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bining traction by means of adhesive plaster applied to the leg up to the knee joint, terminating in straps which are buckled to the foot piece of the

brace. If the symptoms are very

acute, crutches may be used in addition to the brace, and a very light plaster of Paris cast be applied to the knee before putting on the brace.

While acute symptoms are present, the brace is worn night and day; after a number of months, when the acute symptoms have subsided, i. e., the muscular spasm and pain, etc., the brace may be left off at night, carefully watching the patient for recurrence. As the patient improves the brace may be removed for a few hours each day. The caliper brace may now be substituted; the two bars are cut off, turned inward at a right angle, and fastened to the heels of the shoes. The bars are made a little longer than the leg, so that the heel does not touch the bottom of the shoe when the patient is walking.

Abscesses, if large and superficial, are to be treated by incision and drainage. Sinuses may be curetted, and in cases of long standing suppuration, excision or arthreotomy may be indicated. Amputation may be necessary in very bad cases.

For Knock Knee and Bow Legs see Pædiatric Section (Rhachitis).

ACHILLODYNIA

This is an inflammation of the bursa lying between the tendo Achillis and its insertion into the os calcis.

Etiology. Strain or injury, usually caused by pressure of shoe. Rheumatism, gout, or gonorrhoea is often the apparent cause of the condition. Symptoms. Pain in the back of the heel, aggravated by use of the foot. Local tenderness on pressure; swelling.

Treatment. Hot air, massage, strapping with adhesive plaster to make pressure over the bursa. In severe cases a plaster of Paris cast. A rubber heel to soften the jar of each step. In chronic cases removal of the bursa by surgical procedure may be indicated.

ANTERIOR METATARSALGIA

Also called Morton's painful affection of the foot. Depression of the anterior arch.

It is a neuralgic pain in one of the phalangeometatarsal articulations, most frequently the fourth. It is a condition of adult life. It is usually

unilateral, the second foot becoming affected later. Women are most frequently affected. This has a direct bearing on the etiology, namely, the wearing of improperly shaped shoes. It is often associated with flat foot. Gout, rheumatism, and general debility are factors in the etiology. Nervous people also are prone to it.

The symptoms are paroxysms of severe neuralgic pain in the front of the foot, followed by a long continued dull ache and sometimes slight swelling. There is local sensitiveness to pressure. The pain is usually felt only when wearing shoes. The pain is not to be explained by the direct lateral pressure on the sunken anterior arch.

Treatment. A proper shoe of ample width and with a thick sole and a high arch and low heel. If this does not suffice, a metal plate similar to the one used for flat foot, but continued further forward and with an arch under the heads of the metatarsal bones, is to be worn inside the shoe. Temporary relief is obtained by circular strapping of the front of the foot with adhesive. plaster, with a small round pad of felt or leather under the anterior arch.

ANTERIOR POLIOMYELITIS AND PARALYTIC CLUB FOOT

Anterior poliomyelitis is an acute inflammatory disease of the anterior horns of the spinal cord, occurring chiefly in children and resulting in paralysis, more or less complete, of one or both lower extremities. It occurs most frequently in children under the age of five and during the warm months, June to September. The fact that sometimes two children in one

family or several children in a neighborhood are attacked with the disease at the same time leads one to think of it as an infectious disease of microbic origin. It also occurs in epidemic. form.

SYMPTOMS.-The onset is very sudden; a child perfectly well is attacked with fever, gastric disturbances, and sudden paralysis, or, going to bed in perfect health, wakes up the next morning and finds that it cannot move. The lower limbs alone or all four extremities may be

paralyzed. The arms quickly recover their power. The paralysis leaves the legs more slowly, some muscles remaining permanently palsied. If the destruction in the nerve centres has been very great, the muscles never recover, the nutrition and growth of the bones of the affected limb are seriously interfered with, and as time goes on the limb may become many inches shorter than the other. The reflexes are lost. The skin of the feet

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becomes bluish and the extremities are cold from impaired circulation, due to loss of innervation. Sensation is not lost.

The DIAGNOSIS is usually not made until the paralysis has set in.

The TREATMENT of the acute stage must be as energetic as possible, with a view to limiting the inflammation in the spinal cord and the consequent destruction of the nerve centres. It includes counterirritation to the spine, the application of cold in form

of ice bags over the spine, and placing the patient on the abdomen to lessen congestion.

After the inflammation has subsided and the chronic stage has set in, it is very important to begin to exercise the muscles passively and actively and to employ massage and electricity. The Krukenberg pendulum apparatus is invaluable in the treatment of these paralyzed muscles; with its aid, even very young children can, with the employment of a little tact, be made to exercise regularly. Parents should be instructed how to manipulate the limbs in order to overcome the tendency to deformity caused by the unopposed action of the healthy muscles.

It is a great mistake to apply braces immediately, for, while they may hold the limbs in a straight position, they cause considerable atrophy of the muscles on account of interference with their use and on account of the pressure of the straps and bands making up the brace. When the muscles have recovered their power as much as they can, it may become necessary to apply a brace to prevent deformity caused by the action of the unopposed muscles and by the force of gravity (toe drop). The kind of brace used will vary according to the extent of the paralysis, a simple upright bar extending to the knee and a foot piece being sufficient. for light cases of toe drop or valgus, or double upright bars extending to the hips, with a band about the waist and no joint at the knee or ankle, will be of considerable aid in walking where the thigh and leg muscles are both affected.

FIG. 198.-TALIPES EQUINUS FROM INFANTILE
PARALYSIS. Girl fourteen years.

A form of treatment extensively used and of growing importance is tendon transplantation. The idea of this surgical intervention is to transfer the power of a strong, active muscle to a paralyzed one, and to make it do the work of the paralyzed muscle. This operation is of great value when the limb is only partly paralyzed and there remain some healthy muscles which

can be spared from their original purpose and grafted upon some other muscle. In combination with the transplantation, we can also effect a lengthening or shortening of muscles, and it is by the combination of these three methods that the best results are obtained and a cure brought about which formerly was impossible. As examples of the classes of cases in

the tendo Achillis or from the peroneus longus may be sewed on to the tibialis anticus or posticus.

Paralytic Club Foot.-In shortening of the tibialis anticus, if necessary a splice of the tendo Achillis may be sewed upon the paralyzed peroneus longus or the extensor longus digitorum communis.

In paralysis of the quadriceps femoris, the sartorius has been successfully transplanted upon the paralyzed quadriceps extensor femoris. After the operation is completed, the limb is placed in an overcorrected position in a plaster of Paris bandage and retained there for from four to six weeks. The after-treatment consists of massage, gymnastics, and electricity, and the wearing of a retentive apparatus for some months to prevent recurrence. In severe cases, arthrodesis, or removal of the ankle joint, is indicated, as a stiff foot is preferable to the flail joint and furnishes proper support to the body.

FLAT FOOT

Flat foot is that deformity in which the foot is held fixed in the pronated and abducted position. According to Whitman, who proposes the term weak foot, it is one in which the attitude of rest or inactivity persists. The weight of the body falls upon the internal border of the foot and it is supported to a great degree by the ligaments.

There are several varieties. The congenital is due to pressure upon the foot in a faulty position in utero; it is not uncommon.

The acquired, traumatic form follows sprain, luxation, or fracture of the bones of the ankle joint. It is the usual result of badly set fractures of the lower extremity of the tibia or fibula.

The paralytic form is due to paralysis of the plantar flexors and supinators of the foot, following anterior poliomyelitis, cerebral paralysis, etc. The rhachitic form is due to bearing weight on the softened bones, and is seen very frequently in connection with knock knee.

The static flat foot is the most important variety. It occurs most frequently in young adults, more especially males, among those who are obliged to stand a great deal or to carry heavy weights. In long continued standing, in order to take the strain from the muscles which assist in holding up the arch, the patient assumes the attitude of rest. He abducts the limbs slightly (spreads them apart), rotates the legs a little outward, slightly flexes the knees, and holds the feet strongly abducted. In this position the weight of the body falls on the inner border of the foot and the ligaments alone support the arch. The deformity is caused by reflex muscular spasm, which in time holds the limb in a false attitude. Flexion in the astragalotibial articulation with extension in the mediotarsal joints is the earliest position of deformity, and it is soon accompanied by abduction and pronation.

SYMPTOMS.-In the earliest stages there are no objective symptoms, and we must be guided entirely by what the patients say. The patient notices that he tires easily; he usually complains of one foot first, for the condition rarely begins in both feet at the same time. The fatigue is felt, not in the foot, but in the calf muscle; this then increases as a feeling of tension and stiffness in

the calf, a dull ache. Then, after a greater exertion or long standing or walking on hard floors or a pavement, this feeling extends downward to the internal malleolus, in the tendon of the tibialis anticus, and about the same time the tension is felt in the inner border of the foot. The patient dislikes walking over rough pavements; every stone or unevenness of the ground is painful to him. In this stage the flat foot begins to exert an influence over the patient's mode of life. He walks less and less, uses the cars oftener, sits where he formerly stood, and no longer runs up or down stairs or jumps off the street car; in other words, tries to spare his feet as much as possible. Coldness and numbness and increased perspiration caused by impaired circulation and weakness are common symptoms. There is often a severe burning sensation in the sole of the foot. In the advanced stage of the affection the arch is broken down; the foot is strongly everted, the head of the astragalus standing out as a prominent lump below the internal malleolus; and there is spasm of all the leg muscles,

FIG. 200.-KRUKENBERG'S PENDULUM APPARATUS FOR