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 SPIRAL DRAWINGLearn to create spiral art and geometric drawings
using pencil, pen, and more

BY Jonathan stephen harris

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 table of contents
© 2020 Quarto Publishing Group USA Inc.
Artwork and text © 2020 Jonathan Stephen Harris

First published in 2020 by Walter Foster Publishing, an imprint of The Quarto Group.
26391 Crown Valley Parkway, Suite 220, Mission Viejo, CA 92691, USA.
T (949) 380-7510 F (949) 380-7575 www.QuartoKnows.com

All rights reserved. No part of this book may be reproduced in any form without
written permission of the copyright owners. All images in this book have been
reproduced with the knowledge and prior consent of the artists concerned, and no
responsibility is accepted by producer, publisher, or printer for any infringement of
copyright or otherwise, arising from the contents of this publication. Every effort has
been made to ensure that credits accurately comply with information supplied. We
apologize for any inaccuracies that may have occurred and will resolve inaccurate or
missing information in a subsequent reprinting of the book.

Walter Foster Publishing titles are also available at discount for retail, wholesale,
promotional, and bulk purchase. For details, contact the Special Sales Manager by
email at [email protected] or by mail at The Quarto Group, Attn: Special Sales
Manager, 100 Cummings Center, Suite 265D, Beverly, MA 01915, USA.

ISBN: 978-1-63322-822-1

Digital edition published in 2020

eISBN: 978-1-63322-823-8

Printed in Singapore
10 9 8 7 6 5 4 3 2 1

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 Introduction....................................................................................4
Perspective Basics.........................................................................6
Tools & Techniques.......................................................................8
Adding Color................................................................................ 10
Triangle...........................................................................................12
Square.............................................................................................16
Square Pattern............................................................................ 20
Hexagon........................................................................................24
Cube.............................................................................................. 28
Heart.............................................................................................. 34
Cross.............................................................................................. 36
Perspective Pattern.................................................................... 40
Overlapping Spiral Pattern..................................................... 44
Worms........................................................................................... 48
Curved Pattern............................................................................52
Cross Perspective Pattern........................................................ 58
Symmetrical Pattern................................................................. 64
Sailboat........................................................................................ 68
Tree.................................................................................................72
Cupcake........................................................................................76
Diamond Ring............................................................................. 82
Rose............................................................................................... 86
Eye.................................................................................................. 90
Butterfly......................................................................................... 94
Panda............................................................................................ 98
Lion............................................................................................... 102
Giraffe..........................................................................................106
Elephant........................................................................................112
Gallery........................................................................................... 118
About the Artist......................................................................... 128

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 Introduction Have you ever seen a magic trick and asked yourself, “How did they do
that?” How about an optical illusion? Optical illusions have long held
my interest; in fact, it was while trying to create new optical illusions
that I developed my spiral drawings. The decorative elements in these
drawings create the illusion that they were drawn with curved lines,
when in reality, they consist of straight lines.

Spiral drawings may look intimidating, but with just a little guidance,
they can easily be achieved! Geared toward the beginning artist, The Art
of Spiral Drawing explains how to draw these basic optical illusions. It
also includes a few more advanced tutorials for those ready to take their
spiral art to the next level. Spiral drawings are impressive to look at, and
once you get the hang of the drawing method, there’s no limit to what
you as an artist can come up with!

Line Illusions
Optical illusions are the tricksters of the art world; they cause confusion and disagreement
between our brains and our eyes.
Someone viewing an optical illusion may think they’re seeing one thing, but upon carefully
studying the image, the viewer will realize it’s something different. I always say that spiral
drawings are created using line illusions, but that’s not a specific type of illusion. The optical
illusion that most closely resembles the one used in spiral drawings is actually the Wundt
illusion, which is named after German psychologist Wilhelm Wundt (1832-1920).
In Wundt illusions, straight lines appear to be curved. The exact reason why the brain causes
the eyes to see the lines as curved is not entirely understood, but it may have to do with the
impression of depth created by linear perspective, a form of perspective in which parallel
lines appear to converge, creating the illusion of depth. Our eyes want the lines to be curved
because that’s what makes the most sense to our brains in that moment.
While the actual Wundt illusion is not drawn in this book, the idea behind this illusion is
similar to the concept behind spiral drawings. I use straight lines of different lengths and
sometimes add color to make the resulting image appear to consist of curved lines. This
makes the image look much more difficult to create than it actually is. You can recreate
these images by following the steps and techniques featured in this book.

4 THE ART OF SPIRAL DRAWING

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 THE ART OF SPIRAL DRAWING 5

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 Perspective Basics

Optical illusions are a tricky thing. When viewing an optical illusion, your brain
works slower than your eyes to trick you into seeing what’s not actually there—
often through the use of perspective, color, light, and/or patterns.
In this book, we will explore an area of art that some might not consider an
optical illusion; however, I feel that it does fall into this category. I call this
technique “a spiral line drawing.” These drawings are not traditional three-
dimensional art that jumps out at you, although that does happen in some
instances. Rather, the lines merge to create movement and a finished product
that looks more complicated than it is.

6 THE ART OF SPIRAL DRAWING

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 The process involves drawing straight lines that create curvature, giving the illusion that the lines are curved and/or
that curved lines were drawn. The curved lines appear to spiral toward the center in what is sometimes referred to as
a “logarithmic spiral.” Each curved line that reaches from one corner of the original shape (for example, a triangle) to
the center of the spiral is roughly the same length as one side of the original triangle. The lines work together to create
depth, perspective, and an elegant three-dimensional form.
What makes this form so appealing is that the distances between the curves of the spiral increase in geometric
progression, similar to what can often be seen in nature. This phenomenon occurs in seashells, galaxies, bands of
tropical storms, and many other places. In my opinion, the fact that this pattern happens organically in nature is what
makes it so appealing to the viewer. Many artists enjoy creating this soothing pattern for themselves.

I hope that you will use the techniques shown in this book to
create countless drawings of your own!

THE ART OF SPIRAL DRAWING 7

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 Tools & Techniques

I use a few basic tools and drawing techniques to create my spiral drawings.
1 I always draw on 110-lb. card stock. This heavyweight paper is durable and doesn’t crease easily.
Also, it can withstand almost any medium without buckling.
2 F or subject matter that requires accuracy, I begin my drawings with an HB or a #2 pencil; then I
use permanent markers to outline.
3 I do not use a ruler, but you should feel free to do so if you find it helpful!
4 I erase with a kneaded eraser, also known as a putty rubber. Try not to use a hard eraser if you
can avoid it. Your paper can handle some erasing, but it’s very important to draw lightly. You can
always make a drawing darker, but it’s difficult to go back and erase a mark that was applied
using too much pressure.
5 T o add color to my drawings, I like to use Crayola® markers. They are affordable, they produce
well-defined colors, and you can blend them simply by applying more pressure.

8 THE ART OF SPIRAL DRAWING

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 THE ART OF SPIRAL DRAWING 9

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 Adding Color

Adding color often makes for the finishing touch in a drawing. Using color
on your spiral line drawings does more than that, however. Various coloring
techniques can actually be used to further the illusion of a spiral drawing.
1 Coloring can add depth, which enhances the visual perception and helps grab viewers’
attention.
2 F or depth and 3-D forms, use darker colors for the inside of the spiral patterns and lighter colors
for the outside edges.
3 F or an additional effect, leave the outside edges of each inside space white. Just don’t color all
the way to the edge. This will really make the image pop!
4 Y ou can use any colors you like in your spiral drawings, but try to stick to the main rules of color
theory for the best-looking final image. Use colors that complement or contrast with each
other based on their location on the color wheel. You can also choose to go monochromatic
for a more sophisticated look. Avoid using jarring colors that will only detract from your spiral
drawing.

If you’re nervous about adding color to a drawing, make a

photocopy of it and color it in. This will take away any fears of
making mistakes and give you lots of options for playing with color.

10 THE ART OF SPIRAL DRAWING

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 THE ART OF SPIRAL DRAWING 11

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 triangle
STEP ONE
Start by drawing a triangle with
three sides of equal length.

STEP TWO
From the top point of the triangle,
draw a diagonal line to the
bottom line.

12 THE ART OF SPIRAL DRAWING

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 Another Random Document on
Scribd Without Any Related Topics
axis of the foot. The diagnosis can be made from the position of the
foot. The foot is adducted and rotated inward, as in a case of
clubfoot. The sole of the foot is directed inward. The inner edge of
the foot is concave and shortened while the outer edge appears
lengthened. The external malleolus and head of the astragalus are
very prominent on the outer side of the foot. Below and behind the
inner malleolus the scaphoid projects beneath the skin.
Dislocation Outward. This occurs after forced adduction of the foot.
The symptoms are the opposite of those of the inward variety. The
foot is in the position of a flat foot, its inner edge depressed and
outer edge raised. The inner malleolus is close to the sole of the
foot, and in front of it the head of the astragalus forms a
prominence. The injury is not infrequently compound, so that the
astragalus presents into the wound.
Dislocation Backward. The cause is usually a plantar flexion of the
foot. The signs are very pronounced; the head of the astragalus can
be seen and felt lying upon the upper surface of the scaphoid and
cuneiform bones. The anterior portion of the foot is shortened while
the heel is lengthened and the tendo Achillis is very prominent.
Dislocation Forward. This follows forced dorsal flexion of the foot,
the patient falling forward after landing with his heels upon the
ground. The diagnosis can be made because of the lengthened
anterior portion of the foot and the shortened heel. An important
point in the diagnosis of subastragaloid dislocation is the absence of
any prominence due to the projection of the body of the astragalus,
in front, behind, or to either side of the malleoli, as is seen in the
case of the tibiotarsal dislocations. A second diagnostic point is the
abnormal position of the calcaneus and scaphoid with relation to the
malleoli and astragalus. The swelling is usually so great that a
diagnosis is very difficult without the use of the X-ray.
Treatment of Subastragaloid Dislocations. Reduction can
usually be effected in recent cases by manipulation and traction. In
the inward variety the existing adduction is at first increased.
Pressure is now made over the outer side of the adduction and the
inner side of the foot, and the foot is then strongly abducted. In the
outward variety, the abduction is first increased. Pressure is then
made over the outer side of the foot until reduction is effected. In
the backward variety, the plantar flexion is first increased and the
foot is then strongly flexed in the opposite direction. In the forward
type, forced dorsal flexion will effect reduction. The foot should be
placed upon a posterior molded splint for three weeks, after which
passive motions are begun. If the reduction is impossible, an
arthrotomy with excision of the astragalus may be necessary.
Total Dislocation of the Astragalus. This form of dislocation is
much more frequent than those of the ankle joint proper, or of the
articulation between the astragalus, calcaneus, and scaphoid. The
displacement of the astragalus may occur in one of six directions:
forward; outward and forward; inward and forward; inward;
backward, and by rotation.
The most frequent variety is the “outward and forward.” In this
variety the foot is rotated markedly inward and the external
malleolus is very prominent. The foot is in a clubfoot position. The
dislocated astragalus can be felt as an irregular angular bone just
below the external malleolus.
Treatment is the same as in subastragaloid dislocations.
Dislocation of the Metatarsal Bones. This may be either
complete or incomplete at Lisfranc’s joint. It occurs most often in an
upward direction. The dorsum of the foot is more convex than
normal, while the sole of the foot is flattened. One can see and feel
the displaced ends (upper) of the metatarsals on the dorsum of the
foot. The foot is shortened and the toes point inward.
Dislocations of the individual metatarsal bones are much rarer. The
middle ones are displaced upward, and the first and fifth, inward and
outward respectively.
Dislocation of the Toes. This occurs most often in the
metatarsophalangeal joint of the great toe after forcible flexion. The
dislocation may be complete or incomplete. In the former case, the
proximal end of the first phalanx and the dorsum of the foot are
prominent, and the head of the metatarsal bone projects on the sole
of the foot. The reduction of toe dislocations presents no difficulties.

SPRAINS
Definition. A sprain is a joint wrench due to a sudden twist or
traction, the ligaments being pulled upon or lacerated and the
surrounding parts being more or less damaged.
Sprains of the Ankle. On account of its flexibility and constant use
in weight-bearing, the ankle is the joint most frequently sprained.
Sprains are common in a limb with weak muscles; in a deformed
extremity in which the muscles act in unnatural lines, and in a joint
with relaxed ligaments.
A joint, once sprained, is very liable to a repetition of the damage
from slight force.
Symptoms. The symptoms manifested in a sprain are as follows:
severe pain in the joint; nausea and sometimes syncope;
impairment, or loss of motion; severe pain upon motion; early
swelling if hemorrhage is severe—in any case swelling begins in a
few hours; movement of the joint becomes difficult or impossible;
the tear in the ligament may be distinctly felt; in a day or two pain
and tenderness become intense and discoloration becomes marked.
Diagnosis. Usually the diagnosis is easy to make, but in all doubtful
cases an X-ray picture should be taken in order to be certain that a
fracture does not exist.
Treatment. The first indication is to arrest hemorrhage and to limit
inflammation. For the first few hours apply pressure and an ice-bag.
Wrap the joint in absorbent cotton, wet with iced water; apply a wet
gauze bandage, and put on an ice bag.
In a mild sprain, use lead and opium wash. In a severe sprain, place
the extremity upon a splint and apply to the joint flannel kept wet
with lead-water and laudanum, iced water, tincture of arnica or
alcohol and water. If the pain is severe, a small dose of morphine
should be given.
Judicious bandaging limits the swelling. When the acute symptoms
begin to subside, rub stimulating liniments, such as chloroform or
arnica, upon the joint once or twice a day and employ firm
compression by means of a bandage of flannel or rubber. Later in
the case use hot and cold douches, massage, passive motion and
the bandage.
Another method of treatment of sprains of the ankle is by strapping
with adhesive plaster, but it is advisable only for slight injuries. In
severe cases, in which extensive laceration of the ligaments is
suspected from the marked extravasation, it is best to immobilize the
foot in a plaster-of-Paris splint for two weeks; later baking in a hot-
air oven (see “Arterial Hyperemia”) with massage, and active and
passive motion are advisable.
In simple sprains, the fixation does not produce serious stiffness,
and without fixation the repair of the ligaments is only partial. In the
latter case, the result is weakness of the ligaments and an instability
of the foot which leads to frequent recurrence. This explains many
habitual sprains. On the other hand, under appropriate treatment, a
sprain should recover without leaving any functional disturbance.
 CHAPTER XVII

DEFORMITIES

PES PLANUS, OR FLAT FOOT

The terms weak foot and flat foot will be used to designate the mild
and the severe forms of the same condition which include all the
deviations from the normal height of the arch of the foot.
Flat Foot may be congenital or acquired, the former being a very
infrequent deformity, and the latter one of the most common
pathologic conditions.
Congenital Flat Foot is a deformity of infrequent occurrence, and
in some cases is associated with defective formation of the bones of
the foot. In this condition the whole foot is displaced outward in
relation to the leg; the sole is rolled outward, the inner malleolus is
prominent and the foot is abducted on itself, and in severe cases, it
cannot be replaced in its normal position on account of the
contracted tissues.
Treatment. The foot should be massaged and, by gentle
manipulation, forced into its proper position and held by a plaster-of-
Paris dressing, changed at the proper intervals. A tenotomy may be
required to bring the foot into its proper position.
When the child begins to walk, a well-fitting arch support should be
worn.
Acquired Flat Foot. The common form of acquired flat foot is the
static variety, which is an expression of a disproportion between the
body weight and the sustaining power of the muscles and ligaments.
Common Causes. 1. The use of improper shoes is by all means the
most frequent cause of flat foot, and frequently makes all of the
following causes more pronounced.
2. Weakness and insufficiency of the muscles, resulting from poor
general condition; advancing age; convalescence from acute illness;
from childbirth; and from injuries of the leg, especially fractures.
3. Prolonged standing, especially on hard wood and stone floors.
4. Rapid body growth.
5. Rapid increase in body weight.
6. Excessive weight bearing.
7. Shortened condition of the gastrocnemius muscle.
Other causes are rickets; inflammation of the ankle joint, as in
tuberculosis; or, as a result of a badly treated fracture of the ankle-
joint; or, as a result of paralysis of the muscles of the inner side of
the leg.
Pathology of Acquired Flat Foot. The pathologic condition is due
to change in the relations of the bones rather than to any change in
the bones themselves. The abnormal position is an exaggeration of
the normal yielding of the foot under weight bearing. The front of
the astragalus rotates inward, and with it the bones of the leg turn
at the hip-joint.
The deformity is essentially a displacement of the astragalus on the
bones of the tarsus. The scaphoid, cuneiform, and the base of the
first metatarsal move downward and inward with the head of the
astragalus; the outer border of the foot is made more concave and
the inner border becomes convex in extreme cases. In the severest
cases, the head of the astragalus, and scaphoid may be displaced
below the plane of the other bones. The ligaments are respectively
shortened and stretched in the severest cases and there is a loss of
motion in certain of the tarsal articulations, due to faulty apposition
of joint surfaces, and to constant strain.
Symptoms. The feet burn and tire easily and feel stiff and lame.
They may swell, and the size of the shoe worn must be then
increased. Later, a painful period generally begins in which walking is
avoided and a dragging pain in the arch and behind the inner
malleolus is noticed. This is increased by walking and standing and
tender points may be found under the scaphoid and on the upper
surface of the heel. The foot feels strained and irritated and is a
constant source of discomfort. The inner malleolus is generally more
prominent and the foot is displaced outward in relation to the leg.
The height of the arch is somewhat diminished; it may be much
lowered, or it may be flat on the ground.
When the foot is really flattened, it presents two types, one the
flexible flat foot, in which the arch can be restored by gentle
manipulation; the other, the rigid foot, which is held by structural
changes in the position of deformity.
An intermediate type is sometimes seen, in which the peroneal
spasm is so great that the foot is held abducted and everted as long
as the spasm lasts (spastic flat foot.)
Some symptoms of flat foot that are less generally recognized, which
are of great value in diagnosis are: corns, ingrowing nails, callosities
on the sole of the front of the foot, enlargement of the great-toe
joint, and pain (especially at night) in the calves of the legs and
backbone, which is aggravated by standing and walking.
Diagnosis. The diagnosis of flat foot, whether flexible or rigid, is
made chiefly by inspection. The difficulty comes in the milder cases,
which form the bulk of those seen, and in which the changes in form
are slight.
Symptoms. The symptoms, as described by the patient, are the
most reliable and points of tenderness under the arch or heel would
help to confirm the diagnosis. Some help may be obtained from a
wet impression of the foot, on a piece of paper, but the slighter
cases show but little changes in the imprint. In most normal feet,
the outer border of the foot touches the paper, and in flat foot, only
two areas bear the weight, one on the inner side of the front of the
foot, and one under the inner part of the heel. An X-ray picture is
often of great assistance.
The diagnosis of rheumatism is frequently made in flat foot, and is
often the source of much misdirected treatment. Rheumatism should
be diagnosed only in connection with unmistakable symptoms of
rheumatism in the upper extremities.
So-called “rheumatic” pains in the knees and hips may be secondary
to flat foot.
Prognosis. As a rule, this condition does not recover spontaneously.
Under ordinary conditions, uncomplicated cases should be at once
relieved by proper treatment, and in time should be cured.
Unfavorable factors are: great weight; disease of the ankle-joint; the
presence of bony spurs under the os calcis.
The prognosis is more favorable in young adults than in persons of
advanced age. Patients, who without relief have worn the ordinary
supports sold at the stores will, as a rule, manifest extreme
sensitiveness as to the fit of any of the supports which may be
applied.
Treatment. The foot must be restored and held in its normal
position and measures must be adopted to quiet local irritability or
inflammation, and to strengthen the muscles. The best treatment
does not consist in the permanent wearing of a flat-foot support; the
support should be regarded in the same light as one uses a crutch in
a fracture of the leg.
As a preliminary to all treatment, the use of proper shoes must be
insisted upon. A shoe should be as wide in front, as the unshod foot,
when bearing the weight of the body.
Supports. Flexible supports may be made of boiler felt; one
objection to these is their liability to stretch. They are of service in
young children, in mild cases, and in convalescent cases where it is
desirable to have the patient use a flexible instead of a stiff support
in order to bring the muscles into play.
Rigid supports are best made of tempered spring steel (18 to 20
gage), forged hot to fit a cast of the foot. They may also be made of
phosphor-bronz, celluloid or aluminum.
The shape of the plate is largely a matter of judgment. The easiest
way to determine the shape of the plate to be used in a given case
is to have the patient stand with the operator’s hand under the inner
side of the foot; the operator then places the foot in the normal
position and notes where the pressure must be applied to secure the
proper correction; when the anterior part of the foot is flattened, a
slight dome must be constructed in the front of the plate; when the
os calcis is clearly tilted over, the plate must have two flanges at the
heel to hold it in place. In general, the plate must reach forward to a
point just behind the great-toe joint, and must furnish support as far
as the front of the heel. The plate should be higher on the inner
side, and a flange formation is generally necessary to accomplish
this. An outer flange prevents the foot from slipping off the outer
side of the plate. When the foot no longer requires support, the
plate should be gradually discontinued.
The “Thomas” sole may be used in mild cases. This is made by
building up the inner part of the sole of the shoe one-eighth to one-
quarter of an inch higher than the outer side, thus securing a slight
inversion of the foot.
Exercise and massage of the deficient muscles should form a part of
the routine treatment in all cases of flexible flat foot.
To diminish local inflammation and irritability, the foot should be
soaked in hot water; hot and cold alternate douches should be
applied, and hot-air treatment and massage should be employed.
Rigid Flat Foot. Rigid flat foot cannot be successfully treated until
the position of the foot is corrected. The patient should be
anesthetized, and, by the use of a wedge as a fulcrum, the bones
should be forced into position. A pressure of about two hundred
pounds is generally necessary to effect this reduction. After this, the
foot is placed in a plaster cast, in extreme adduction and is allowed
to remain thus encased for three weeks. After this, a properly fitted
plate should be worn. The results are usually satisfactory.
Operative Treatment. Cases that have resisted all other forms of
treatment, may be cured by the removal of a wedge-shaped piece of
bone, with the base downward and inward at the point of greatest
inward convexity, that is, in the neighborhood of the head of the
astragalus. Osteotomy of the front of the os calcis and neck of the
astragalus will at times be necessary for a radical cure.
Many other operative procedures have been advised for flat foot and
they have been employed with varying successes.
Hallux Flexus or Hammertoe. The upward prominence of a toe
(usually the second or third) in a rigid position, is known as hallux
flexus or hammertoe. In this condition the toe is flexed in its second
joint so that the end bears on the ground, while the junction
between the phalanges makes a prominence upward. Helomata and
callosities may develop on the end of the toe, but the chief
discomfort is in the disturbances which arise on the prominence
which presses against the side of the foot-gear.
Treatment. A knowledge of the forces at work will show how futile
must be any effort to correct this deformity by strapping or
bandaging. There is a shortening of the plantar fibres of the lateral
ligament of the joint. The trouble does not lie in the flexor tendons,
as it seems, and operations directed to this point fail. Even with
incision of the lateral ligaments, followed by the application of a
splint, recurrences are common and amputation must be the
procedure.
The condition described as hammertoe may exist in several or in all
of the toes, the great toe being least often involved. This occurs
most often as a result of wearing improper shoes, but is sometimes
the consequence of paralysis.
Flexed or Clawed Toes. Extreme flexion of all but the great toes
causes the weight to be borne by their dorsal aspect. In this
condition the toes, and especially the small ones, develop painful
helomata on the prominent joints, and the small toe may become
the source of great discomfort.
Treatment. Radical surgical measures are here indicated. Tenotomy
or amputation is essential to a cure.
Painful Heel. Painful heel is a suggestive but unscientific term
applied to tenderness of the under side of the heel. It is associated
with one of the following conditions:
1. Spurs running out from the under side of the os calcis found by
the aid of the X-ray.
2. Inflammation of the bursae under the os calcis.
3. Flat foot.
4. Gonorrhœa.
5. Focal infection.
Treatment. Where a spur of bone causes the unpleasant
symptoms, the excrescence should be excised.
When focal infections are the primary cause of painful heel,
operative procedure to remove the source of infection is imperative
and will prove curative.
Palliative measures are: massage, douches, hot air, a metal plate
worn under the painful area, rest. The back of the foot should be cut
away to relieve pressure.
Metatarsalgia—Morton’s Disease. Metatarsalgia is characterized
by an acute pain, cramplike in character, occurring at the base of the
third or fourth toes.
The pain comes on suddenly while the foot is in action, and is
usually accompanied by a “snapping of the bones.” The pain is so
acute that it is not uncommon for the patient to seek relief by taking
off the shoe and rubbing the foot.
In persons suffering with this condition it will be regularly noticed
that the weight is thrown upon the ball of the foot, on the
metatarsophalangeal joints, either because of a weak foot, or
because of a tendency of the toes to turn up.
Treatment. 1. Proper strapping to raise the arch and bring the ends
of the toes down.
2. A pad across the ball of the foot behind the metatarsal heads,
also brings the toes down.
3. Recommend shoes, wide across the ball, with a higher or lower
heel than ordinary, as the case indicates.
Hallux Valgus. The term hallux valgus is applied to a deviation or
displacement of the great toe outward, toward the outer border of
the foot.
In normal feet, the line of the great toe when prolonged backward,
should pass through the centre of the heel. This relation in civilized
communities is seen only in the feet of infants. In adults it is
observable only in the bare-footed races.
Cause. It is frequently associated with flat foot, gout and
rheumatism, but it is primarily due to the use of inappropriate foot-
gear. It is only considered pathologic when the deviation is more
than fifteen degrees.
Pathology. The displacement outward (which reaches 30 to 40
degrees in the average case and may reach 90 degrees) of the
phalangeal part of the great-toe joint, uncovers the inner part of the
head of the metartarsal bone, and here the cartilage degenerates,
and the bone becomes condensed at its outer part. The inner lateral
ligament is lengthened and thickened and the sesamoid bones
become displaced outward and are often thickened.
Under the skin, at the inner and prominent aspect of the foot, is to
be found a bursa, which is liable to inflammation under pressure,
and is known as a bunion. The inflammation in this sac may extend
to the joint and thus disintegrate it.
Symptoms. The toe is displaced outward and a reddened and shiny
condition of the thickened skin exists over the inner prominence and
perhaps over the top of the toe joint. The great toe if seriously
displaced, must lie over or under the other toes, the former being
the more common position. In other cases the second toe may be
crowded up as a hammertoe. The joint is painful and the inner toes,
being crowded to the outer side of the foot, are the seat of corns
and callosities. Flat foot is frequently associated with this condition.
Treatment. In mild cases, the stocking should be split to allow a
separate stall for the great toe, and broad toed boots should be
worn. If flat foot exists, a support should be supplied for its aid in
restoring the position of the great toe. In severe cases, nothing
short of an operation is likely to be of value. A toe-post may be worn
for a time in mild cases.
Amputation of the head of the metatarsal bone gives uniformly good
results.
The toe is straightened and flexible; ankylosis with this operation
does not occur.
In operations for hallux valgus there are two distinct purposes acting
as determining factors in making a choice in a given case as to
which is indicated. These are: (1)the radical operation for the
correction of the deformity, and (2)the palliative operation for the
alleviation of symptoms by the removal of the hypertrophied portion
of the metatarsal head which is exposed to pressure. Among
operations in the first mentioned class, the one known as the Mayo
operation is, in all probability, the best. The entire head of the
metatarsal is amputated, and the bursa is turned in over the cut end
of bone, to diminish the amount of shortening and to prevent
ankylosis of the joint. This latter consideration, however, is an
unnecessary one, for in operations within this joint, ankylosis does
not occur when the synovial surface of the phalanx is left
undisturbed, even when the bursa is not employed as an intervening
pad.
In the other class of operations for the relief of symptoms, no
attempt is made to straighten the toe. A wedge-shaped piece of the
exostosis is removed, against which pressure has caused symptoms.
A palliative operation devised by Dr. Robert T. Morris of this city, is
one easy of accomplishment and serves every purpose where a
radical operation is interdicted. It is known as the “button-hole”
operation because of the fact that only a small incision is made
immediately above the protuberant bone through which a sharp
chisel is inserted, cutting off the offending “button” of bone.
An operation which in the hands of the authors has proven of
distinct value, and which has probably not been previously described
eliminates both the deformity and its painful symptoms. This
operation which is described below, is less severe than other radical
operations and not very much more so than the usual palliative
ones.
The incision is made on the dorsum of the great toe over the
offending joint and just to the inner side of the extensor tendon.
This tendon is held to the outer side, out of the way. The knife
penetrates the capsule of the joint and opens it above and laterally.
An effort is made to preserve the integrity of the capsule below
(floor) as only the intra capsular end of the metatarsal is removed.
These two factors are of the utmost importance. When the joint
capsule is slit open along its dorsal and two lateral aspects, sufficient
room is obtained for the insertion of the wire saw, and all of that
portion of the metatarsal lying within the joint proper is removed.
There is thus accomplished a correction of the deformity with very
little shortening of the great toe. Usually its length after this
operation is about the same as the second toe.
The next step in the operation is closure of the synovial sac or joint
capsule. A stitch on either side and two above are all that is
necessary. The floor of the sac remains intact and nothing beneath
it, in the ball of the foot, has been disturbed. Many operators invade
this area and remove the sesamoids. This is unwarranted as the
transverse level of the ball of the foot is lost, and the weight is put
directly upon the newly formed joint, depriving it of its normal
support, or of padding from below.
One other omission in this operation is that of the bursal flap over
the raw end. This is found entirely unnecessary as results prove, and
its omission hastens healing considerably. The bursa over the
metatarsophalangeal articulation in these cases is nearly always
inflamed, and consists of a mere fibrous pad. Its dissection from the
normal position is a real loss at that site, and of questionable benefit
over the cut bone, as motion in the joint is as good or better without
it.
The skin closure is made without drainage, and no wet dressing
employed for fear of the solution filling the cavity whence the bone
was removed and carrying with it infectious material. A dry sterile
dressing is all that is required, and a splint to maintain a straight
position for the toe.
Four or five days complete rest for the part are ordinarily sufficient.
Following this, walking about the room is permitted with the aid of a
stick. After ten days, when the patient can get about fairly well
without the assistance of a stick, the foot may safely be shod with
an “arctic” of sufficient size.

CLUBFOOT OR TALIPES

The most common form of clubfoot, and therefore the deformity of

that character most frequently encountered, is characterized by
inversion of the sole of the foot, elevation of the heel, and a twisting
and turning of the front part of the foot. This deformity is typical of
congenital clubfoot, which, as stated, is the most common form of
that deformity. The acquired form is usually the result of infantile
paralysis.
Congenital Clubfoot is most frequently double, and males are
more frequently affected than females; in unilateral or one-sided
clubfoot, one side is not more frequently affected than the other.
Etiology. Very little is known as to the cause of congenital clubfoot
but it is not infrequently associated with other congenital
deformities. It appears to be hereditary in a great many instances.
The greater number of cases appear without definable cause, except
perhaps from intra-uterine pressure. There are, however, a number
of these cases that are associated with malformation of the bones of
the foot and leg, such as absence of the scaphoid; defect of the
tibia; fusion of a number of the tarsal bones.
Pathology. The sharp adduction and plantar flexion, at the tarsal
joints, produce a deformed position of the foot. As a result of these,
the heel is small and elevated; the dorsum of the foot is prominent;
and the outer border usually, and, in extreme cases, the dorsum of
the foot, bears the weight of the body in walking and in standing;
the sole of the foot is bent sharply in, and twisted at the tarsal joint.
In fact, all the bones are changed in shape, and the inner muscles,
tendons and ligaments are shortened by contraction, while the ones
to the outer side are lengthened.
The distortion of certain individual bones is of importance. The
astragalus is the seat of the most important changes. It is tipped
downward at its front end, and its posterior part articulates with the
tibia, its anterior articular surface projecting under the skin; its neck
is elongated and bent inward and downward, so that its scaphoid
articulation faces inward and downward and not forward.
This is the most important change in clubfoot, because the anterior
end of the astragalus, the head of the bone, carries inward and
downward with it the scaphoid, the three cuneiforms, and the inner
three metatarsal bones. The scaphoid articulates with the inner side
rather than the front of the astragalus and, in extreme cases, forms
a joint surface with the inner malleolus. It may be somewhat
changed in shape, being flattened and drawn inward and upward.
The os calcis is generally poorly developed, and its front end is
rotated downward, and bent inward; the outer surface of the bone is
more convex and the inner surface more concave than normal, and
since the anterior facet looks inward and downward, it carries with it
the cuboid and the two external metatarsal bones. The changes in
the other bones are not important; the chief obstacles to reduction
lie in the os calcis and in the astragalus.
Soft Parts. The muscles, ligaments, tendons, and fascia at the
lower and inner side of the foot are shortened, and lengthened at
the outer and upper side. The plantar fascia being one of the chief
obstacles to reduction, the tendons are displaced, especially those
on the inner side of the foot.
Symptoms. Double clubfoot is usually accompanied by an awkward
and unsteady gait, in which each foot is in turn lifted high to clear
the foot on the ground, and the toeing in is, of course, excessive.
The weight is borne on the outer side of the foot, and all elasticity of
gait is absent.
On the outer border of the foot, where the weight is borne,
callosities and bursae develop; the calves of the legs are small, and
the knee joint may be lax.
The gait in single clubfoot is less awkward, but characterized by the
same features. The foot is rigid in the deformed position, and in
cases of marked deformity, the foot cannot be manipulated into the
normal position.
Diagnosis. Congenital clubfoot cannot be mistaken for any other
condition. The diagnosis is self-evident.
Prognosis. There is no tendency of this deformity to right itself, or
to improve. Early and proper treatment will, if continued long
enough, insure a cure in children and an improvement in adult
cases; but it must be remembered that there is a decided tendency
to relapse, even after operation, unless the foot is kept in an
overcorrected position for a number of years.
Treatment. In young infants, treatment should be begun as early
as two weeks after birth and should consist in frequent gentle
massage and manipulations. After the part can be brought into an
overcorrected position by gentle manipulation, it should be put up in
a plaster cast, for a period of three weeks and this treatment should
be continued until the position of the foot is corrected.
The manipulations consist in grasping the dorsum of the foot gently
but firmly with one hand, and holding the leg with the other. The
foot is then dorsally flexed and everted. This treatment should be
repeated at least three times a day and should not be rough enough
to cause the infant to cry.
Treatment of clubfoot in older children and adults is a much more
difficult proposition and consists in the combination of two or more
methods of procedure.
In order to correct the extreme adduction in these cases, extreme
force must sometimes be employed. This may be accomplished by
bending and bearing down on the foot, with its outer border resting
on the apex of a wooden wedge. The rotation of the foot is
corrected by grasping the foot in one hand, and the heel in the
other, and twisting with the necessary amount of force. The
inversion of the sole is also corrected by the use of this wedge as a
fulcrum.
In this way the tendo Achillis and the plantar fascia are stretched,
and the dorsal flexion is secured by laying the patient on the face
with the knee bent and the front of the thigh resting on the table.
The lower leg is then vertical, and by bearing down on the front of
the foot with the necessary amount of force, dorsal flexion of the
foot is secured, and by hooking the fingers around the os calcis, its
position is improved.
A modified Thomas wrench may be used in the correction of
clubfoot; but this must be done with great care, as the violence
practised in this method, the tearing of the ligaments and other soft
parts, is often attended with great danger; osteomyelitis,
tuberculosis, neuritis, and even death from fat embolism, and
extensive sloughing of the soft parts are not infrequently seen after
the use of this and other bone crushing instruments.
The removal of a wedge of bone from the outer side of the foot and
the removal of the neck of the astragalus are employed. Tenotomy
and the transplantation of tendons are also often practised, when
other methods of treatment fail.
Acquired Clubfoot. The cause of acquired clubfoot maybe infantile
paralysis, joint disease, traumatism, or it may be due to affections of
the brain or spinal cord.
Paralysis. Infantile paralysis affecting the muscles of the front and
outer side of the lower leg, will result in a condition similar to
congenital clubfoot. Other paralytic causes are: spastic or cerebral
paralysis, hereditary ataxia, etc.
Traumatic. A condition resembling clubfoot may result from
improperly treated fractures of the ankle-joint or tarsal bones.
Joint Disease. In tuberculosis, arthritis deformans, and other
diseases of the ankle-joint, a condition similar to clubfoot is
sometimes seen as a result of muscular contraction.
Talipes Equinus is rarely congenital. It is usually due to infantile
paralysis of the extensor muscles, or to cicatrical contraction of the
calf muscles, as a complication of hip disease. It varies from inability
to flex the ankle beyond a right angle, to walking on the heads of
the metatarsal bones. The astragalus is partially displaced forward
and forms a prominence on the dorsum of the foot; the plantar
fascia is shortened and callosities and bursae are formed under the
heads of the metatarsal bones. Primarily, the obstacle to reduction is
the tense Achilles tendon, and in advanced cases the shortened
plantar fascia and posterior ligament of the ankle-joint constitute
obstacles.
Talipes Equino-Varis (down and in foot) is the most common form
of this deformity.
It is either congenital or acquired, and in the latter case it is due to
infantile paralysis of the extensor and peroneal muscles. The heel is
drawn up, and the anterior half of the font is drawn inwards and
inverted. The inner border of the foot is shortened, and in neglected
cases the patient walks on the outer side of the cuboid, under which
a bursa is formed. Secondary contraction of the plantar fascia,
ligaments, and short plantar muscles follows. There is a great
increase in the obliquity of the neck of the astragalus in congenital
cases, so that the scaphoid and anterior half of the foot, together
with the dorsal tendons are carried inward. As a result of the
equinus, the upper surface of the astragalus projects forward, and
only its posterior portion comes in contact with the tibia and fibula.
The ligaments of the inner side of the foot are shortened and the
shape of the other tarsal bones is secondarily altered.
Talipes Equino-Valgus (down and out foot). This condition is rare
as a congenital deformity. The anterior half of the foot is deflected
outward, and the inner border comes in contact with the ground.
The scaphoid is placed outward, and the head of the astragalus
projects into the sole.
The acquired variety results from paralysis of the tibialis posticus and
flexors, with secondary contraction of the peronei muscles.
Talipes Calcaneus is rare as a congenital deformity. It is usually
the result of infantile paralysis of the muscles of the calf. The patient
walks on the heel, and the anterior half of the foot is drawn up.
Valgus or varus are associated with it; the more common form is
talipes calcaneo-valgus.
Talipes Cavus (Pes Cavus), or hollow foot, is a condition in which
the arch of the foot is greatly exaggerated. It is rarely congenital but
is frequently seen in connection with clubfoot, especially in its
paralytic forms. In its mildest form, it exists in a highly arched foot,
often hereditary. It may also be the result of too short shoes
(Chinese ladies’ foot).
Treatment. The condition is best remedied by division of the
contracted soft parts, a forcible reduction of the bones, held in place
by plaster of Paris. When the patient begins to walk, it is advisable
to have a stiff, flat, steel plate placed in the length of the shoe
between the layers of the leather sole, running from which, over the
dorsum of the foot, is a stout leather strap. At each step, downward
pressure is thus exerted on the dorsum of the foot.
 CHAPTER XVIII

THERAPEUTIC MEASURES

HYPEREMIA

Hyperemia as a therapeutic agent was described by Bier and is of

two kinds, active and passive. The former is the same as the arterial,
while the latter is the venous. Between the blood of active and
passive hyperemia there are important physical and chemical
differences, the one containing much free oxygen with but little
carbonic acid and alkali, while the other presents the exactly
opposite character.
In active hyperemia normal elements of the blood are kept in active
motion, while in the passive form they are allowed to escape, more
or less, into the tissues.
Hyperemia possesses a great many properties:
1. Power to diminish pain.
>
2. Bactericidal action.
3. Absorptive property.
4. Solvent action.
5. Nutritive power.
6. Suppression of the infection.

Hyperemia may be produced in three ways; first, by means of the

elastic bandage or band; second, by cupping glasses, and third, by
hot air. The first two produce venous or passive hyperemia, and the
third, arterial or active hyperemia.
Passive Hyperemia. This obstructive hyperemia is produced by
means of a thin, soft rubber elastic bandage, two or three inches in
width, better known as the Esmarch, or Martin bandage. When this
is applied moderately tight around a limb about six or eight turns,
one layer overlapping the other, pressure is evenly distributed over a
comparatively wide area, causing the subcutaneous veins below the
constriction to swell; the extremity becomes somewhat bluish red in
color, also larger and edematous, giving a feeling of warmth to the
touch.
The rubber bandage, properly applied, should not cause any
uncomfortable feeling and there should be absolutely no pain
present. At all times one must be able to feel the pulse below the
site of the bandage. If the bandage is applied too tight, the skin of
the limb looks grayish-blue and there appear whitish, or vermilion
colored spots, which grow larger and larger, as long as the too
tightly drawn bandage is on. Paresthesia and pain, with
disappearance of the pulse, can also be noted.
The two cardinal rules to be observed in the application of the
bandage are: (1) absolutely no pain with the application of the
bandage; (2) the pulse at all times must be felt below the bandage.
In cases which require the bandage to remain in place from sixteen
to twenty hours each day, it will be necessary to first apply a soft
flannel bandage underneath the rubber one in order to prevent
pressure necrosis.
Frequently changing the location of the bandage up and down the
extremity, and treating the skin with alcohol rubs, will also be helpful
to patients with a tender skin. The elastic bandage must always be
placed upon a healthy area, proximal to the diseased part. All
dressings should be removed while the compressing bandage is on,
in order that the part may become hyperemic.
Wounds or sinuses are covered with sterile gauze and kept in place
with a towel, fastened with a few safety pins.
In acute inflammation, septic wounds and phlegmons, the increased
inflammation is apt to frighten the beginner, but this is a desired
phase of the treatment.
As a prophylatic against infection, it cleanses the wound, produces a
local immunization and reaction before the infection has a chance to
work; the earlier the bandage is applied the more remarkable is the
effect.
For incised wounds of the foot with division of the muscles and
tendons, if the tissues are not too seriously injured, the muscles and
tendons should be united and the skin closed with interrupted
sutures sufficiently far apart to allow free excretion. No drainage is
employed and a slight compressing dressing is applied. The elastic
bandage is applied very lightly, producing only a slight venous
engorgement and the bandage should remain on from ten to
eighteen hours a day.
As soon us the symptoms of acute inflammation subside, the time of
application of the bandage is reduced. If signs of suppuration are
present, the wound should be promptly opened and the pus
evacuated. The knife takes care of the pus; hyperemic treatment
fights the infection.
In gonorrhoeal arthritis of acute or chronic nature, and in cases of
tuberculosis of the bones and joints, the passive form of hyperemia
is especially indicated.
The use of cupping glasses is limited to abscesses, furuncles and
sinuses.
Active Hyperemia, or arterial hyperemia, is produced by means of
hot-air boxes such as the Tyrnauer electric apparatus, or the gas
apparatus of Betz.
Active hyperemia increases the arterial blood to any part of the
body, thus favoring the absorption of chronic exudates, infiltrates,
adhesions, etc. Dry, hot air permits the use of a high degree of
temperature without injury or pain to the respective part.
For neuritis of the foot, ulcers, especially diabetic, perforating and
varicose, and for the stiffness following a chronic inflammation, or
after a fracture, the arterial form of hyperemia gives good results.

COLD

Cold, or the rapid abstraction of heat, is a remedial measure that is

nearly always available and is possessed of very great power for
good in selected cases.
When cold is applied for its limited and local action, it is always used
with two objects in view, namely, (1) to cause localized contraction
of the blood vessels, which through inflammation are engorged, so
that the parts are swollen and reddened; or (2) temporarily to
anesthetize or benumb the nerve terminals, for the immediate relief
of pain, in the hope that the temporary paralysis may ultimately
result in such changes as to produce a cure.
Cold, in some form, is a popular remedy for a sprain, or any injury
likely to be followed by inflammatory processes. A very useful
remedy for the sprain of an ankle, when it is a recent accident, is to
let the patient sit with the foot elevated, with a cloth wrung out in
ice water, and an ice bag applied over the affected part.
In the treatment of localized pain or inflammation, cold is used in a
number of ways, largely depending upon the will of the physician
and the means of the patient. The simplest, cheapest, and perhaps
the best method of using cold, is to place cracked ice in a rubber
bag, the latter to be thoroughly watertight, lay it over the inflamed
part, surrounding it with a towel so as to prevent the moisture,
which appears on the surface from condensation, from wetting the
clothing.

HEAT
Heat is used locally for a number of purposes in the same manner
as cold, and the choice of heat or cold in the treatment of any acute
form of inflammation depends almost entirely upon the wish of the
patient, who generally can tell at once which will give him the
greater comfort.
In sprains of the ankle, nothing compares to a hot foot-bath
prolonged for hours, the object being to decrease the pain and
swelling, thereby regaining the use of the limb.
The high degree of heat which can be borne by gradually increasing
the temperature of the water by the addition of small quantities of
scalding water, is extraordinary, and the favorable results obtained
are in direct ratio to the height of the temperature.
Between these soakings, the part should be dressed with lead and
opium wash, and rubbed with ichthyol ointment or camphor
liniment.
Hot-water bottles or bags are also used locally for the relief of
congestion and pain.

THE HIGH FREQUENCY CURRENT, OR VIOLET RAY

The Violet Ray or High Frequency Current is one which is in a

rapid state of to-and-fro vibration and is applied through vacuum
glass attachments or electrodes, which are excited to a beautiful
violet color. The discharge may appear to the eye to be a single
spark, but it is made up of a number of successive sparks, following
each other with such extreme rapidity that they are said to oscillate
(change directions) millions of times per second, a speed that the
eye cannot note. The rapid oscillations have the effect of producing
the following phenomena:
1. the high frequency current is unipolar, that is, does not require a
complete circuit.
2. glass does not insulate the high frequency current as it does
ordinary electricity.
3. the high frequency current generates enormous quantities of
ozone during its flow.
4. the current does not produce any pain.
5. the high frequency current produces a cellular massage.
The contractile effect is expended upon the individual cells making
up the tissues, instead of on individual muscles.
If a sedative effect is desired, keep the electrode in contact with the
part; if a stimulating effect is desired, hold the electrode away from
the surface; the farther away, the longer the spark.
A uniform spark of any length can be produced by administering the
current through layers of toweling, or through the clothing; the
length of the spark depends upon the thickness of the layers.
The use of the high frequency current in surgery is limited to
sprains, stiff joints, neuritic pains, and adhesions due to
inflammatory exudates. Fulguration for the destruction of growths is
obtained by employing a pointed metal electrode.

RUBEFACIENTS

Rubefacients. These are agents which revulse by causing

congestion of the skin:
1. Turpentine. A few teaspoonfuls of oil of turpentine sprinkled
over a piece of flannel wrung out of hot water, applied to the skin
and covered with oiled silk or dry flannel, constitutes the turpentine
stupe. Twenty minutes is the maximum for this application.
2. Mustard. Mustard flour (the black being the stronger), mixed
with tepid water into a paste, spread thinly on a piece of muslin or
paper, and covered with gauze or thin cambric, is an excellent
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