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 [{414}] 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 [{415}] 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.