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I have made no attempt to discuss the various conditions more or less amenable to radium and x 49^ ASHLEY: SHOES. I New Yo>k Medical Jooiina rays, but to mention only some of those in which their vaUie as therapeutic agents is firmly established and their supremacy acknowledged. REFERENCES. 1. VVKKHAM and DeGRAIS: Quoted by Russell H. Boggs, in American Journal of Ronlgenology, April. 1915, p. 731. 2. HOWARD A. KELLY: Surgery, Gynecology, and Obstetrics, March, 1917, p. 27". 3- SIDNEY LANGE: American Journal of Rontgenology, February, 1916, p. 72. 4- HOWARD A. KELLY: Woman's Medical Journal, January, 1916. SHOES. PHYSIOLOGICAL AND THERA- PEUTIC. By Dexter Cialis 80 Mg Side Effects D. Ashley, M. D., New York. {Continued from page 437.) Painful, weak feet with no deformity and slight perceptible loss of motion except in the toes are perplexing. Not a few patients showing no marked deformity or loss of motion and wearing fairly good shoes, complain bitterly of their feet. Many of these have thin feet, sensitive skin, and very little heel cushion, or they have small bones out of proportion to the weight of the body. We must be careful not to let the neurotic element be too prominent in our minds as a causative factor of these symptoms. There are many etiological factors which should be eliminated before conclud- ing that we have a neurotic case. With hardly an exception there is muscular weakness, an absence of tone, whether the foot is thin or fleshy. Cialis 80 Mg Side Effects The foot is painful, the patient is sufifering. Is it a purely static condition, is there inherent weakness, bone anomaly or disease, toxic or infectious arthritis, metabolic disturbance or sequelae? It may be»a problem taxing the most skilful diagnostician. These patients should be given physiological or therapeutic shoes as required, while searching for the causative factors; they should be directed to strengthen the entire muscular and nervous system by outdoor, brisk walking upon soft turf, when not contraindicated, combined with general and special Cialis 80 Mg Side Effects exercises to strengthen the intrinsic muscles of the foot ; a diet easily digested and low in proteins ; in summer months an outdoor life, walking with bare feet in sand, or mud, with the head protected and no more clothing than is necessary. This will greatly benefit the nervous and muscular elements and correct many dietetic or metabolic conditions. The first visible indication that the foot is suffer- ing from undue restraint, inherent weakness, or disease is often marked by the unbalanced shoe (Fig. 15) when walking or standing. Upon exam- ination we find a pronated foot, a splay foot, flaccid, painful or nonpainful foot, non painful per- haps because occupation has not required much of this particular foot, produced by footwear that inhibits all or nearly all the muscular movements of the foot. To restore balance in a pronated foot, or an abducted foot, a therapeutic shoe is needed. This foot Cialis 80 Mg Side Effects rocks over on the inner tubercle of the Cialis 80 Mg Side Effects calcaneus, much as when the "genteel" position is assumed. In a simple pronated foot the ankle seems especially prominent without falling of the internal longitudinal arch. This deformitv takes place mostly in the subastragaloid jnini. Ti is of first importance to successful treatment to control the calcaneus (Fig. 7). To this end it is necessary to have a strong, snug counter to grasp the heel (Fig. Cialis 80 Mg Side Effects 8). The physiological heel seat, deeper on the outer side where the lesser tubercle may rest, will help to control this deformity. The correction of pronation should he aided further by a moder- ately broad heel, at least as wide as the wearer's real heel, not the width of the squashed out, fleshy portion of the heel. Flare or extend the inner side one eighth inch or more. \% pointed out in a previous paper, most machine made shoes have the heel flared on the outer side Fig. iz. — .\ well placed mechanical device to assist in straighten- ing the toe and reducing the bunion. Note that the great toe is pushed up against the leather as far as it will go. and cut under on the inner side. This fault should be corrected by all means. The inner side elevation should be built from one eighth to three eighths inch higher than the outer elevation, giving suf- ficient cant to overcorrect and adduct the calcaneus and to prevent the bulging of the internal malleolus. The inner Cialis 80 Mg Side Effects comer of the heel may be moved forward one eighth to three eighths inch, the breast making a diagonal or sinuous line across the Cialis 80 Mg Side Effects shank after the manner of the modified Thomas heel ; or the breast may be moved forward in total on the shank and made one or more lifts higher than the back elevation of the heel, materially stabilizing tlie heel ASHLEY: SHOES. 499