attacks may pass off, leaving additional thickening of the surrounding structures, or they may go on to suppuration, which may be followed by extensive cellulitis of the foot, perforation of the metatarso-phalangeal joint of the great toe, septic arthritis. necrosis, etc. Moreover, as time goes on, these joints frequently undergo the changes characteristic of osteo-arthritis.

In hallux valgus the great toe may be deflected so as to lie under or over the second; in the latter case (which is the usual one) the toe is also rotated so that its upper surface looks somewhat inwards, and its

FIG. 79.-DIAGRAM ILLUSTRATING THE PRINCIPLES TO BE OBSERVED IN MAKING BOOTS. C shows the deflection of the great toe and the cramped position of the others entailed by wearing the ordinary pointed-toed boots; it will be seen that the point of the boot is opposite to the middle line of the sole. B shows the outline of the sole of a boot constructed on sound anatomical principles. The inner border of the front part of the sole is nearly parallel to the long axis of the foot, the boot comes to a point opposite the great toe, and is sloped away from that point to the outer border in accordance with the length of the other toes, which are thus not cramped at all. A, a very usual form of so-called anatomical boot which, while it is free from the most flagrant faults of the usual pointed-toed variety, is not so good as B. The inner border of the sole is not quite straight, and so tends to deflect the great toe somewhat, while the squareness of the end of the boot both leaves a lot of unnecessary space between it and the toes and detracts considerably from the appearance of the foot. (After Meyer.)

inner border is directed towards the sole. Thus there is adduction of the toe combined with rotation, and it is important to bear this compound. deformity in mind when attempting to remedy the condition.

The affection is essentially produced by ill-fitting boots, those in which the toe of the boot comes to a sharp point opposite the middle line of the foot being the chief offenders. A boot pointed in this way. crowds the toes together, and if it must be brought to a point, the latter should be towards the inner side of the foot so as not to deflect the great toe from its normal line (see Fig. 80).

Bunion is especially marked in those who suffer from gout or rheumatoid arthritis; it is probable that one of these conditions is necessary for the full development of the trouble.

Cases of hallux valgus may come under observation: (1) at an early

stage, when the divergence of the toe and the enlargement of the end of the bone are comparatively slight; (2) when the condition is well developed, with considerable en

largement of the bone and the formation of a bursa over it; and (3) when the bursa has suppurated and a sinus is left.

TREATMENT. — In the early stage much may be done to render the patient comfortable and to prevent further development of the deformity by the use of properly constructed boots combined with some mechanical arrangement designed to counteract the adduction of the great toe. The boots must be long enough, not too narrow, and the inner border of the sole, as far as the extremity of the great toe, must be almost straight. The most suitable boots, on the whole, are those in which the inner border is straight and passes well beyond the tip of the great toe, and of which the outer border is rounded to correspond to the curve of the other toes (see Fig. 79). They cannot be said to be comely, but nevertheless they must be worn in these cases.

A

B

FIG. 80.-DIAGRAM SHOWING THE RELATIONSHIP OF THE IMPRESSION OF THE FOOT TO THE LINES WHICH

BOUND ITS OUTLINE.-A is a normal foot. B, a mild degree of hallux valgus. The outline in A with the corners rounded off, represents the proper outline for a boot. B similarly treated illustrates the faulty shape of boots made

with the point in the centre. (Modified from Whitman.)

In addition, means must be employed to press the toe into position and to overcome the adduction. In quite early cases a pad of lint may be worn between the first and second toes, but it is apt to press injuriously on the other toes, and does not always attain the desired. end. A better plan is to have the socks made with a separate compartment for the great toe (the so-called 'digitated socks'), to see that a suitable boot is worn, and to have the toe frequently manipulated so as to bring it into a straight line with the inner border of the foot. In most cases, however, it is advisable, for a time at least, to employ some form of apparatus to keep the toe in its proper position; a common one is what is known as a 'toe-post,' made by fastening a vertical piece of stout leather to the sole of the boot in the interval between the great and the second toes (Fig. 81). The great toe is first brought straight by introducing a small roll of flannel between it and the second toe. The boot is then put on and the great toe slips into its proper position, the

narrow flannel roll between the two toes being removed by pulling upon a string fastened to one end; the flannel uncoils and is withdrawn. A digitated sock must be worn if a toe-post is used. The plan answers well for the slighter cases, but when the deflection is great and the trouble is of long standing, considerable friction is caused by the pressure of the great toe against the post, and pain and sometimes ulceration results, so that the patient is unable to continue it. Under these circumstances a

FIG. 81.-DIAGRAM TO ILLUSTRATE THE EMPLOYMENT OF A 'TOE-POST.' The toe-post' is seen in the cleft between the great toe and the second. It is made of stout leather or wood, and is fixed to the sole of the boot, which should be of the shape shown in the figure. The great toe is thus confined in a compartment from which it cannot escape, and no lateral deflection is permitted.

FIG. 82.-A METHOD OF IMPROVISING A TOE-POST. A piece of paper is cut to the shape shown in A corresponding to the outline of the anterior part of the foot. This is divided into two along the line ab. These pieces are laid on a second piece of paper so that the distance between them is equal to twice the depth of the foot, measured between the great and second toe. The two lines cd and ef are now drawn, and a paper pattern made as shown in B. This is cut out in block tin which is folded along lines corresponding to the dotted lines in B, so as to produce the appearance shown in C. This is put into the boot and forms a toe-post.

special form of splint must be employed. A great variety of these have been introduced; a fairly satisfactory one is here figured (see Fig. 83); it is applicable to cases of medium severity in which there is no marked. rigidity. It consists of a metal spring running along the inner border of the foot and curving outwards beneath the ball of the great toe. The spring runs nearly to the tip of the great toe, and to its extremity is attached a band which passes around the point of the toe, the other extremity of the apparatus being fastened to the ankle by an elastic band. Opposite the arch of the instep the spring articulates, by means of a movable joint, with a small vertical plate, which takes purchase from

the instep and acts as a fulcrum. An elastic band runs from the posterior end of the splint over the outer side of the foot, around the ankle, and down over the inner side, where it is fastened to a hook on the vertical piece or fulcrum. The effect of this is to draw the posterior end of the splint outwards towards the heel, whereby the front portion, and with it the great toe, is carried inwards, and the faulty position rectified. The apparatus will go inside a boot of fair size, and most patients can wear it and walk without marked inconvenience. Any apparatus for the correction of this deformity must

be worn by night as well as by day, for if it be discarded at night, the toe tends to assume the faulty position again, and the cure is retarded. Should there be any tenderness of the joint or inflammation of the bursa over it in these milder cases, the application of lead or lead and opium lotion, with the foot in the elevated position, usually reduces it rapidly.

A

a

a

B

When the deformity is more severe, and the patient suffers considerable pain, it is best to adopt operative measures at once, for apparatus is not likely to do much good and only acts as an additional impediment to locomotion; the permanent enlargement of the bone, which is the chief cause of the trouble. cannot be diminished by anything short of operation. In addition to this also, the bursa over the joint will probably have undergone a series of attacks of inflammation and its walls will be permanently thickened, so that palliative measures are not likely to give more than temporary relief.

FIG. 83.-BUNION SPRING. The spring is applied to the foot as shown in A and the great toe secured to it. The fulcrum of the lever a rests immediately behind the enlarged head of the metatarsal. The band at the posterior end of the spring is then carried outwards across the sole at right angles, across the front of the instep, round behind the ankle and downwards again across the front of the instep to the inner border of the foot, where it is attached to the fulcrum a; this is shown in B. Sufficient traction must be exerted on the band to pull the toe into position; if this cause pain, as much traction must be employed as can be borne with comfort, and this can be gradually increased. The boots in which these springs are worn should have specially stout soles so as to avoid all risk of breakage. (Krohne and Sesemann.)

Of the operative procedures employed for the cure of hallux valgus we prefer the following. After thorough disinfection of the part, an incision is made along the inner border of the dorsum of the toe, from just beyond the articular surface of the head of the metatarsal bone backwards to half an inch behind the point at which the enlargement of the bone ceases. The incision should be convex upwards, but its extremities should not be carried too far down towards the plantar surface for fear of subsequent pain in the scar (see Fig. 84). A flap is turned down so

as to expose the whole of the enlarged end of the metatarsal, and the bursa is dissected out; the periosteum should not be taken up with the flap. The thickened portion of the bone is removed by means of a chisel and hammer, the line of the incision being from behind forwards, and parallel to the long axis of the shaft of the metatarsal. The whole of the enlarged inner surface of the head of the metatarsal is removed, and with it generally a small portion of the articular surface. The margins of the cut bone surface are rounded off with a chisel or a gouge so as to leave them absolutely smooth and without any sharp edge; failure to adopt this precaution may lead to considerable pain afterwards,

and possibly also recurrence of the trouble. The internal lateral ligament is necessarily detached from its insertion into the metatarsal bone. After removal of the bone, it is well to introduce a tenotomy knife into the joint and to divide the external lateral ligament and any other resistant structure, so as to remedy the adduction properly. In very bad cases it may be necessary to divide the long extensor tendon, but in the majority of cases this is not called for.

After the ligaments have been divided, the toe is brought forcibly inwards, and the deformity somewhat over-corrected-that is to say, the great toe is brought into a position of slight abduction.1 The rotation of the toe upon the metatarsal bone, to which reference has already been made (see p. 280), should also be carefully corrected; it is generally necessary to divide the outer part of the dorsal ligament in order to do this. When

the toe has been brought into the desired position, an attempt should be made to shorten the internal lateral ligament so that it may form an obstacle to recurrence of the deformity. It is not easy to do this accurately; the best plan is to pass catgut sutures through the remains of the ligament, and fasten it to the periosteum behind the cut surface of the bone. The wound should be stitched up without a drainage-tube.

A straight splint should be applied along the inner border of the foot from the heel to beyond the toes; it should be padded especially thickly immediately behind the area of operation. When the posterior part of the splint has been fastened to the heel and the instep, a considerable lateral deflection of the toe can be obtained by drawing it towards the extremity of the splint by a separate bandage. The deformity will then be over1 The terms' adduction' and 'abduction' are used in relation to the middle line of the foot and not of the body.