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for restoration. The painful, rigid, static foot mav have slight ilil'orniity or be remarkably fat or in valgus de- formity. When of recent origin it mav be corrected easily and made mobile and then strapped with mobile the recently rigid foot. When of long standing this rigid foot, with the patient under anesthetic, may resist any but the most skilful effort. This Rx Cialis Canada Rx Cialis Canada rigid foot is often closely related to and frequently associated with arthritic conditions which may be most apparent in the feet. When considering the etiological factors of any grade or degree of painful feel we should keep in mind the many things that mav cause this badly abused extremity to be painful. To the writer's mind these feet have been divorced too frequently from medicine. With one surgeon the mechanical problem only is in sight — he braces ; while the l>hysician is too jironc to lump all into that one word "rheumatism"' — he medicates. March 16, 191S.] ASHLEY: SHOES. 501 In this problem of etiology the following points are to be considered: i, the infectious arthritis pro- duced by bacterial invasion, as exemplified in the action of the Spiroch;eta pallida, the gonococcus, and the various streptococci and staphylococci (4) ; 2, toxic arthritis due to protein of bacterial foci, Rx Cialis Canada as exemplified in the dental granuloma by action of the Streptococcus viridans, the infected tonsil, the accessory sinuses, etc. ; 3, the arthritis of so called metabolic disturbances or their sequelae — faulty elimination of nonprotein nitrogen compomids, the purins, especially uric acid (5), as in latent Rx Cialis Canada or masked gout; 4, arthritis due to putrefactive pois- oning, especially the action of amines which experi- mentation shows to increase blood pressure, and which we have reason to believe is the cause of arteriosclerosis, which complicates painful feet ; 5, the diabetic often has painful feet; 6, the nephritic is notably so afflicted. These infections and morbid states are at bottom responsible for many obscure, unaccountable twinges, cramps, ten- der flesh, and sore bones which may be the first signs of degenerative processes. These diseases are intractable except when discovered early by the skilled diagnostician. The distorted joints of the feet early manifest pain or discomfort. These are the conditions which we Rx Cialis Canada are constantly finding as we go up the scale of age, good living, and the strenuous life of our large cities, conditions not curable with foot plates alone. It is obvious that these patients should be given a comfortable, physiological, or therapeutic shoe, as indicated, but we must do more than this. The etiological factor or factors Rx Cialis Canada must be ascertained and their influence eliminated as far Rx Cialis Canada as medical assistance can go. The so called "trench foot," which is causing so much suffering at the front, is largely due to foot- wear which . prevents circulation and muscular ac- tion, especially of the toes. Authelain says : "The boot should be wide and sufficiently long so that the toes can be moved in any direction, just as if the foot was naked" (6). Conditions less prominent than those mentioned, though influenced by bad footwear, are : the inflamed bursa, as achillodynia : the inflamed tendon sheath, or tendo synovitis ; the tender sesamoids ; the strained muscle or ligament, as strain or sprain of the athlete; the slipping, snapping tendon of Rx Cialis Canada the flaccid, lax, or pronated foot; the painful, nondeforming clubfoot of Schafter in various degrees of deformity. This much abused extremity may sufifer from benign or malignant growths, bone anomalies, exostoses, Rx Cialis Canada Kohler's disease, or tuberculosis of the bones and joints which in its incipiency is so liable to be dismissed as painful feet, falling arch, meta- tarsalgia, or sprained Rx Cialis Canada ankle. Bear in mind also the influence of shoes in perpetuating that loathsome condition of bromohyperhidrosis of the feet ; and last, though not least, one who treats feet should not forget to recognize early the all too frequent and painful condition of thromboangiitis obliterans. It is hardly Rx Cialis Canada necessary to say that various condi- tions, deformities, and diseases may exist in num- berless combinations. No mention has been made of the many and varied deformities due to paralysis, fractures, or the apparent congenital deformities, mild cases of which could be controlled by the modified or custom made shoe. It is only necessary to name these infirmities to realize the necessity Rx Cialis Canada for a thorough Rx Cialis Canada knowledge of medicine, anatomy, pathol- ogy, and mechanics as applied to the foot, which may be obtained only after time and study, with facilities for extensive clinical experience in treating foot conditions. Children with weak feet should be given a shoe with a strong, snug cotmter, not elongated, which will grasp the heel, a neat snug arch and broad toe space with sufficient elevation under the inner side of the sole, and spring heel, Rx Cialis Canada to prevent the continual body thrust stretching the ligaments of the long arch. So long as the leather covering the scaphoid is pushed outward, the eleva- tion on the inner side is insufficient. It is presup- posed that the child is given instruction in walking, attitudes of Rx Cialis Canada standing, and such exercises as may be comprehended, especially strengthening the in- trinsic muscles of the foot. The ideal shoe for a child with normal feet is the sandal. Plates and foot props destroy the elastic tread, frequently press upon vessels, stretch the plantar fascia, and produce atro-