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SECTION II
ORTHOPEDIC SURGERY
CHAPTER II
THE FOOT AND ITS RELATION TO MILITARY SERVICE
THE SOLDIER'S FOOT
The importance of the foot in the development and maintenance of an army has long been recognized; with the advance of civilization this problem has assumed an even greater importance. The foot of primitive man, by virtue of his means of livelihood, was trained to go and so was ready for the warpath at a moment's notice. The foot of the man of today, equally by virtue of his means of livelihood, is called upon less and less for active function and is used more and more as a passive support in standing, with all the con-sequent attendant ills of weakened muscles and faulty foot posture. It is inevitable, therefore, that the number of men unfit for military service should be greatly increased by foot disabilities and that the care of the foot should become a question for serious consideration in the training of the recruit. In the World War the difficulty of this phase of the medical service was still further increased by the urgent need for large numbers of troops, the universal draft, and the location of the theater of operations overseas.
In reviewing this work for the period of the World War, the features which seem to stand out as of especial importance and value are two-the instruction of the various branches of the service in foot requirements, and the examination of the recruits, with the prophylactic care based thereon. Beginning with but few trained workers, a system which satisfactorily stood the test of time and of varying conditions was perfected gradually and fairly early by the division of orthopedic surgery.
INSTRUCTIONS IN REQUIREMENTS WITH RESPECT TO THE SOLDIER'S FOOT
Before the World War it had been pointed out that the satisfactory solution of the foot problem is possible only through the cooperative efforts of the medical officer, the line officer, and the soldier himself.1 Hence, from the beginning the necessity for the systematic instruction of these three classes of personnel was recognized. Obviously the plan which was finally approved 2 must be limited to the minimum requirements.
As far as the medical officer was concerned, it was evident that knowledge of the foot and its relation to the military service needed to be systematized and made available for Army use. Accordingly, a concise description of the mechanics of the foot, its disabilities and their treatment, was prepared for the Surgeon General by a few members of the American Orthopedic Association very shortly after our entrance in the war. This was first used in mimeographic form for distribution to camp surgeons. Later, it formed the foundation for the opening chapters of the War Manual of Military Orthopedic Surgery.3 This more general information was supplemented from time to time by circulars
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and special instructions covering various phases of the subject, such as the examination of the foot in border-line cases,4 the rapid examination of the feet of recruits, and the salvaging of foot defectives. Instruction in the affections of the foot was systematically carried out throughout the training camp period as a part of the minimum amount of general orthopedic training required of all medical officers in medical officers' training camps, and also in the special clinical courses in military orthopedic surgery for medical officers assigned to the orthopedic division. With the establishment of these special courses at Camp Greenleaf and in the various special schools in university centers, the opportunity was afforded of satisfactorily instructing officers before their assignment to camp duty, in the foot requirements of the soldier. At Camp Greenleaf a course of four weeks' duration was given to a class of 25, a new class being admitted each month.5 Not all of the men trained in this course were retained in the orthopedic group, as some finally proved better qualified for other branches of the medical service and hence were transferred. The university courses were of six weeks' duration. Later, in the perfected plan of instruction for medical officers conducted at Camp Greenleaf, a more intensive course in foot prophylaxis and treatment, as well as in other orthopedic affections. was given to all medical officers. These special courses of instruction were supplemented finally in the training camps by lectures and practical instruction by the consulting surgeons and the camp orthopedic surgeons.
Line officers and candidates for commission were required to have "a total of at least three hours of instruction in the care of the foot and its coverings" and in other simple orthopedic affections.4 This instruction was given at first by simple talks and later by the use of moving pictures. Of the latter, three reels were prepared at the Army Medical Museum to illustrate the chapters on the foot in the War Manual of Military Orthopedic Surgery.
For all enlisted men it was prescribed that "at least one hour's practical instruction in the care of the foot and its coverings (and the treatment of minor injuries) be given once a month by the surgeon of the organization, under the supervision of the orthopedic department." 4 A course of instruction was also prescribed for selected enlisted men of the Medical Department to "be given at all training camps and other stations to fit them for rendering proper assistance in shoe fitting. the care of the feet. (and the treatment of minor orthopedic afffections).'' As an aid in this work, a short pamphlet on Minor Foot Ailments was issued and two editions distributed.
PERSONNEL FOR EXAMINATION AND CARE OF THE SOLDIER'S FOOT
Recognizing that the examination and care of the foot was most important during the training period, the effort was made to assign for camp duty only medical officers who were known to have had orthopedic experience. The number with orthopedic training naturally soon proved inadequate and the positions then had to be filled with those trained in the special courses. In order to coordinate and systematize the work in the various camps, a corps of consulting orthopedic surgeons was next formed to fill the double function of consultation and inspection. To facilitate the work of these officers, the country
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was divided into zones, so that the camps in a given zone were, as far as possible, within reasonable traveling distance of each other, and a consultant was assigned to each zone. These consulatants usually spent a week or 10 days in each camp. They reported to the Surgeon General by letter in the regular routine and personally as frequently as the distance of the zone from Washington justified.
The enlisted personnel also formed an important part of the Army foot service. A particularly useful group comprised the selected enlisted men of the Medical Department, to whom reference was made above, who were given special instruction in shoe fitting, the care of the foot and the treatment of minor orthopedic affections. A sufficient number of these were trained to permit assignments to be made to the various organizations as they were sent overseas. Assistance was also rendered by another class of enlisted men who were already trained in the treatment of minor foot ailments-the chiropodists. Those secured by transfer early in the war soon demonstrated their usefulness to such an extent that the desirability of having all qualified chiropodists who might be accepted in the draft made available for this work became evident. The necessary authority was secured and, through the cooperation of the officers of the National Association of Podiatrists in notifying the Surgeon General whenever a qualified chiropodist was ordered to camp, it was thus possible to obtain his immediate assignment to the Sanitary Corps for work under the orthopedic division. A second group which rendered a most important service consisted of the cobblers. They, too, required some training by the orthopedic surgeons in the method of making shoe alterations. In order to secure a sufficient number to care for the early work with the recruits and the later needs of the organization, the most practical plan proved to be to secure the temporary assignment of cobblers, where found, to the orthopedic department. When returned to their organizations, they were competent to care for this important detail of foot work.6
ESTIMATION OF POTENTIAL FOOT EFFICIENCY
The estimation of the potential efficiency of certain types of foot for military service was unquestionally most difficulty not only for the medical members of the local draft boards and the camp surgeons of the earlier days of the World War but often even for the trained orthopedic specialist as well. Such an estimation calls for an adleqjuate appreciation of the difference between foot form and foot function, an understanding of the demands made upon the individual's foot by both his occupation and his avocation, and the ability to evaluate the symptoms and signls of foot strain in its incipiency. When to this is added the confusion resulting from the frequent attitude of the individual toward the service, the attempt on the one hand to minimize or conceal past or existing trouble through his desire for acceptance and, on the other hand, to simulate the comparatively well-known symptoms of foot strain in order to escape the draft, it is not surprising that an occasional athlete was rejected because of a low arch, while many individuals with normally high arches but with potentiality weak feet were accepted, nor even that many foot defectives were sent overseas.
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FOOT EXAMINATION
The recognition and correction of remediable foot defects, the segregation of recruits requiring a more gradual system of training, and the elimination of any with actual disability who may have been inadvertently passed by the draft boards are among the first important details to which attention must be given at the time of the induction of the recruit into the service. This was most readily accomplished in the casual detachment or depot brigade, where the recruit was first quartered on entering the service. In case he was transferred to a large camp or cantonment, it could be carried out satisfactorily in quarantine barracks, if he was first sent there, but if sent directly to his organization, arrangement had to be made for the examination through the regimental commander and care taken to interfere as little as possible with the work of the organization. One obstacle to success in handling the work in the casual detachment or depot brigade was that there might be no issue of equipment until the recruit reached his permanent assignment and hence shoe alterations could not be made. The attempt to obviate this difficulty by attaching to the man's service slip a separate record of the examination with recommendations as to alterations was not entirely successful, owing to these separate records being lost or thrown away through failure to recognize their importance. 6
In the beginning, as was to be expected, many difficulties were encountered. The number of foot defectives was relatively larger among the early recruits, due in part, at least, to the inevitable lack of experience of the medical members of the local draft boards with orthopedic principles and to the patriotic desire to ensure that no shirkers escaped. When these early recruits reached camp, the medical service was as yet too imperfectly manned and too insufficiently organized to carry out routine examination and treatment in the most efficient manner, and even their importance was not always fully recognized by all officers. The supply of shoes was frequently insufficient to enable the men to be fitted promptly and properly. Finally, an efficient method for handling those presenting the more severe types of disability and those suspected of malingering had not yet been instituted. With increasing experience these difficulties tended gradually to grow less or disappear entirely, and a system was perfected which proved most satisfactory.
ROUTINE METHOD OF RAPID EXAMINATION
With large numbers of recruits a method of examination is required which is both rapid and accurate. Various methods were tried in the different camps, of which the following may serve as an example:7
The men are examined standing on a table. The table should be high enough to come to the shoulder level of the seated surgeon. The man walks across the room and mounts the table, standing in front of the examiner. The way he walks across the room and the way he mounts the table are an excellent index of the functional ability of his feet. By inspection the surgeon notes visible defects, then putting a hand on each foot the position of the scaphoid is noted with the thumbs. The toes are pushed up next and any rigidity noted. Then the man is instructed to give his left foot to the examiner, holding the knee straight. The examiner's left explores the heel for any abnormality; the right hand grasps the forefoot and tests the functions of the sub-astragaloid and midtarsal joints. Lastly, the forefoot is pushed up and the condition of the ankle joint and the tendo Achillis is noted. In this
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position the sole of the foot is inspected for callosities. The right foot is examined in the same way, except that the examiner reverses his hands.
With the use of this system, it was found possible for two orthopedic surgeons and four clerks to examine and record the results of 100 foot examinations per hour.
ANALYSIS OF FOOT DEFECTS FOUND IN RECRUITS
For practical consideration the foot defects may be divided broadly into four groups: (1) Defects correctible by simple shoe alterations; (2) those usually producing disability for full military duty; (3) those correctible by operative means; (4) defective muscular strength or development.
The Surgeon General stressed the importance of taking especial care in the examination of recruits to detect those slighter deviations from the normal in foot form and posture which are potential sources of disability. Pronation, flattening of the longitudinal arch,
limitation of dorsal flexion, flattening of the transverse arch, and cavus, existing in a degree insufficient to produce disability under the ordinary demands of civil life, are naturally aggravated and may become exciting causes of foot strain under the arduous demands of training and the increased weight imposed by the pack. Of all the orthopedic foot work carried on during the training period, the prophylactic correction of these defects was undoubtedly productive of the greatest good.
Pronation, alone or associated with abduction of the forefoot, and flattening of the longitudinal arch, when there is no loss of flexibility and no structural change, are simple postural deviations which were most commonly found in those whose occupation had been either sedentary or one requiring prolonged standing. The free use of the toes permitted by the Army shoe, with the active thrust from the forefoot soon acquired in training, tended naturally to the permanent correction of these defects
FIG. 39.- The tomahawk wedge in place
fects, providing the fatigue incident to the early days of training did not aggravate them to a degree where they became pathological. Assignment to special squads for more gradual training and the use of corrective exercises were of definite advantage in the more pronounced cases. In most, however, the simple wedging of the heel on the inner margin, or of both heel and sole (figs. 38 and 39), to a degree
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proportionate to the amount of the deviation, fully met theindications. Limitation of dorsalflexion, or "short heel cords," of moderate degree, required merely aslightly higher heel.
In simple flattening of the tranverse arch and other defects of the forefoot, the anterior heel (fig. 40) was found to meet all needs most admirably. As used in the British Army, the anterior heel consisted of a simple cleet of leather fastened to the outside of the sole
FIG. 40.- Anterior heel in position
just back of the ball. In our camp experience, however, it was found more satisfactory to place the piece of leather forming the heel between the layers of the sole, as in this position it could be used even with a thick sole anti also did not wear down as quickly.
Cavus, or contracted foot, is a type of foot form of much more frequent occurrence than is generally realized. It was found to be "exceedingly common among our southern troops, especially fromn the Delta States."8 The greater strain thrown upon the metatarsal heads by the reduction in the weight-bearing surface of the sole through the high arch is greatly increased in military life by the active function required of the forefoot and by the burden of the pack. Under these conditions even mild degrees became potential sources of serious disability. In order to fit the "cavus foot" the shoe must have a high shank, and as cavus is more frequent in the slender type of foot a narrow width is necessary. The Army shoe, ideally as it is adapted to the great majority of feet, does not meet the requirements of the foot with cavus. In the milder degrees, however, it was possible to alter it so as to overcome the difficulty very satisfactorily by a slight modification of the anterior heel just described, the leather insert being simply made longer so as to extend farther back toward the heel (fig. 41).
For the more severe cases additional pieces of leather were inserted or a similar elevation was attached to an insole and fastened inside the shoe. With a little training the company cobblers soon became very proficient in making these alterations and were able to finish the individual ones in a few minutes.
When the foot was so changed that the shoe alterations mentioned were insufficient to correct the defects, it was found possible in only a relatively few cases among white troops to make the individual fit for active overseas service. The conditions which proved thus disabling were "flaccid flat feet with marked
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abduction and eversion, rigid or spastic flat feet, rigid arthritic or post-traumatic feet, marked cavus, pes varus or valgus following fracture, extreme hallux valgus, with painful bunion or metatarsalgia, hallux rigidus, amputation, partial amputation or severe derangement of the joints of the great toe, and proved exostosis of the undersurface of the os calcis."7 In negro troops these conditions differed somewhat. The foot of the negro possesses greater flaccidity, which is compensated for by greater muscular development, and many negroes who had no subjective symptoms were found with flat feet associated with abduction and eversion. 7 In the earlier months of the war it was a difficult matter to handle properly these cases with disabling conditions, but with the establishment of the foot camp, and later of the developmental battalion," a way was provided for testing them out and arranging their assignment to noncombat duty.
The operative results of most abnormalities of the foot, such as hallux valgus contracted foot, hammertoe, had been long known to be generally certain and satisfactory, not only in civil life but also in the Army during peace time. Hence, after we entered the war it was felt that conservation of man power would be promoted by operating on all such conditions found among the recruits. It was soon recognized, however, that equally good results could not be secured under war conditions. The probable difference in the mental attitude of the drafted recruit, the arduous work which the operated foot was soon called upon to perform, and the comparatively short period which could be devoted to convalescence were apparently the main factors in causing this difference. This policy, ideal as was its conception, proved economically a failure, and hence a circular letter was issued by the Surgeon General, November 12, 1918, advising against such elective operations.
Recruits with insufficient muscular strength apparently constituted, everything considered, the most troublesome group. They were of two kinds--those in whom the strength was below the requirement owing to excessive weight; those with insufficient muscular development. The first class readily responded in most instances to the rigors of training and required merely the corrective shoe alterations and a more gradual method of training. A large proportion of men with insufficient muscular strength also responded to the same measures. There still remained a considerable number, however, whose muscles could not be brought up to the strength required for active duty, even when detailed to special squads for preparatory training. This is not surprising when it is considered that not only had large numbers of them been engaged in sedentary pursuits, with little or no opportunity for outdoor activities, but also that in many a constitutional or even a congenital cause for the defective development existed. Hence, its correction in the comparatively short period that was available, however scientifically training might be carried on, could not be expected. The recognition of these muscularly unfit was naturally difficult for medical officers who had had no experience with the demands made by an active military campaign. So, in the efforts at conservation, some of these border-line cases were allowed to go overseas. Another class of this group, in which the muscular strength proved insufficient, but for an entirely different reason, comprised recruits assigned to fill vacancies in regiments partly or completely trained. Under these conditions it sometimes happened that feet which would
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have proved entirely adequate under the ordinary method of training broke down because the muscular strength was not sufficient to meet the great demand suddenly made upon them.
SUMMARY OF THE ESTIMATION OF FOOT EFFICIENCY
In view of the importance of the estimation of foot efficiency for military service, a summary of the chief points brought out in our camp experience seems desirable. Since the abnormalities of the foot which have been found disabling are clearly defined in Army Regulations, only those deviations from the normal which may or may not cause disability need be considered.
Experience shows that this estimation must be based on a study of the form and the function of the foot and the development of the muscles by which it is activated, careful consideration being given also to the relation between the work previously required of it and that demanded by active military duty.
In considering foot form, the height of the arches alone has little significance. Considerable difference exists within normal limits, due to race, the character of the work done, and the type of foot coverings worn. Between the high arch of the decendants of the Spaniard and the low arch of the negro there is marked variation, and yet the two may be equally efficient. The arches of one who has done heavy work and those of the athlete, particularly when the work or play was begun early in life, are relatively low and the forefoot spread, and yet both have been trained to withstand great strain. Similarly. the foot which has never worn a shoe, as occurs among our mountain people, presents a lower, broader aspect, although its strength is beyond question. Pronation with abduction of the forefoot and eversion (toeing out) may be present in moderate degree as purely postural defects, and, provided the foot is flexible and the muscular development good, they are of importance only as far as prophylaxisis concerned. Only when these deviations of slighter degree are complicated by impairment of flexibility or poor muscular development, or when they are present in more than moderate degree, are they likely to prove disabling.
It is the function of the foot, however, on which the final determination in doubtful cases depends. Foot form is necessarily always of secondary importance to foot function. Hence, in the last analysis the essential requirements of the soldier's foot are normal flexibility and good muscular development, since without these normal function is impossible. Loss of flexibility even in a single joint or in a single direction must always be regarded with suspicion and its cause determined. Moderate limitation of dorsal flexion alone, however, is often the result of simple adaptive shortening of the calf muscles from the constant wearing of high-heel boots and responds readily to prophylactic heel alteration. Limitation of motion from old fractures or arthritis, even when present in only slight degree, is usually disabling, while loss of flexibility in more than slight degree from any cause is practically always so. The accurate evaluation of the potential muscular strength in doubtful cases is perhaps the most difficult factor of all in the estimation of foot efficiency. When poor muscular development exists in feet presenting deviations from the normal of sufficient degree to act as potential causes of disability, the decision is relatively simple. But
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when the poor muscular development exists alone, it is by no means so easy. In the latter instance all the factors bearing on the condition must be considered-its cause and duration, that is, whether congenital or acquired, and, if the latter, whether due to constitutional defects, disease or simple lack of exercise, the attitude of the recruit toward service, and whether provision can be made for graduated training, are all of importance.
THE FOOT CAMP AND THE TRAINING BATTALION
In our early camp experience it was a difficult matter to handle satisfactorily the doubtful cases of defective feet and those which had broken down in training, and to determine definitely the ones able to meet the demands made upon the soldier. This difficulty was solved by the formation of a special organization, called the foot camp. Apparently this plan was developed about the same time in several camps. The men were assigned to this camp on special detail. Lists for admission and discharge were made out twice a week. When the development battalion was formed, the foot camp naturally became part of it.
Men were examined in groups within 24 hours after admission to the camp, the shoe measurements being verified, shoe alterations made, and the drill class suitable in each case designated. A division into three classes proved most convenient-no drill, drill, and heavy drill. Foot exercises, performed barefoot, were given all the men at setting-up drill, those in no-drill class receiving two half-hour periods daily and the others one. The no-drill class was given foot exercises and light detail, the drill class infantry drill, graduated to its ability, and the heavy drill class went on marches in addition to performing its other work.
Three types of cases were encountered in the foot camp-the real defectives, the timid, and the malingerers. Men with actual remediable defects responded satisfactorily to the system carried out. The timid likewise usually responded to the effect produced by the careful examination, the assurance that there, was no serious trouble, and the confidence acquired through the graduated work. The malingerers could soon be recognized in the foot camp and were then assigned to the hard and disagreeable tasks. Privileges were granted only to men doing heavy drill, it being explained to the others that since their foot condition was such that they could not do full duty, it was inadvisable for any extra strain to he put on the feet. This method proved a great incentive to work.
By this system it was possible to test the men out thoroughly and to return the physically fit for duty to their organizations, the others being disposed of otherwise, as the conditions warranted. Out of 822 men handled in the foot camp in four and a half months, 614 were returned to their organizations, 447of these going back to full duty, while 167 were recommended for domestic duty or discharge. 7
THE ARMY SHOE
The standard shoe issued by the Army during the World War proved to be all that could be expected of any shoe. It was found that practically 98per cent of feet could be satisfactorily fitted with this shoe.10 Shoes on similar lines but with a more marked "inflare " were also used at times, but
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proved less suitable; for, while the feet of the younger soldiers would adjust themselves to these more pronouncedly curved shoes, those of the older ones could not, with the consequent development of corns on the toes where they pressed against the outer border of the shoe.6
Our camp experience as a whole merely verified the recommendations already made 1 in regard to the fitting and care of the shoe. The difficulties encountered in shoe fitting were not due, therefore, to the shoe itself but to an insufficient supply, irregularity in the time of issue, lack of men properly trained in shoe fitting, and the attitude of the soldier himself. These difficulties, too, had previously been recognized and fully covered in the report of the Army Shoe Board. An insufficient supply of shoes is to be expected in the early part of any war, particularly when large numbers of men are being called for service. When the supply of shoes is adequate, however, an early and a uniform time of issue is of distinct advantage. It was found that when the shoes were issued within the first three days after the men were inducted into the service, the shoe alterations could be made before the period of quarantine was past. With the definite directions for shoe fitting given in Army Regulations, any reasonably intelligent soldier can soon be taught the necessary skill, and the chief consideration is rather whether he possesses the essential qualities of responsibility, patience, and the ability to handle men. It was possible soon to train sufficient men for all needs. The greatest obstacle to successful fitting was after all the attitude of the recruit himself. Many with poorly developed feet, and without experience in the demands made by outdoor pursuits, had no appreciation of the difference in shoe requirements and so, through ignorance, and also frequently through pride, used every expedient to avoid wearing shoes of the correct size. As the recruit developed into the soldier, this obstacle largely disappeared.
Thelittle that our experience added to our knowledge of the Army shoe waslimitedlargely to the method of making the alterations for the correction ofpostural and other defects. 8 To facilitate the work of making these alterations in the camps, the necessary pieces for insertion were furnished as a part of the cobbler's outfit and supplies.
Theeffect of the Army shoe on the appearance and development of the footand in thecorrection of many of its defects, particularly those of the fore-foot,was most striking. Of theminor foot ailments, corns gradually disappeared, bunions ceased to bepaintul, crooked toestended to straighten, and ingrown nails gave no further trouble. 11 Anterior arch troubles, which are promoted by the distortion and constriction of the forefoot caused by improperly shaped and incorrectly fitted shoes, usually responded to the free use of the forefoot permitted by the Army last, aided, if necessary, by the anterior heel. 10 Similarly, the normal use of the foot as a whole resulted in a marked development of its tissue and gave it "an appearance of health commensurate with the work it had to do." 11
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REFERENCES
(1) Munson, E. L.: The Soldier's Foot and the Military Shoe. George Banta Publishing Company, Menasha, Wisconsin, 1917.
(2) G. O. No. 133, W. D., October 11, 1917.
(3) Medical War Manual No. 4, Military Orthopedic Surgery Prepared by the Orthopedic Council. Lea and Febiger, Philadelphia and New York, 2d edition, 1918.
(4) Circular No. 23, W. D., S. G. O., August 13, 1917.
(5) Geist, E. S.: The School of Clinical Military Orthopedic Surgery, Camp Greenleaf. American Journal of Orthopedic Surgery, 1918, xvi, No. 8, 488.
(6) Rugh, J. T.: Foot Prophylaxis. American Journal of Orthopedic Surgery, 1918, xvi, No. 8, 529.
(7) Mebane, T. S. The Foot Problem. The Military Surgeon, 1918, xliii, No. 4, 377.
(8) Rich, E. A.: Static Defects of the Feet. Journal of the American Medical Association, December 14, 1918, lxxi, 1980.
(9) G. O., No. 45, W. D., May 9, 1918.
(10) Rugh, J. T.: The Army Shoe. Journal of the American Medical Association, Chicago, October 12, 1918, lxxi, 1215.
(11) Rugh, J. T.: The Foot of the American Soldier. Pennsylvania Medical Journal, January, 1919, xxii, 198.
