excreted by the glands evaporates. Calf skin is not so efficient for foot covering, in that evaporation is limited; both of these leathers are far superior to either patent leather or colt skin, which latter are absolutely air and water tight, and should never be used as a foot covering. The stocking should be of a material that will absorb moisture, and cotton or woolen hose are best for this purpose and will assist in keeping the feet dry and normal.

Again, the nails of the toes are often unfavorably affected by the modern shoe, especially the nails of the great toes. The toe box of the average shoe is made of stiff, unyielding material so that if the shoe is narrow or short, irritation or undue pressure is brought to bear upon the nail or the surrounding tissues, causing disease. It is especially necessary to obviate the possibility of pressure of the soft tissue of the nail groove against the hard nail substance, because if such a condition arises and is allowed to persist, calloused nail grooves, helomata and often ingrown toe nails result. In the same manner, pressure on the various parts of the nail may cause club nail, onychia or paronychia. Simple packing of the nail grooves with absorbent cotton, if properly done, is often the means of avoiding serious nail lesions, which, as a rule, are very painful.

In this connection it would be well to remember that it is most important that the nails be cut properly. The corners of the nails should never be removed, unless there is some trouble beneath the part. Removal of the corners of the nails changes the position of the surrounding soft tissues, which depend upon the hard nail substance for support, and thereby causes them to collapse. This is one of the primary etiologic factors of ingrown toe nail.

The bony structures of the foot have suffered extensively since the advent of modern footgear, and the treatment of the lesions in which the osseous tissue is involved is of importance to the podiatrist as well as to the surgeon or orthopedist. Many deformities of the foot are such that only the surgeon is qualified to successfully treat them, but the more common lesions properly come under the care of the podiatrist, and should be treated by him.

Pointed shoes cause displacement of the metatarsal bones, with subsequent nerve compression; hallux valgus is a common deformity due to misfitting shoes. These latter conditions are the result of improper footgear, as also of incorrect posture and of faulty locomotion.

The soft tissues of the foot have suffered to a great extent because of the modern shoe, especially the muscles that arise in the leg and are inserted in the foot. Upon these muscles principally depend the motions of the foot, especially those of flexion, extension, adduction and abduction. The calf muscles, as previously stated, become shortened, due to the high heels. Additionally the muscles on the outer side of the leg are shortened while those on the inner side are lengthened. The long extensors of the toe are also shortened.

When it is remembered that there are twenty muscles in addition to the twelve muscles of the leg inserted into the foot, the limited motion of this area, as compared to other parts of the body, is apparent. Take for instance, the movements of the toes in the average adult. The action of the great toe is markedly limited and that of the lesser toes is almost lost. This loss of action is brought about by a lack of use of the digits of the feet. The hands and fingers being used continuously, the movements of these digits are active and numerous. The toes have a like muscular supply, but are far less efficient. The ability of the barefoot races to use their toes as accessory fingers, is proof that lack of development is due to lack of motion because of the toes being encased for most of the time in footgear.

Hygiene of the Foot. The many perverted functions of the foot that have been brought about by the use of modern footgear have made it essential that this part of the body be given special attention both by the specialist and by the individual himself. There are several essentials for proper foot care with which everybody should be familiar, and it is the duty of the podiatrist to instruct his patients in these essentials. The general hygiene of the foot is little understood by the average layman, and the fact that a patient takes a daily bath is no indication that the feet are being properly cleansed. To accomplish this the foot should be washed with soap and water, care being taken that any excrementitious matter which may have accumulated between the toes is thoroughly removed. It is best to use warm water for this purpose, and when the feet have been thoroughly cleansed they should be rinsed in cold water. This closes the glands which have become dilated by the heat; if allowed to remain open, they will over-functionate. The foot must be dried well, especially between the toes, and after this has been done, alcohol may be applied to assist in this purpose. Alcohol is both astringent and dehydrating. In cases of a normally dry skin, alcohol may be dispensed with; instead, a small quantity of an animal oil should be rubbed into the skin; lanolin is very efficient for this purpose.

Water, as a therapeutic agent, is used extensively and has many advantages that are lacking in other remedial measures. It is one of the most ancient of remedies, and its value has been recognized to such an extent that there are large institutes in this and other countries devoted exclusively to hydrotherapy.

No other agent is capable of producing so great a variety of physiologic effects as water; it is easily obtained and is also readily adaptable for the various conditions in which it is of benefit. Pastor Kneipp obtained excellent results with his water cure in Europe, and although his methods are not original creations, and their application was largely empiric, they attracted international attention. The entire system of treatment as practised by him was based upon some hygienic principle, and most of the results achieved were due to the application of common sense.

Water has three properties to which its value as a therapeutic agent are due; first, its power to absorb and communicate heat; second, its solvent properties; third, the ease with which it changes its physical state from the liquid to the solid or gaseous form. These three properties, either alone or combined, are to be considered when water is applied to the body as a therapeutic agent.

A given quantity of water by weight can absorb more heat than any other substance. The readiness with which this heat is absorbed makes it possible to apply either heat or cold to the body. Thus, ice applied to the body will melt, and in doing so will extract a large amount of heat from the tissues. It is valuable therefore in conditions such as local infections, in which the heat of the body is above normal.

Every substance is more or less soluble in water. Water is therefore called the universal solvent. Water is the medium by which foods are dissolved and absorbed in digestion; water also dissolves and carries off the waste products to the various organs of elimination.

For therapeutic application, the temperature of water varies from 32 degrees, F. to 120 degrees, F., depending upon the condition in which it is used and also the purpose of its use. Foot baths are of special interest to the podiatrist, so that it is necessary to be familiar with the particular type of foot bath that is valuable in the treatment of foot lesions.

The alternate foot bath is used for stimulating the cutaneous circulation, and acts as a general tonic for the nerves and other tissues. The bath is given as follows: the feet are placed in hot water for two minutes and then plunged into cold water and kept there for 30 seconds. They are then returned to the hot water for two minutes and back into the cold water for 30 seconds. This is repeated a number of times, always starting with the hot water and finishing with immersion in cold water. This bath affords great relief to those suffering with tired feet after having worn shoes for a long period. As a general hygienic adjunct, the alternate foot bath is of great benefit, and should be employed at night before retiring.

Foot Care of Infants and Adolescents. About eighty per cent. of the civilized, shoe wearing people, are foot afflicted to a greater or lesser degree, and most of this can be traced to neglect of the feet in infancy and youth. Many of the most common diseases found in adults might have been avoided if proper care had been taken and the causative factors removed in proper time.

The foot of an infant, which has never worn a shoe, is really a perfect foot, and it is the only stage in life in which the perfect foot is commonly found. The toes are spread and the forefoot is slightly adducted. When the first footgear is selected for the infant (it must be borne in mind that the foot grows rapidly at this age) the shoe should be of sufficient length and width to allow for this growth. The softest materials should be used for the first shoes of the infant, for as the feet are not used in walking at this age, the necessary support to locomotion received from the material in the shoe, is a negative factor.

When the child commences to walk, the shoes should be changed, and a sole should be provided. The upper should be of kid, and should extend slightly above the ankle. Laced shoes should be used, and continued throughout the entire period of infancy and youth. The normal adduction of the forefoot should be considered and the outer border should curve inward in a gradual line. The foot should be measured for shoes with the child bearing its weight on the foot. This allows for the spread of the foot in weight bearing, and measurements taken under these conditions give assurance of a proper fit.

As the infant grows, the muscular strength of the legs is increased, and eventually the limbs are strong enough to support and carry the body weight. It is at this time that the child will commence to walk by natural impulse or instinct. From the short, jerky, uncertain step, there is a gradual improvement and, with time, the infant gains confidence and strength and the step soon becomes firm and steady. The question is often asked of physicians and podiatrists by anxious mothers: “why is it that my baby does not walk?” It seems to be a source of worry to them, for as these mothers watch other children walking, they become envious and attempt to teach their children to walk. Walking is a natural function and it is foolhardy to insist upon infants attempting this foray until the bones to which the muscles are attached are sufficiently unyielding and the muscles involved can coordinate for that purpose. The use of artificial means of assistance for the child, viz., the various contrivances on the market that support the child under the arms and allow the feet to drag on the ground, should be discouraged.

Premature locomotion causes an unnatural strain upon the legs and feet and is often the cause of malformations which continue on in later life. Many foot and leg lesions can be attributed to an over-anxious mother who insisted upon her child walking before the time was ripe for it to do so. Therefore it behooves every mother to allow nature to have its way, and to wait until the legs are strong enough. In cases where walking is unsteady, it may be advisable to assist the strengthening of the muscles by massage and passive motion.

The use of appliances to assist a child which already walks should be guarded, and only when there is something pathologically wrong should they be employed. Weak-ankle shoes, or weak-ankle braces or supports, although they apparently help the child’s gait, really retard the normal motions at the ankle joint, and there is little possibility of a compensatory increase in strength of the parts as a result of their use. When the ankle is continuously supported by some outside agent, the normal support, i.e., the muscles of the leg, become weaker. This is because they are not used, and atrophy is the result. When conditions are such that assistance must be sought, the part should be exercised by massage, exercises and passive motion. It is often a difficult matter to prescribe exercises for a child, but if given in a cheery way, so that the child thinks it is playing a new game or is having heaps of fun, the results are often remarkable. The First Institute of Podiatry is now planning an exercise room for children of the poor whose locomotion is impaired and the experiment will be watched with interest.

As the child grows into adolescence, the shoes should be changed often enough to allow for the normal growth of the foot. It is better to buy shoes oftener, than to attempt economy at the expense of health. The parents should acquaint themselves with an orthopedist or a podiatrist to advise and a competent shoe man, under the direction of the advisor, should fit the shoes of the growing child. Thus, caring for the same foot over a protracted period, such a specialist is better able to judge the size and shape best adapted for the individual. Walking and other forms of exercise should be encouraged, especially those exercises that develop the muscles of the foot and leg. It must be borne in mind that the flat foot and weak foot of later life are caused by deficient muscular action of certain groups of muscles.

Foot Care of Adults. After the foot has attained its full growth, and the bones have become calcified, correction of the lesions involving the bony tissue is difficult. Young persons who have been accustomed to wearing shoes with a straight inner line, and with broad toes, will pass into middle age without much, if any foot trouble. Slight friction or pressure may produce small helomata, but these are of little consequence and are easily relieved by intelligent care and treatment.

As previously stated, pointed and narrow shoes with high heels are responsible for many of the local foot lesions, and corrective treatment should be begun at as early a period as possible. When a person reaches middle age, the bones of the foot have become set. Attempts at correction, such as the prescribing of shoes with a straight inner line for such persons, cause the foot to be put into an entirely new position, and because the bones have become firmly set, such a new departure is frequently fraught with discomfort, and at times causes other bone and muscle troubles which are painful.

In younger adults, correction should be gradual. It is inadvisable to adopt radical measures for those who have been wearing incorrect shoes, or who have been walking and standing incorrectly for a long period of time. A woman who has been wearing high-heeled shoes for a few years, has a shortening of the calf muscles which should be corrected, but to change from a two-inch heel to one a half-inch high, without gradually reducing the height, will cause extreme discomfort. Appropriate exercises should be advised and the style of the footgear should be gradually and not abruptly changed as the foot responds to treatment.

Walking is one form of exercise in which every able-bodied person can indulge, and is a means of maintaining body health as well as of keeping the muscles of the foot and legs strong. Like every other form of exercise, it should be practised with caution. The individual who walks long distances is placing an undue strain upon the muscles of the lower extremity, and instead of being benefited, he is being harmed. The position of the foot is important in walking. The foot should point forward, and the forefoot should swing slightly inward with each step. In this way all of the muscles of the leg receive their proper share of work. The pace should be brisk and steady, yet not fast enough to cause the person to suffer in breathing. Slow, leisurely strolls are useless as a medium for muscular improvement, and are simply a waste of time.

The Care of the Soldier’s Foot. The foot of the soldier is subjected to unusual strain, both on the march and while in the trenches, and special care is necessary if the maximum of efficiency is to be maintained. Hygiene should be practised to a greater extent than under ordinary circumstances, and immediate attention should be given to minor troubles that might pass unnoticed in civil life.

The feet should be washed daily, and if long marches are contemplated, they should receive this attention both before and after the march. The feet should be thoroughly dried after each washing, and dusted with some foot powder that will absorb moisture. Lycopodium is the best base to use in foot powders. Socks should be examined and if found torn or badly mended, should be discarded because the pressure of the spots that have been darned may result in painful troubles. Shoes should be large enough to accommodate the spreading of the anterior arch in walking, yet should be snug in the heel to prevent the foot from sliding and creating friction. When soldiers are to serve in the trenches their feet should be given special attention, to prevent the possibilities of trench foot and other foot lesions that are the result of trench life. It has been proven by those who have gone thoroughly into the matter that the water and mud which is found in the trenches is responsible for these lesions, therefore it is necessary to guard against it reaching the feet of the men. In addition to wearing rubber boots, the feet should be thoroughly rubbed with some greasy substance immediately before entering the trenches. Mineral oils are best, and although the process of rubbing the feet and legs with oil is repulsive to the men, it should be compulsory, as it is the means of preventing loss of limbs. Cloths dipped in melted paraffin and then wrapped around the feet will suffice to keep the water from the skin.

Immediately after a siege in the trenches, the feet should be thoroughly washed with soap and warm water, carefully dried, and dusted with an antiseptic foot powder. One containing boracic acid and talcum will answer ordinary purposes. If abnormal lesions develop, these should be treated in keeping with the requirements.

The men should receive instructions at regular intervals, and lectures on the care of the foot should be given by the officer in charge of that particular branch of the medical department. Foot inspections should be made at prescribed times, and during these inspections, the podiatrist can easily determine whether or not the men are in need of foot attention beyond that which comes with self-care. The feet should also be examined before a march of ten miles or more, and should be re-examined immediately after the march. This procedure will save the men from developing any serious trouble, as the beginning of any such trouble is thus detected, and proper preventive treatment can be applied, sufficiently timely.

One or two podiatrists should be attached to each ambulance train while the troops are on the march, so that they are available at short notice. The immediate application of a shield or pad over some part of the foot that is being irritated will often save the individual from foot infection that may be serious. Too much care cannot be given the feet of the soldiery as their efficiency is based upon their powers of locomotion. It was the opinion of the first Napoleon that an army moved upon its stomach. By that he meant that plenty of proper food was essential to every fighting force. In these times, it is conceded that the foot-whole alone can be counted as competent soldiers, important as may be the food question. It behooves us, therefore, to give to the men who are willing to offer up their lives for their country’s weal, the very best possible care, and although the foot of the soldier has received no special attention in the past, the time is now ripe for the recognition of the podiatrist as an integral part of every officered unit in the Medical Corps of the Army and of the Navy. From a national economic standpoint alone, this recognition should be accorded because it must be clear that unless proper precautions are taken to note the condition of the soldier’s feet before he goes overseas, thousands will be found unavailable for first line work and will thus constitute themselves an incubus rather than an aid to the fighting force of our country.