Cloud Computing: Concepts,

Technology, Security & Architecture

Thomas Erl & Eric Barceló Monroy
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Praise for the Second Edition

“This book is a solid and comprehensive overview of the cloud

concepts and the real mechanics of how the cloud works. It does a
nice job of not only explaining cloud function and architecture but
the business impact. It’s a great foundation for creating a cloud
roadmap.”

—Jo Peterson, VP Cloud and Security, Clarify360

“The book provides a comprehensive and well-researched guide to

cloud computing. It covers a wide range of topics, from the basics of
cloud computing to advanced architectural considerations. The book
is written in a clear and concise style and is packed with valuable
information and Case Studies. I highly recommend this book to
anyone who wants to learn more about cloud computing.”

—Jorge Blanco, Managing Director, Corporate Reinvention and

Education Director, Glumin

“With its comprehensive insights and vendor-neutral approach, this

book truly shines as a beacon of knowledge in the complex world of
cloud computing. The author’s emphasis on informed decision-
making and alignment with business objectives sets the stage for
success in adopting this transformative technology. By navigating the
dangers and challenges, the book empowers readers to make
strategic choices, safeguarding their organizations from potential
pitfalls. From fundamental concepts to practical considerations, each
chapter provides a roadmap for unlocking the full potential of cloud
computing. With its invaluable case studies, architectural insights,
and focus on service quality metrics and SLAs, this book is an
indispensable resource for anyone seeking to harness the power of
the cloud. It serves as a cornerstone in the Cloud Certified
Professional program, providing a solid foundation for further
exploration in this dynamic field. A must-have for every forward-
thinking professional.”

—Valther Galván, Chief Information Security Officer

“This is the most complete book on cloud computing concepts

available. It starts with a solid foundation and builds from there. The
case studies complement the content and illustrate the possibilities
and difficulties.”

—Emmett Dulaney, University Professor and Author

Praise for the First Edition

(Affiliations were current when the first edition was released, but
may have changed.)

“Cloud computing, more than most disciplines in IT, suffers from too
much talk and not enough practice. Thomas Erl has written a timely
book that condenses the theory and buttresses it with real-world
examples that demystify this important technology. An important
guidebook for your journey into the cloud.”

—Scott Morrison, Chief Technology Officer, Layer 7 Technologies

“An excellent, extremely well-written, lucid book that provides a

comprehensive picture of cloud computing, covering multiple
dimensions of the subject. The case studies presented in the book
provide a real-world, practical perspective on leveraging cloud
computing in an organization. The book covers a wide range of
topics, from technology aspects to the business value provided by
cloud computing. This is the best, most comprehensive book on the
subject—a must-read for any cloud computing practitioner or anyone
who wants to get an in-depth picture of cloud computing concepts
and practical implementation.”

—Suzanne D’Souza, SOA/BPM Practice Lead, KBACE Technologies

“This is a great book on the topic of cloud computing. It is
impressive how the content spans from taxonomy, technology, and
architectural concepts to important business considerations for cloud
adoption. It really does provide a holistic view to this technology
paradigm.”

—Kapil Bakshi, Architecture and Strategy, Cisco Systems Inc.

“I have read every book written by Thomas Erl and Cloud Computing
is another excellent publication and demonstration of Thomas Erl’s
rare ability to take the most complex topics and provide critical core
concepts and technical information in a logical and understandable
way.”

—Melanie A. Allison, Principal, Healthcare Technology Practice,

Integrated Consulting Services

“Companies looking to migrate applications or infrastructure to the

cloud are often misled by buzzwords and industry hype. This work
cuts through the hype and provides a detailed look, from
investigation to contract to implementation to termination, at what it
takes for an organization to engage with cloud service providers.
This book really lays out the benefits and struggles with getting a
company to an IaaS, PaaS, or SaaS solution.”

—Kevin Davis, Ph.D., Solutions Architect

“Thomas, in his own distinct and erudite style, provides a
comprehensive and a definitive book on cloud computing. Just like
his previous masterpiece, Service-Oriented Architecture: Concepts,
Technology, and Design, this book is sure to engage CxOs, cloud
architects, and the developer community involved in delivering
software assets on the cloud. Thomas and his authoring team have
taken great pains in providing great clarity and detail in documenting
cloud architectures, cloud delivery models, cloud governance, and
economics of cloud, without forgetting to explain the core of cloud
computing that revolves around Internet architecture and
virtualization. As a reviewer for this outstanding book, I must admit I
have learned quite a lot while reviewing the material. A ‘must have’
book that should adorn everybody’s desk!”

—Vijay Srinivasan, Chief Architect - Technology, Cognizant

Technology Solutions

“This book provides comprehensive and descriptive vendor-neutral

coverage of cloud computing technology, from both technical and
business aspects. It provides a deep-down analysis of cloud
architectures and mechanisms that capture the real-world moving
parts of cloud platforms. Business aspects are elaborated on to give
readers a broader perspective on choosing and defining basic cloud
computing business models. Thomas Erl’s Cloud Computing:
Concepts, Technology & Architecture is an excellent source of
knowledge of fundamental and in-depth coverage of cloud
computing.”

—Masykur Marhendra Sukmanegara, Communication Media &

Technology, Consulting Workforce Accenture

“The richness and depth of the topics discussed are incredibly

impressive. The depth and breadth of the subject matter are such
that a reader could become an expert in a short amount of time.”

—Jamie Ryan, Solutions Architect, Layer 7 Technologies

“Demystification, rationalization, and structuring of implementation

approaches have always been strong parts in each and every one of
Thomas Erl’s books. This book is no exception. It provides the
definitive, essential coverage of cloud computing and, most
importantly, presents this content in a very comprehensive manner.
Best of all, this book follows the conventions of the previous service
technology series titles, making it read like a natural extension of the
library. I strongly believe that this will be another bestseller from one
of the top-selling IT authors of the past decade.”

—Sergey Popov, Senior Enterprise Architect SOA/Security, Liberty

Global International
“A must-read for anyone involved in cloud design and decision
making! This insightful book provides in-depth, objective, vendor-
neutral coverage of cloud computing concepts, architecture models,
and technologies. It will prove very valuable to anyone who needs to
gain a solid understanding of how cloud environments work and how
to design and migrate solutions to clouds.”

—Gijs in ’t Veld, Chief Architect, Motion10

“A reference book covering a wide range of aspects related to cloud

providers and cloud consumers. If you would like to provide or
consume a cloud service and need to know how, this is your book.
The book has a clear structure to facilitate a good understanding of
the various concepts of cloud.”

—Roger Stoffers, Solution Architect

“Cloud computing has been around for a few years, yet there is still
a lot of confusion around the term and what it can bring to
developers and deployers alike. This book is a great way of finding
out what’s behind the cloud, and not in an abstract or high-level
manner: It dives into all of the details that you’d need to know in
order to plan for developing applications on cloud and what to look
for when using applications or services hosted on a cloud. There are
very few books that manage to capture this level of detail about the
evolving cloud paradigm as this one does. It’s a must for architects
and developers alike.”

—Dr. Mark Little, Vice President, Red Hat

“This book provides a comprehensive exploration of the concepts

and mechanics behind clouds. It’s written for anyone interested in
delving into the details of how cloud environments function, how
they are architected, and how they can impact business. This is the
book for any organization seriously considering adopting cloud
computing. It will pave the way to establishing your cloud computing
roadmap.”

—Damian Maschek, SOA Architect, Deutsche Bahn

“One of the best books on cloud computing I have ever read. It is

complete yet vendor technology neutral and successfully explains
the major concepts in a well-structured and disciplined way. It goes
through all the definitions and provides many hints for organizations
or professionals who are approaching and/or assessing cloud
solutions. This book gives a complete list of topics playing
fundamental roles in the cloud computing discipline. It goes through
a full list of definitions very clearly stated. Diagrams are simple to
understand and self-contained. Readers with different skill sets,
expertise, and backgrounds will be able to understand the concepts
seamlessly.”

—Antonio Bruno, Infrastructure and Estate Manager, UBS AG

“Cloud Computing: Concepts, Technology & Architecture is a

comprehensive book that focuses on what cloud computing is really
all about…. This book will become the foundation on which many
organizations will build successful cloud adoption projects. It is a
must-read reference for both IT infrastructure and application
architects interested in cloud computing or involved in cloud
adoption projects. It contains extremely useful and comprehensive
information for those who need to build cloud-based architectures or
need to explain it to customers thinking about adopting cloud
computing technology in their organization.”

—Johan Kumps, SOA Architect, RealDolmen

“This book defines the basic terminology and patterns for the topic—
a useful reference for the cloud practitioner. Concepts from
multitenancy to hypervisor are presented in a succinct and clear
manner. The underlying case studies provide wonderful real-
worldness.”

—Dr. Thomas Rischbeck, Principal Architect, ipt

“The book provides a good foundation to cloud services and issues
in cloud service design. Chapters highlight key issues that need to be
considered in learning how to think in cloud technology terms; this is
highly important in today’s business and technology environments
where cloud computing plays a central role in connecting user
services with virtualized resources and applications.”

—Mark Skilton, Director, Office of Strategy and Technology, Global

Infrastructure Services, Capgemini

“The book is well organized and covers basic concepts, technologies,

and business models about cloud computing. It defines and explains
a comprehensive list of terminologies and glossaries about cloud
computing so cloud computing experts can speak and communicate
with the same set of standardized language. The book is easy to
understand and consistent with early published books from Thomas
Erl.… It is a must-read for both beginners and experienced
professionals.”

—Jian “Jeff” Zhong, Chief Technology Officer (Acting) and Chief

Architect for SOA and Cloud Computing, Futrend Technology Inc.

“Students of the related specialties can fulfill their educational

process with very easily understood materials that are broadly
illustrated and clearly described. Professors of different disciplines,
from business analysis to IT implementation—even legal and
financial monitoring—can use the book as an on-table lecturing
manual. IT specialists of all ranks and fields of application will find
the book as a practical and useful support for sketching solutions
unbound to any particular vendor or brand.”

—Alexander Gromoff, Director of Science & Education, Center of

Information Control Technologies, Chairman of BPM Chair in
Business Informatics Department, National Research University
“Higher School of Economics”

“Cloud Computing: Concepts, Technology & Architecture is a

comprehensive compendium of all the relevant information about the
transformative cloud technology. Erl’s latest title concisely and clearly
illustrates the origins and positioning of the cloud paradigm as the
next-generation computing model. All the chapters are carefully
written and arranged in an easy-to-understand manner. This book
will be immeasurably beneficial for business and IT professionals. It
is set to shake up and help organize the world of cloud computing.”

—Pethuru Raj, Ph.D., Enterprise Architecture Consultant, Wipro

Cloud Computing
Concepts, Technology, Security & Architecture

Second Edition

Thomas Erl

Eric Barceló Monroy

with contributions from

Professor Zaigham Mahmood and Dr. Ricardo Puttini

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Copyright © 2024 Arcitura Education Inc.

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permission must be obtained from the publisher prior to any
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To my family and friends

—Thomas Erl

To Eva, Pareni, Víctor, and Diego with all my love

—Eric Barceló Monroy

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and Inclusion

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Contents at a Glance

Foreword
About the Authors
Acknowledgments
CHAPTER 1: Introduction
CHAPTER 2: Case Study Background
PART I: FUNDAMENTAL CLOUD COMPUTING
CHAPTER 3: Understanding Cloud Computing
CHAPTER 4: Fundamental Concepts and Models
CHAPTER 5: Cloud-Enabling Technology
CHAPTER 6: Understanding Containerization
CHAPTER 7: Understanding Cloud Security and Cybersecurity
PART II: CLOUD COMPUTING MECHANISMS
CHAPTER 8: Cloud Infrastructure Mechanisms
CHAPTER 9: Specialized Cloud Mechanisms
CHAPTER 10: Cloud Security and Cybersecurity Access-
Oriented Mechanisms
CHAPTER 11: Cloud Security and Cybersecurity Data-Oriented
Mechanisms
CHAPTER 12: Cloud Management Mechanisms
PART III: CLOUD COMPUTING ARCHITECTURE
CHAPTER 13: Fundamental Cloud Architectures
CHAPTER 14: Advanced Cloud Architectures
 CHAPTER 15: Specialized Cloud Architectures
PART IV: WORKING WITH CLOUDS
CHAPTER 16: Cloud Delivery Model Considerations
CHAPTER 17: Cost Metrics and Pricing Models
CHAPTER 18: Service Quality Metrics and SLAs
PART V: APPENDICES
APPENDIX A: Case Study Conclusions
APPENDIX B: Common Containerization Technologies
Index
Contents

Foreword
About the Authors
Acknowledgments
Chapter 1: Introduction
1.1 Objectives of This Book
1.2 What This Book Does Not Cover
1.3 Who This Book Is For
1.4 How This Book Is Organized
Part I: Fundamental Cloud Computing
Chapter 3: Understanding Cloud Computing
Chapter 4: Fundamental Concepts and Models
Chapter 5: Cloud-Enabling Technology
Chapter 6: Understanding Containerization
Chapter 7: Understanding Cloud Security and
Cybersecurity
Part II: Cloud Computing Mechanisms
Chapter 8: Cloud Infrastructure Mechanisms
Chapter 9: Specialized Cloud Mechanisms
Chapter 10: Cloud Security and Cybersecurity
Access-Oriented Mechanisms
Chapter 11: Cloud Security and Cybersecurity
Data-Oriented Mechanisms
 Chapter 12: Cloud Management Mechanisms
Part III: Cloud Computing Architecture
Chapter 13: Fundamental Cloud Architectures
Chapter 14: Advanced Cloud Architectures
Chapter 15: Specialized Cloud Architectures
Part IV: Working with Clouds
Chapter 16: Cloud Delivery Model
Considerations
Chapter 17: Cost Metrics and Pricing Models
Chapter 18: Service Quality Metrics and SLAs
Part V: Appendices
Appendix A: Case Study Conclusions
Appendix B: Common Containerization
Technologies
1.5 Resources
Pearson Digital Enterprise Book Series
Thomas Erl on YouTube
The Digital Enterprise Newsletter on LinkedIn
Cloud Certified Professional (CCP) Program
Chapter 2: Case Study Background
2.1 Case Study #1: ATN
Technical Infrastructure and Environment
Business Goals and New Strategy
Roadmap and Implementation Strategy
 2.2 Case Study #2: DTGOV
Technical Infrastructure and Environment
Business Goals and New Strategy
Roadmap and Implementation Strategy
2.3 Case Study #3: Innovartus Technologies Inc.
Technical Infrastructure and Environment
Business Goals and Strategy
Roadmap and Implementation Strategy
PART I: FUNDAMENTAL CLOUD COMPUTING
Chapter 3: Understanding Cloud Computing
3.1 Origins and Influences
A Brief History
Definitions
Business Drivers
Cost Reduction
Business Agility
Technology Innovations
Clustering
Grid Computing
Capacity Planning
Virtualization
Containerization
Serverless Environments
3.2 Basic Concepts and Terminology
 Cloud
Container
IT Resource
On Premises
Cloud Consumers and Cloud Providers
Scaling
Horizontal Scaling
Vertical Scaling
Cloud Service
Cloud Service Consumer
3.3 Goals and Benefits
Increased Responsiveness
Reduced Investments and Proportional Costs
Increased Scalability
Increased Availability and Reliability
3.4 Risks and Challenges
Increased Vulnerability Due to Overlapping Trust
Boundaries
Increased Vulnerability Due to Shared Security
Responsibility
Increased Exposure to Cyber Threats
Reduced Operational Governance Control
Limited Portability Between Cloud Providers
Multiregional Compliance and Legal Issues
 Cost Overruns
Chapter 4: Fundamental Concepts and Models
4.1 Roles and Boundaries
Cloud Provider
Cloud Consumer
Cloud Broker
Cloud Service Owner
Cloud Resource Administrator
Additional Roles
Organizational Boundary
Trust Boundary
4.2 Cloud Characteristics
On-Demand Usage
Ubiquitous Access
Multitenancy (and Resource Pooling)
Elasticity
Measured Usage
Resiliency
4.3 Cloud Delivery Models
Infrastructure as a Service (IaaS)
Platform as a Service (PaaS)
Software as a Service (SaaS)
Comparing Cloud Delivery Models
Combining Cloud Delivery Models
 IaaS + PaaS
IaaS + PaaS + SaaS
Cloud Delivery Submodels
4.4 Cloud Deployment Models
Public Clouds
Private Clouds
Multiclouds
Hybrid Clouds
Chapter 5: Cloud-Enabling Technology
5.1 Networks and Internet Architecture
Internet Service Providers (ISPs)
Connectionless Packet Switching (Datagram
Networks)
Router-Based Interconnectivity
Physical Network
Transport Layer Protocol
Application Layer Protocol
Technical and Business Considerations
Connectivity Issues
Network Bandwidth and Latency Issues
Wireless and Cellular
Cloud Carrier and Cloud Provider Selection
5.2 Cloud Data Center Technology
Virtualization
 Standardization and Modularity
Autonomic Computing
Remote Operation and Management
High Availability
Security-Aware Design, Operation, and
Management
Facilities
Computing Hardware
Storage Hardware
Network Hardware
Carrier and External Networks
Interconnection
Web-Tier Load Balancing and Acceleration
LAN Fabric
SAN Fabric
NAS Gateways
Serverless Environments
NoSQL Clustering
Other Considerations
5.3 Modern Virtualization
Hardware Independence
Server Consolidation
Resource Replication
Operating System–Based Virtualization
 Hardware-Based Virtualization
Containers and Application-Based Virtualization
Virtualization Management
Other Considerations
5.4 Multitenant Technology
5.5 Service Technology and Service APIs
REST Services
Web Services
Service Agents
Service Middleware
Web-Based RPC
5.6 Case Study Example
Chapter 6: Understanding Containerization
6.1 Origins and Influences
A Brief History
Containerization and Cloud Computing
6.2 Fundamental Virtualization and Containerization
Operating System Basics
Virtualization Basics
Physical Servers
Virtual Servers
Hypervisors
Virtualization Types
Containerization Basics
 Containers
Container Images
Container Engines
Pods
Hosts
Host Clusters
Host Networks and Overlay Networks
Virtualization and Containerization
Containerization on Physical Servers
Containerization on Virtual Servers
Containerization Benefits
Containerization Risks and Challenges
6.3 Understanding Containers
Container Hosting
Containers and Pods
Container Instances and Clusters
Container Package Management
Container Orchestration
Container Package Manager vs. Container
Orchestrator
Container Networks
Container Network Scope
Container Network Addresses
Rich Containers
 Other Common Container Characteristics
6.4 Understanding Container Images
Container Image Types and Roles
Container Image Immutability
Container Image Abstraction
Operating System Kernel Abstraction
Operating System Abstraction Beyond the
Kernel
Container Build Files
Container Image Layers
How Customized Container Images Are Created
6.5 Multi-Container Types
Sidecar Container
Adapter Container
Ambassador Container
Using Multi-Containers Together
6.6 Case Study Example
Chapter 7: Understanding Cloud Security and Cybersecurity
7.1 Basic Security Terminology
Confidentiality
Integrity
Availability
Authenticity
Security Controls
 Security Mechanisms
Security Policies
7.2 Basic Threat Terminology
Risk
Vulnerability
Exploit
Zero-Day Vulnerability
Security Breach
Data Breach
Data Leak
Threat (or Cyber Threat)
Attack (or Cyber Attack)
Attacker and Intruder
Attack Vector and Surface
7.3 Threat Agents
Anonymous Attacker
Malicious Service Agent
Trusted Attacker
Malicious Insider
7.4 Common Threats
Traffic Eavesdropping
Malicious Intermediary
Denial of Service
Insufficient Authorization
 Virtualization Attack
Overlapping Trust Boundaries
Containerization Attack
Malware
Insider Threat
Social Engineering and Phishing
Botnet
Privilege Escalation
Brute Force
Remote Code Execution
SQL Injection
Tunneling
Advanced Persistent Threat (APT)
7.5 Case Study Example
7.6 Additional Considerations
Flawed Implementations
Security Policy Disparity
Contracts
Risk Management
7.7 Case Study Example
PART II: CLOUD COMPUTING MECHANISMS
Chapter 8: Cloud Infrastructure Mechanisms
8.1 Logical Network Perimeter
Case Study Example
 8.2 Virtual Server
Case Study Example
8.3 Hypervisor
Case Study Example
8.4 Cloud Storage Device
Cloud Storage Levels
Network Storage Interfaces
Object Storage Interfaces
Database Storage Interfaces
Relational Data Storage
Non-Relational Data Storage
Case Study Example
8.5 Cloud Usage Monitor
Monitoring Agent
Resource Agent
Polling Agent
Case Study Example
8.6 Resource Replication
Case Study Example
8.7 Ready-Made Environment
Case Study Example
8.8 Container
Chapter 9: Specialized Cloud Mechanisms
9.1 Automated Scaling Listener
 Case Study Example
9.2 Load Balancer
Case Study Example
9.3 SLA Monitor
Case Study Example
SLA Monitor Polling Agent
SLA Monitoring Agent
9.4 Pay-Per-Use Monitor
Case Study Example
9.5 Audit Monitor
Case Study Example
9.6 Failover System
Active–Active
Active–Passive
Case Study Example
9.7 Resource Cluster
Case Study Example
9.8 Multi-Device Broker
Case Study Example
9.9 State Management Database
Case Study Example
Chapter 10: Cloud Security and Cybersecurity Access-Oriented
Mechanisms
10.1 Encryption
Another random document with
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growth and of preventing the right-hand habit. It is to be expected
that after deformity has occurred there may result a series of
perversions of function in nerves, as well as in viscera; thus,
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Active treatment should consist, first, of correction of bad postural
and other habits by methods as vigorous as are military drill and
discipline. Patients tire easily after such exercise, and sufficient rest
should be taken, the patient lying symmetrically upon the back.
There is usually opportunity with young children for great ingenuity in
devising suitable exercises without making them too irksome. They
should be taught to play games at least as much with the left hand
as with the right. Gymnastic exercises, especially those with dumb-
bells, will be found effective, and it is advisable to have a heavier
dumb-bell in the left hand than in the right. The more severe cases
should be handled with great care in order not to overdo that which
should be done. Each case should be studied by itself, which means
that such cases should not be taught in classes. Roth calls that “the
key-note position” which is closest to the normal that the individual
can voluntarily and comfortably assume. From this as a basis the
surgeon should work up. Perhaps as much can be done without
apparatus as with it, particularly if will power is concentrated on the
effort. This is harder with the young, but pride may sometimes be
appealed to as a substitute for volition. As strength is gained more
strenuous gymnastics may be prescribed, including suspension from
rings or the simple horizontal bar, while much heavier dumb-bells
may be used, as taught by Teschner.
Mechanical corrective treatment is directed mainly to stretching
shortened ligaments and contracted muscles. For this purpose many
forms of apparatus have been devised. Their principal benefit lies in
increasing backward flexibility at the point where curvature is most
pronounced. As a substitute for such apparatus, and in private
houses, padded stretchers or lounges may be supplied on which
patients may lie either quietly or during massage. Finally the matter
of corrective corsets and braces remains to be considered. External
support takes away from the muscles and ligaments their functions
and work. Nevertheless in some cases this is necessary. No
appliance of this kind that may be supplied should be continuously
worn. It should be removed for work and exercise, as well as for
toilet purposes. Recumbency in bed is much better than too vigorous
bracing. Only in old, neglected, or peculiar cases should it be
considered necessary to resort to much external aid.

CURVATURES FROM OTHER SOURCES.

The relaxation and debility of old age permit of such deformities as
rounded and stooped shoulders, certain degrees of kyphosis, and
sometimes even pronounced stooping and deformity, whose merely
senile causes are more or less combined with rheumatoid arthritis of
the vertebral and costovertebral joints. These features are
accompanied by more or less pain or difficulty in locomotion. Many
instances of ischias scoliotica, referred to in the preceding section,
would find a place among these clinical pictures. Postmortem there
are found exostoses, synostoses, or ankyloses sufficient to account
for the deformity. Rickets also causes skeletal deformities, in which
nearly all the bones may participate, the spine rarely totally
escaping. In such cases various typical and atypical deformities may
be met.
Paralytics may show various curvatures, as do also subjects of
pseudomuscular hypertrophy and syringomyelia. Lordosis is seen in
pregnancy and in congenital hip dislocation, where it is purely
compensatory in each instance and does not outlast its real cause.
In fact it may be encountered as a compensatory feature of any
other kind of spinal curvature.
A still more marked condition of chronic ostitic changes is seen in
spondylitis deformans, which differs little from arthritis deformans of
other joints, save that in these cases it usually spares the joints of
the extremities. It has been known as a rare sequel of gonorrhea,
even in the young. Osteophytic outgrowths occur frequently and fuse
together, causing ankyloses and sometimes great deformity, even to
the extent of making the spine assume a right angle with the
extended limbs. Considerable pain is frequently experienced during
the course of these very slow changes. The entire spine becomes
more or less rigid, consequently there is little or no angular
prominence, while the ribs become immobilized as well. For this
condition there is little or no treatment of any avail. Sometimes
paralysis supervenes and the condition is not infrequently fatal.
Acute osteomyelitis of the vertebræ is occasionally noted. It occurs
nearly always in young and growing children, and is most common in
the lumbar spine. It is essentially the same here as occurring in the
long bones or their joint ends, and has been described in the
previous chapter. Its symptoms may be severe, and it is not
infrequently followed by abscess. When such abscesses point
posteriorly they may be recognized and incised. When, however, pus
takes the anterior path it will probably escape detection, at least until
too late. The prognosis is often unfavorable.

TYPHOID SPINE.
 This name was proposed by Gibney for what seems to be an
infectious periostitis involving the vertebral column, of a character
similar to that which has been described in a previous chapter. It is
characterized by excessive pain, tenderness, and later stiffness. It
may occur during or after mild as well as severe cases of typhoid.

TRAUMATIC SPONDYLITIS.
Kümmel has shown that a traumatic and non-tuberculous ostitis of
the vertebræ occurs, with succeeding kyphosis resembling that of
Pott’s disease, but not so angular, usually without associated
abscesses, but with occasional paralyses. This may occur without
necessary reference to that curvature which may follow a healed or
healing spinal curvature. Inasmuch as the condition occurs only after
the lapse of considerable time after injury, it is questionable whether
it represents any distinct form of disease.

CANCER OF THE SPINE.

Malignant disease of the spine may assume a type either of
sarcoma when primary or carcinoma when secondary. The latter
type is much the more common, and is not so infrequent as an
expression of metastasis from cancer in various other parts of the
body, even the more distant. It is most common in the lower spinal
region. Pain occurs early and is usually severe. It is as often referred
as localized. It may lead to curvature of the spine with some of the
grosser signs of spinal caries, but the prominence, if any occurs, will
be rounded rather than angular. When paralyses occur they usually
assume that type described by Charcot as paraplegia dolorosa. (See
Plate XXXVIII.)
When symptoms of a general type like those produced by spinal
caries occur in adults who are known to have had previous or
present malignant disease the inference will be that they are to be
interpreted as local expressions of the same character. Under these
circumstances treatment can only be palliative. There is no hope of
cure.
 SPONDYLOLISTHESIS.
The term spondylolisthesis implies a partial displacement forward
of the body of the last lower or next to the last lower lumbar vertebra,
usually the former, which slips forward on top of the sacrum with very
little perceptible displacement of arches. The condition may be slight
or well marked, and may or may not be followed by secondary
changes. There appears to be a real fragmentation or separation of
the body from the arch, which may be traumatic, congenital,
pathological, or the sole result of pressure from above; later
exostoses or osteophytes appear about the separation, thus forming
a new fixation and preventing further displacement.
The condition is more common in females and in the young, and
most cases give a traumatic history. In those which do, deformity
may follow accident or it may be long postponed, perhaps until
pregnancy.
Symptoms.—The lesion is recognized by certain alterations of
gait, with a sharp lumbar lordosis and unduly
prominent buttocks and iliac crests, so that these patients much
resemble those having congenital hip dislocation, the pubes being
higher and the sacrum lower than the normal, this diminution of
pelvic obliquity being practically always pathognomonic. On vaginal
or rectal examination undue prominence may be felt above the
sacrum. Some of these cases complain of much pain, either local or
referred, down the limb, the same being made worse by exercise.
 PLATE XXXVIII

Sarcoma of the Spine and Cord. (Goldthwait.)

Diagnosis.—Diagnosis should be made as between this

condition, Pott’s disease, double congenital dislocation
of the hip, and rickets.
Treatment.
—The condition does not admit of extended treatment, save that a
certain proportion of cases are benefited by such fixation as is
afforded by a plaster jacket, which firmly encloses the pelvis and
supports the lower part of the trunk upon it.

KNOCK-KNEE AND BOW-LEG.

The plane of the terminal articular surface of the lower end of the
femur is not at right angles with the axis of its shaft; in other words,
the inner condyle is placed a little lower or beyond the location of the
outer. In this way sufficient angular arrangement of the leg upon the
thigh is permitted so that, with the upper ends of the femora
separated by the width of the pelvis, the knees and the ankles may,
under normal circumstances, be made to touch when the limbs are
fully extended. Thus a slight degree of angular deflection at the knee
is normal. When this is exaggerated to a degree not permitting the
ankles to touch when the knees are in contact the condition is known
as genu valgum, or knock-knee. When, on the other hand, the angle
is lessened or reversed so that the knees are more or less separated
when the ankles are in contact the condition is then known as genu
varum, or bow-leg. These two conditions constitute the typical and
classical types of knock-knee and bow-leg. Other conditions,
however, which lead to the same result occur through various and
irregular curvatures or irregularities of the femur or the tibia, or both,
and there thus may be produced atypical yet most pronounced
instances of these same deformities. These deformities may be
apparent almost from birth, may appear during early childhood, or
not until adolescence. As a rule they are not manifested until young
children are learning to walk. Whenever they appear before this time
they are expressions of infantile rickets, which should be recognized
as such and corrected by mere manipulation while the bones are still
flexible, the correction being maintained, and by suitably feeding and
medicating the patient. (See the general subject of Rickets.)
In fact rickets supplies the explanation for the great majority of
these deformities; incomplete ossification and calcification of the
bones accounting for the comparative ease with which they yield to
pressure or other deforming influences. Rickety children always
manifest a tendency Fig. 261
to defective
ossification at
epiphyseal lines, and
it is here that the
change usually takes
place. Nevertheless
marked instances of
curvature are seen in
all the bones of the
lower extremity. As
deformity in any given
direction becomes
more pronounced the
tendency to its
exaggeration
becomes greater.
Finally these changes
involve not only the
bones proper but the
ligaments and the
other joint structures,
which yield where
pressure is abnormal
and greatest, thus
completely changing
their shape and
internal relations.
Along with other
changes in knock-
knee there is a
tendency to external
rotation, perhaps
even to spiral
curvature of the tibia; Rachitic changes in limbs. (Lexer.)
the patella lies
outside of its normal position, the tendons are more or less
displaced, while, at the same time, there may be inflection of the feet
as an effort at compensation (Fig. 261).
With the exception of spinal curvatures and torticollis there is
perhaps no more conspicuous deformity than that produced by these
abnormalities at the knee-joint. While at first gait is not seriously
affected, it is in time, especially in cases of double knock-knee.
When these knees are bent to a right angle the angular deformity
disappears and all that remains is the rotation of the tibia. Hence it
follows that all correction of these deformities, either slow or
operative, should be applied to the fully extended leg. In advanced
cases there is frequently a complication with flat-foot, which may or
may not be painful. The condition is rarely produced by paralytic
affections, and should be differentiated from mere atrophy of wasted
and contracted legs. A form of knock-knee is occasionally seen in
the adult, which is of traumatic origin and is due to improper care or
neglect in the treatment of the injury.
Treatment.—The treatment of this condition is either mechanical
or operative. Mechanical treatment varies between the
gentlest expedients and the use of more or less extensive and
cumbersome apparatus. When a young and growing child begins to
show evidence of either of these deformities it is usually sufficient to
supply shoes which are reasonably stiff, and raise one or other
border of the sole and heel, according as we wish to influence the
growth of the limb, i. e., in knock-knee the inner border of the foot is
to be raised, in bow-leg the outer. The consequence of even slight
influence thus constantly maintained when the child is upon its feet is
usually sufficient to rectify slight degrees of these deformities. When,
however, the case is pronounced more radical measures should be
applied. Massage has been recommended along with manipulation,
but should be gently performed. The different forms of apparatus in
use afford various methods of making pressure against that condyle
which is too prominent. It is possible to make them efficient, but only
when they are both well planned and well made in the first place and
intelligently applied and watched. The special forms of apparatus
sold in the instrument stores are of little value. Too often it happens
that when efficient they cannot be tolerated, and that when tolerated
they are inefficient. Much speedier and more satisfactory results are
achieved by operative methods, so that, in general, they may be
regarded as the more desirable.
Operative treatment consists in some modification either of
osteoclasis or osteotomy.
Osteoclasis has to do with the forcible stretching, bending, or even
breaking of those parts which show the greatest effects of the
deformity or are known to be its primary seat. In young children with
tender and still somewhat flexible bones this may be accomplished
by the hands alone, the patient being under an anesthetic. Manual
power failing a simple instrument known as the osteoclast, which
affords a means of applying powerful pressure by the agency of a
screw at just the desired point, is used. Pressure is then applied and
carried to the necessary degree, even with partial or complete
fracture of the bone at fault. In this way is inflicted a simple fracture
which permits of the immediate redressing of the limb, with such
overcorrection of the deformity as seems desirable. The limb thus
treated is completely encased in a suitable plaster-of-Paris splint,
and should be held in the desired position until the plaster is
completely hardened and not likely to yield. Osteoclasis, though it
often appears an exceedingly barbarous procedure, is one of the
most beneficent when properly managed, and is rarely followed by
an undesirable result.
Osteotomy is performed by the use of the chisel and mallet, the
former being introduced through a small incision made in the skin,
passed down to the bone with its cutting edge parallel to the bone
axis until the bone itself is reached, after which it is turned at right
angles to it and the mallet used until the chisel has been driven
partly or completely through the shaft of the bone or the portion
which it is intended to attack. The chisel should be partly withdrawn
and its position changed if it is necessary to continue its use. Thus
by a partial division of the bones of the young it is possible usually to
so weaken them that, without undue force, and by manual power,
they are fractured at the desired point. The operation should be done
with the most complete aseptic protection. The procedure
recommended by Macewen is now universally accepted. The
incision is made at the inner side of the thigh just above the tubercle
for the adductor magnus, and the osteotome (as the chisel especially
made for this purpose is called) is passed through it, down to the
bone, turned at right angles, and made to cut nearly through the
shaft. Lest it become too firmly wedged it may be moved a little
laterally after each blow of the hammer. The operation, if properly
done, is practically bloodless; the small opening made for the chisel
is sealed at the moment of its withdrawal, the deformity corrected
with the least amount of handling or disturbance, and the plaster-of-
Paris bandage immediately applied, with the leg in exactly the
position which it is desired should be maintained. Such a dressing
may be left for three or four weeks before being changed. One
change is usually sufficient, and in from six to seven weeks the
patient is allowed to slowly regain use of the member.
A special set of osteotomes, after Macewen’s pattern, is furnished
by the instrument dealers for those who practise osteotomy. It
consists of a set of three straight chisels, consecutively numbered,
the first being a little thicker and the third the thinnest of the three,
and thus made with the intent to use the thickest first in order that in
the notch made by it the thinner instruments can be subsequently
more easily manipulated.

BOW-LEGS.
Bow-legs are nearly always of rachitic origin, occurring with less
angular deformity, and as the result of the warping or bending of
bones which are not sufficiently rigid to sustain the weight they are
made to carry. Most cases of bow-legs have their origin within the
very early years of childhood. Other cases are seen in infancy and
before children have ever borne much weight upon their feet. The
deformity must be accounted for by muscle tonus, mere muscle
activity serving to place enough stress upon the bones to swerve
them from their normal axes. The bones probably bend outward
because the muscles on the inner side are the stronger. Children
thus affected walk not so much with a limp as with a waddle, with the
feet rather apart, and some inversion of the toes. Double and
complicated curves occur in many of these cases, both femurs and
tibias participating, and having an anterior as well as a lateral
bowing. Such complications materially increase the difficulty of any
treatment.
Treatment.—The treatment of bow-leg is generally considered
simpler than that of knock-knee. Occurring in young
and growing children it can be overcome, if taken early, by the
expedient already mentioned, elevating the outer border of the sole
of each shoe. The more mechanical and the purely operative
methods of treatment are essentially the same as those just
described for knock-knee, based on similar but reversed principles.
In the very young manual force will often serve the purpose of a
more formal osteoclasis, but the osteoclast may be used whenever it
seems indicated. In those cases where the bowing is due to abrupt
and almost angular deformity, osteotomy is indicated. This is made
on exactly the same principles as mentioned above. In all instances
spiral curvatures should be overcome so far as possible during the
process of forcible correction and dressing in the plaster-of-Paris
bandages ordinarily used. Here, as previously, all treatment should
be addressed to the limbs in their fully extended position. If the rings
of the ordinary osteoclast be sufficiently padded and protection
afforded in this way, the skin rarely sloughs, and the damage, which
is, at least, theoretically done to the tissues, is quickly repaired.
Failure in union after any of these operations is exceedingly rare.

CLUB-FOOT; TALIPES.
In general the term talipes is applied to any malformations of the
foot by which it is more or less misshaped and its function impaired.
The commonest of these is that known and described below as
talipes equinovarus. Of these various deformities there are four
principal types, according as the foot is inverted, everted,
hyperflexed, or hyperextended. More particularly they are:
1. Talipes equinovarus, the commonest type, the ordinary
club-foot;
2. Talipes valgus, or flat-foot;
3. Talipes equinus;
4. Talipes calcaneus.
 These forms may be variously blended, as well as seen in varying
degrees from the slightest possible deviation to the most pronounced
form. Statistics show that about one child in every five hundred is
born with some form of club-foot.
Club-foot may be either of acquired or congenital origin. Acquired
club-foot is essentially always of paralytic nature, following usually
infantile paralysis or those injuries by which nerves have been
divided or caught in callus or in tumors. As the result of such loss of
nerve or muscle power, in certain muscle groups, malpositions of the
feet are caused which simulate those of congenital origin.
1. Congenital Club-foot; Talipes Equinovarus.—This consists
anatomically in
an inward dislocation at the metatarsal joint of the anterior part of the
foot, in consequence of which the relations of all of the other
component parts of the foot are deranged; the scaphoid is swerved
on to the inner and lower side of the astragalus to such an extent as
to touch the internal malleolus; the cuneiforms follow the scaphoid
and the metatarsals follow the cuneiforms; the cuboid is shifted to
the inner side and does not articulate squarely with the calcis. In
infants these bones are cartilaginous, but as the individuals grow
and these miniature bones develop and ossify they take similar and
abnormal shapes and positions. The calcis is drawn into a more
vertical position than normal by drawing up the heel, and is even
somewhat rotated on its own vertical axis; thus its anterior
articulating surface is made to look obliquely inward. This
displacement of bones causes dislocation of tendons, the anterior
group being drawn mostly to the inner side. The patient walks more
and more on the outside of the foot, and as he does this adventitious
bursæ develop on the outer border, which become very thick and
form in time large callosities. In the most pronounced cases there
occurs, in connection with all this, curvature or spiral inward rotation
of the tibia, and even of the femur of the affected limb, while the
contracted muscles become overdeveloped and those which are
disused underdeveloped (Fig. 262).
Among the causes of club-foot heredity seems to play a
considerable part, as it often happens that two or three club-footed
children are born of one mother. The deformity has been ascribed to
 Fig. 262 abnormal or
exaggerated posture
in utero, with
compression. This
theory is at least
attractive and has the
force of argument
from antiquity, for
Hippocrates thus
believed.
Unquestionably the
normal intra-uterine
position of the fetus
includes a certain
degree of
equinovarus. Yet if
this were the real
cause the condition
Talipes equinovarus. would occur
apparently much
more frequently. It has been ascribed also to disparity in strength
between opposing groups of muscles, that group which causes the
deformity being naturally the stronger, it being at the same time
unimportant whether one group is relatively too strong or the other
relatively too weak. Most monstrosities or seriously defective infants
have also club-foot, from which some argue that the central nervous
system has something to do with it; yet it has been shown in over
1200 cases of club-foot that only twice did such defect of the central
nervous system as spina bifida occur. The embryologists and
comparative anatomists regard it as an expression of arrested
development, while evolutionists consider it an atavistic reversion to
an earlier anthropoid arrangement. None of these theories really
satisfactorily explains the deformity. Therefore we should hold that
either there are different and variable causes or that we have not yet
found the true one.
Treatment of Congenital Club-foot.—There being in these cases no
tendency to spontaneous improvement, mechanical or operative
treatment, or both, are required. If these be afforded early the
prospects of restoration, practically to the normal, are good, but
treatment should be begun early and conducted with great care and
patience. It is not so difficult to correct the deformity, but correctional
supports should be worn for a relatively long time, while the older the
case the more difficult become all the features, both mechanical and
durational. Parents are often eager at first, but later become
inattentive or careless. The main objects are to be attained by
correction of position by force or by division of contracted or
shortened tissues, or retention in position, with the addition of any
other features which may influence growth and development
according to normal standards. Of these we will speak first of
rectification: (a) bloodless, as by purely mechanical force, or by
means of certain apparatus, and (b) operative, as by subcutaneous
tenotomy, aponeurotomy, etc., or by open incision, through which are
performed osteotomy, excision, astragalectomy, tarsectomy, etc., as
the operator may see fit.
In all of these the anterior part of the foot is to be forced outward
as well as raised, two distinct features, which should be combined
but not confused.
In the young infant gentle force applied many times a day, with the
persuasion of a strip of adhesive plaster, applied beneath the foot
and over its outer border, and spirally upward to the inside of the leg,
can be made effective in mild cases; but overstretching of the tendo
Achillis is a necessary part of this maneuver every time it is
practised. The more positive method consists of fixation of the foot in
overcorrected position within a plaster or starch bandage, the same
extending above the knee, which should be slightly flexed, the
dressing to be renewed every two or three weeks, and correction
increased until it has become overcorrection.
In well-marked and in resistive cases an anesthetic should be
given, while by the use of sufficient force, which may be relatively
great, but which should be gently applied, the resisting tissues are so
stretched, if necessary to the point of something yielding, that but
slight pressure is required to hold the foot in an overcorrected
position. When the knife is required the tendo Achillis should always,
and the plantar tendons and fasciæ usually, be subcutaneously
divided, under aseptic precautions. The foot is then enveloped in
suitable dressings and put up in overcorrected position for two or
three days, in a rigid dressing at first of starch, but after this in
plaster of Paris; this is the writer’s plan of procedure. The insertion of
the point of the tenotome sufficiently deep to divide all resistive
ligaments and tissues (e. g., the astragaloscaphoid or the
calcaneocuboid) nowise complicates this method, but makes it more
efficient.
Cases which are resistant are best submitted at once to open
operation (that is, after vigorous stretching of the contracted tissues),
always under strict asepsis. After decades of milder ineffectual
methods it remained for A. M. Phelps, of New York, to show the
benefits of this method by which all contracted tissues on the
concave aspect of the foot are exposed and divided. Incision is
made here from the top of the inner malleolus to the inside of the first
tarsometatarsal joint. With a little care the artery can be avoided, but
I have never seen any harm come from its division. Everything which
proves resistant is divided, even the inner osseous ligaments.
Sometimes the incisions can be made in wedge-shape, or obliquely,
so that the wound does not remain so widely open. No attempt is
made to close this wound. The operation may be done bloodlessly,
under the Martin rubber bandage, but whether this be used or not
any vessel which can be recognized as such should be tied;
otherwise the wound is snugly packed with gauze (upon which I like
to use Peru balsam). An ample surgical dressing is applied over it.
This is covered with gutta-percha tissue, to prevent too free access
of air to the blood which will ooze into the dressing, and the whole is
then covered with a starch bandage, in overcorrected position; this is
left, according to circumstances, for from three days to a week—the
longer the better. Then everything is removed, fresh gauze placed in
the wound, which will be found already largely filled up; fresh
dressings are applied, and the foot put up in plaster of Paris, with or
without a fenestrum or any provision by which the region of the
wound may be easily uncovered for necessary renewal of dressing.
It is in the most pronounced types of cases only, with marked bone
deformity, or those in which previous operations have failed, that the
still more radical division or removal of some part of the tarsus is
necessary. As to this no universal rule can be applied save this: take
out sufficient to correct deformity. In some cases it will be sufficient to
excise the astragalus (astragalectomy). In other cases it is better to
remove a wedge-shaped piece of the tarsus, without reference to the
name of the bones attacked (tarsectomy). I have never found it
necessary to touch the external malleolus, though this has been
suggested, nor to do osteotomy of the calcis or of the leg bones
above the ankle, as a few have done.
These operations are usually practised, after a preliminary
stretching, through a curved incision on the outer aspect of the foot,
through which, at the same time, the thickened bursæ may be
removed, or the callosities included in the incision. The chief
convexity of the incision should be over the os calcis at its anterior
portion. As the dissection is made the tendons are drawn aside and
spared. If it be necessary to divide one or more of them it should be
re-united later. According to the density of the structures a strong
knife may be used, and strong scissors, or an osteotome
manipulated either by hand or with the hammer. After sufficient V-
shaped or wedge-shaped bone has been removed the defect should
be held together, if practicable, by buried tendon sutures or wire; it is
rarely necessary to use drainage. The external wound may be
loosely closed with buried sutures, a suitable dressing applied, and
the foot put up in a rigid splint; this should permit of removal, or at
least inspection of the wound after a few days, for renewal of those
dressings which are saturated with blood and for application of new
dressings. After this the foot and leg should be put up in
overcorrected position in plaster of Paris.
In aggravated cases of club-foot Wilson believes combined
operation to give better functional results than can be obtained by
any other method. The astragaloscaphoid joint is exposed by an
incision over the prominence of the scaphoid, and, being cleared, is
opened with chisel or bone forceps, while sufficient of the articular
surfaces is removed to destroy them as such and to take out a
sufficiently large wedge-shaped piece from either bone so that the
desired arch of the foot is restored, or even exaggerated. Then the
tendon of the extensor proprius hallucis is exposed and divided just
above the great toe, the upper end of the tendon being drawn out
through the first incision. To Fig. 263
this end is attached a strong
silk ligature. The scaphoid is
then perforated with a bone
drill at some distance from its
superficial aspect and at such
an angle, with the foot in
correct position, that the
canal thus made shall be in
line with the action of the
tendon. The drill is then
withdrawn and the tendon
passed through the opening
by means of its attached silk.
One inch beyond the bony
canal the tendon is cut off
and split in halves, each half
being turned in opposite
direction and fastened to the
periosteum of the scaphoid
with fine silk, while the foot is
held in overcorrected
position, so that the tendon is
sewed in its new place under
moderate tension. The foot is
then dressed in this
overcorrected position in
plaster of Paris, the splint
extending nearly to the knee,
and the wound area being
exposed by a fenestrum cut
in the splint before it is hard.
The location of the incision
over the dorsum or outer
aspect of the foot may be
varied to suit the needs of the
case and the method of the
attack. In a general way a flap
of soft tissues is raised and
tendons, so far as possible, Park’s club foot brace.
are held outward. This is
usually practicable, and it is rarely necessary to divide the latter.
After operation of any type and recovery from the same it will be
necessary for a long time to have the patient wear a corrective
appliance. This should be applied as early as possible, and should
be worn continuously, i. e., night and day; inasmuch as growth is
continuous there should also be continued correctional influences.
Many types of apparatus have been devised. That which the writer
has found effective and has adopted for a number of years is
illustrated in Fig. 263. It may be made single or double, as occasion
requires. A part of the appliance is a spiral spring and a provision for
a constant outward pressure is made upon the foot, by which
inversion is more easily overcome, as well as any inward spiral twist
of the bones of the leg. No such apparatus can be made effective
unless connected suitably with a waist-band. This is, therefore,
included in the shoe shown in Fig. 263. Furthermore the appliance
should be so made as to permit adjustment commensurate with the
rapid growth of the patient, and in order that it need not be too often
renewed. Some degree of mechanical ability is required for its
application and management. The principles are, however, easily
mastered and most parents can soon learn to manage it.
2. Talipes Valgus.—This condition is known also as talipes
planus, or, more briefly, pes planus, the
common names being flat-foot, splay-foot, or pronated foot. A
particularly painful variety has been often spoken of as pes planus
dolorosus.
This type of deformity is rarely of congenital origin. It is
characterized by abduction and pronation of the foot, on whose inner
border there often appear two prominences, one the head of the
astragalus the other the head of the scaphoid. The bones show
much less alteration in actual shape than in club-foot. The scaphoid
is deflected somewhat to the outer side and the astragalus turned a
little outward and downward. A prominent feature is that the arch of
the foot is more or less obliterated, while its inner border becomes
convex instead of remaining concave. This is due in large measure
to relaxation of the ligaments binding the foot to the calcis, especially
that extending from the astragalus (Fig. 264).
Etiology.—The common cause of the condition is lack of sufficient
strength of the parts to carry the weight of the superimposed body. It
is produced often by ill-fitting shoes, accompanied by excessive
strain or rapid growth and gain in weight. It is sometimes
complicated by a certain shortening of the gastrocnemius (Shaffer),
which prevents flexion to its complete degree and compels some
degree of eversion of the foot in completing a step. In some
instances it is induced by previous morbid conditions, such as
rickets, paralysis, diseases of the spinal cord, and postgonorrheal
arthritis. Ill-fitting footwear is the most common cause, as it
compresses the front part of the foot and prevents adaptation of the
foot to the position it should assume when the weight of the body is
thrown upon it. The effect of this weight is to necessitate a greater
divergence of the toes than such shoes permit and gradually causes
the patient to walk on the inside of the foot. Flat-foot is seldom seen
in those who habitually go barefooted.
The condition is best relieved by making a graphic record of each
case. This is done by making the barefooted patient step first on
smoked glass or on wet dusted paper, and then upon a piece of plain
paper. If such a print be compared with the print similarly obtained
from the normal foot it will be seen how different are the points of
contact and how differently distributed is the body weight. A non-
graphic but sufficient inspection may be afforded by having the
patient stand upon a stool whose top is made of glass and by using
a mirror beneath the feet. In any event it will be shown that the inner
border of the foot is at least nearly straight or even convex, whereas
it should be neither.