slow process and the physiological normal sequence of restoration, both in bones and muscles in diseased joints, in contractions, in arthrodesis and paralyzed muscles, we will avoid those deformities and those extreme results of insufficient treatment, because we will think of applying treatment throughout an appropriate length of time.

J. STANLEY WELCH, Lincoln: I always enjoy hearing Dr. Orr talk on this subject, for more than one reason. First, as a citizen of Lincoln I am proud of this institution. Here we have a lot of children who will otherwise become worse than useless citizens brought up to a point where they are at least of some use to the state.

As you know, there are few states in the Union supporting such an institution. I believe it is an asset to any state because of the fact I have just mentioned. Useless children who would become a drag on the state, because so many of them are among poor families, are converted into useful citizens. Next, as a general surgeon I am glad to hear him talk on this subject, because I feel that we always see, when he talks, that a certain lot of these cases should be for us referred cases. They are necessarily slow in their progress at best, and fall without the province of a general surgeon, I think. They are institutional cases-cases which require something which the man in private practice can hardly give them; and that is particularly true if they have little means.

Such a discussion, however, I think often fails to make the general surgeon, or certainly the general practitioner, see wherein he can benefit. Many of these deformities are so gross that the general practitioner does not appreciate where he is at fault in the prevention of them, and that was in a way, a weakness of the paper.

Referring to one item of his paper, viz: the control of the case by the general surgeon, I think that is a point that needs a little emphasis. Take for example, a Colles fracture or Potts fracture. Very often I think we do not come into possession of complete control there at the very beginning. We don't give the patient an anesthetic, and because of the subjective symptoms-the pain-we fail to correct the deformities, and thus as he has said make the orthopedic case for later treatment. That is certainly a point in the control of a Potts fracture. The complete and satisfactory reduction of that deformity I believe can rarely be done without an anesthetic, and I think that is one of many excellent points in the paper which is well worth emphasis.

J. P. LORD, Omaha: Because of my association in this work I feel that I ought to speak in appreciation of Dr. Orr's co-operation and in commendation of his paper which he has very ably presented.

To get at the meat of the matter, how are we going to prevent deformities? This element of time spoken of by Dr. Steindler is such a big factor in the production of this rather gross deformities that it more than anything else, perhaps, is responsible. When we come to consider that we ourselves who are doing orthopedic work find difficulty in controlling patients, having them come sufficiently often to receive attention, or because of the very hopeless character and unsatisfactoriness from their standpoint, of the treatment so far, they gravitate from one to another and float about, and are under nobody's thumb, I think perhaps that is the chief reason why so many of these unsightly deformities are going about. The general practitioner treats these cases, perhaps, during the acute stage and possibly before he is half through it is hinted to him that he has come as often as he ought to, and if they don't get along they will let him know; and unless he is right in this work he does not have the temerity to

insist that these people continue to come month after month and year after year. Some of these gross deformities require perhaps a few years of time in their reduction. That is notably true in the cases of infantile paralysis. The practitioner treats the case; he does what the exigencies of the acute illness require. He may tell the people that they will require after-treatment, but you know with what persistence we have to trephine people's heads to get our instructions carried out, and even that does not do any good. They are indifferent; they don't understand; and it does require a great deal of persistence to accomplish this, and my sympathies are with the general practitioner, although we witness very often cases that would seem to be somebody's neglect, and of course the doctor is the goat. that we are providing for the correction of these deformities we are getting around to the point where we are considering their prevention. Our surgeons objected very much a few years ago because the physicians brought their cases of intestinal obstruction and appendicitis when they were so late, and perhaps the patient was beyond help. Now that we know that these deformities can be relieved, and should be corrected, we are beginning to appreciate that the best time to treat them is in the stage when we can prevent the deformity; and in fact, there is an old formulated definition of orthopedics which says it treats of the prevention, correction and cure of deformity. Prevention is always first.

Now

W. L. ROSS, Omaha: I would just like to speak a word along the line of prevention of deformity. The time to commence treating infantile paralysis for the prevention of deformity is immediately following the subsidence of the fever by the proper use of electricity. I think by the proper use of electricity, applied by the physician himself, a majority of the future deformities following infantile paralysis can be prevented. It takes a great deal of pains and trouble and proper application of electricity, and by that I don't mean that one must have an expensive outfit or anything of that kind. The ordinary faradic current, if properly used, and not over-used at each treatment, will soon begin to bring results, if coupled with that is a proper massage and exercise of the muscles.

I want to speak about one fault, I think, of the general practitioner, in emphasizing the necessity of following up this treatment. It has only recently been demonstrated that you can positively get results. Previous to this the physician in a half-hearted way simply dismissed the patient because he had no confidence in his own treatment, and he could not inspire confidence in the family. Now we absolutely know that by persistent, painstaking treatment a lot of these deformities can be prevented.

Just one case in example. I was called to see a child two months after the attack of infantile paralysis. The child had been abandoned by two physicians as being hopeless for further treatment except such as nature would accomplish. I found the child at five years old unable to turn over in bed, to feed itself, or in any manner have any particular benefit of its limbs. The case was undertaken with the assistance of a good nurse, and by the proper, persistent use of electricity, in about six months' time that child was running about, dressing itself, feeding itself, and since then (the treatment was initiated about two years ago) has been able to attend school and seems in every way a normal child.

Now, just one other phase of the paper, and that is in regard to the tubercular joints. I believe that the influence of the x-ray on the tubercular joints is something that should absolutely be used in every case. The influence of the x-ray towards restoration and prevention of further damage from tubercle bacilli is simply wonderful. It is best illustrated, for

instance, in an ocular way, that all our old tubercular sinuses that used to resist all forms of treatment now yield very rapidly and very satisfactorily and permanently to the use of the x-ray. In the joint trouble we have poor circulation, and nature has not as good a supply of blood there to resist the damage of the tubercle bacilli as in other places. We also know that the x-ray has a tremendous influence upon all the blood-making organs, and the long bones and the joints are included in those. And let me emphasize, don't overtreat. The blood-making organs are very sensitive to the influence of the x-ray, consequently we don't want to exhaust nature by over-stimulation. We simply want to assist nature. If we can produce active hyperemia from day to day, it seems that the tubercle bacilli absolutely stop business.

DR. ORR (closing): I will have to take issue with the last speaker on some points. It seems to me that he is over-enthusiastic in regard to the use of the x-ray in chronic cases. At the orthopedic hospital we make no use of the x-ray whatever for the treatment of tuberculous joints. There are a few men who use the x-ray and think they get good results from it, but we have abandoned it.

With regard to the use of electricity immediately after an attack of infantile paralysis, I want to emphasize again that electricity is valueless except as it is associated with proper mechanical treatment, We must remember that in every patient who has infantile paralysis there is a tendency for a year or two toward spontaneous recovery, and we must make allowance for that as well as for other agencies that seem to contribute something toward the patients getting well.

Dr. Peterson raises the point that it is a bad thing to segregate these children. I can't agree with him in regard to that. It seems to me that we have a proposition which has two sides, viz., Is it more important to have these children associated with other children for the psychical effect, or to have them by themselves for the physiological effect? My opinion is that these children profit by this treatment a good deal more where they can have the specialized treatment that is necessary, than if associated with well children. The average residence of these children in the Nebraska Orthopedic Hospital has been only 152 days, so that is not a very long period. It is better to get them well and then turn them out to associate with normal children, than to sacrifice their welfare and care for this relatively short time.

In regard to the expense, Dr. Peterson spoke of this care as being very expensive. In a way it is, and yet the average expense of providing these children at our institution with hospital care, meals, laundry and an education-they have school every day and special teachers-has usually been about $1.30 per day.

FLAT FOOT.*

P. A. BENDIXEN, M. D., F. A. C. S., Davenport, Ia.

In presenting the subject of flat foot, it is not the intention of the essayist to bring before you anything that is exceptionally new, but I personally feel that it is high time in the modern day and age that we as a profession arouse and stimulate an inquiry into the abuse and misuse of the foot and not permit quackery to handle this part of the body and bring dire results, any more than we would allow them to handle our medical, surgical or obstetrical cases.

Synonyms.-Pes Valgus, pes planus, weak foot, weak ankles, everted foot, kidneyfoot, liver-foot, splay-foot, depressed or fallen arches, low arches. The term flat

foot as used by the general medical profession and the laity, is a term that embraces many more symptoms than would be included in a strict interpretation of the terms "pes valgus" or "pes planus." It might well be defined as a painful condition of the foot due to abnormal static conditions, the chief of which is "the persistence of the passive attitude." It is characterized by the pronation of the foot upon the ankle, and the breaking of the foot at the mediotarsal joint with the abduction of its anterior half, together with a displacement of the bones of the ankle and a flattening or lowering of the longitudinal arch of the foot. It is also characterized by the rotation of the legs, the abduction of the feet, and by a marked alteration in the gait.

During the last ten years there has been an amazing increase in the number of static foot troubles, so that, outside of acute coryza, rhinitis and gastric disturbances, they constitute the most frequent ailment of the inhabitants of the cities of the United States. The reason that the physician does not see more of them lies in the fact that the treatment is mostly in the hands of the shoe-salesmen and chiropodists. There are a number of factories in the United States devoted to the manufacture of flat-foot arch supports or braces, for the shoe stores alone. This enormous increase is due, without doubt, to the demands of the modern fashions, which today call for high-heeled, narrow, and pointed shoes and pumps, together with excessively tight stockings, to be worn from morning till bedtime for all purposes and occasions. previous decades, except possibly for use at dancing or at weddings, only the idle rich (then few in number) wore tight shoes with slender high heels-popularly called French

In

*Read before the Medical Society of the Missouri Valley. at Omaha, Neb., March 26, 1915.

heels; but today even the school girls of our cities imagine that they would lose caste and be considered "de trop" if they could not at least wear high "Cuban" heels and pointed toes all day long. "Commonsense" shoes are no longer to be purchased in the fashionable boot shops nor in those catering to the wants of the laboring people, so that in many instances, especially in small communities, men and women compelled to be improperly shod through the utter impossibility of buying correct shoes. In the larger cities the females coming for treatment out-number the males five to one; in small communities, the affliction is more equally divided between the sexes.

are

Etiology. The remote or underlying causes of static flat-foot may be: congenital, neurogenic, inflammatory, traumatic, and constitutional.

1. Congenital.-The foot of the newlyborn looks chubby and flat, on account of a cushion of fat which lies beneath the arch and fills out the vault. This is a normal condition and is always to be differentiated from true congenital pes valgus, which is usually combined with more or less calcaneus, giving the condition best described as congenital pes calcaneo-valgus.

Due to hereditary influences, the persistence of which is often witnessed in a most striking manner, there may exist at birth, or appear before the child has ever stood upon its feet, a tendency for the foot to pronate and for the child to stand on and walk upon the inner border of the foot. This is often overlooked, or the condition may remain latent until after puberty, when a more or less severe static flat-foot is discovered.

2. Neurogenic Causes.-The paralysis or weakenig of the supinator group of muscles especially the tibialis anticus and posticus, leads to the formation of a paralytic fat-foot. Where such paralysis has been recovered from excessive strain, faulty weight-bearing, or even the unopposed pressure of the bed clothes can in time lead to Hat-foot.

Permanent contractures or spasticity of the supinators give rise to most stubborn conditions. Cerebral palsies of various kinds need only start the abnormal process, hen faulty weight-bearing and use coninue it.

3. Inflammatory changes in the bones and joints of the tarsus, such as arthritis eformans, gout, acute rheumatism, gonorhea, etc., are not infrequent etiological actors. Inflammatory changes in the calf uscles or severe inflammations of the skin

and subcutaneous tissues may be the beginning of the subsequent static foot changes. 4. Constitutional diseases affecting the density and strength of the bones must also be considered as contributing factors. Rickets, chondrodystrophia, osteoporosis, osteomalacia (congenital or acquired), give rise to alteration in the structure, shape, and position of the tarsal bones.

5. Traumatic Causes.-The most common traumatic cause of flat-foot is Pott's fracture (supra-malleolar fracture), which has not been properly reduced and which has been allowed to heal without the complete restoration of the normal relations between the leg, ankle and foot. The violence which tends to produce a Pott's fracture is the forcible pronation of the foot, and in the typical deformity the foot and lower fragments stand in abduction and pronation. The joint space between the malleoli is widened, allowing the astragalus to twist or move in toto to the outside of the normal position and thus shift the line of gravity inward. Unless special attention is given to the proper adduction and supination of the foot in reduction and fixation, a permanent tendency to the formation of the flat-fooot takes place, even though the fragments of the fibula and tibia seem to be in proper position.

Fractures of the os calcis, astragalus, or first metatarsal, as well as rupture of the plantar fascia or the lateral ligaments of the ankle, not infrequently lead to altered function and flat-foot. Trauma to the muscles of the leg can also give rise to similar changes.

The direct cause of all cases of static flatfoot, whether influenced by any of the above-mentioned primary or contributory causes or not, is the alteration in the static conditions of weight-bearing, posture, or gait, or a change in the balance of the body. from such conditions as knock-knee or coxa valgum, bad shoes, etc.

After pregnancy, typhoid fever, surgical operations, lingering diseases, etc., the structures of the feet are often weakened and unable to hold up the weight of the body. A too rapid increase in weight after such conditions, or even in health, may so strain the feet that abnormal function takes place.

Unusual physical exertions in athletes or professional strong men, or the strain of the daily routine in those following occupations in which standing rather than vigorous walking and exercise of the feet are the leading physical exertions, such as policemen, machinists, sales people, etc., especially when the proper shoes are not worn,

tend to destroy the proper balance and function of the feet.

The commonest of all causes, however, is the alteration in the shape of the foot, the strength of its muscles and the area of its effective weight-bearing surface due to improper shoes. The normal unclad foot is broad and short, with the measurement . across the toes as great as, or greater than, that across the ball of the foot. This is best illustrated by the feet of the unclothed savage which, though they may apparently be flat and even slightly pronated, are held in the strong foot position by the broad sweep of the toes, and especially the adduction of the prehensile big toe. The entire tendency of the fashion of all ages and climes has been to compress the toes and ball of the foot into the narrowest possible space, and by raising the heel from the ground, to cause only the compressed toes and ball to touch the ground, thus giving the appearance of a tiny, narrow foot, so sought after by the devotees of Fashion.

The role of the stocking in compressing the toes and feet has never been sufficiently emphasized. To produce an illusion of sheerness, it has become the practice to knit stockings of especially strong cotton or silk threads, with the feet, ankles and lower leg several sizes too short and narrow, so that when the stocking was stretched out over the foot and ankle, there is produced the maximum compression of the foot, which in many cases is more severe than that produced by shoes.

Pathology. The most important changes from the normal anatomy occur in the astragalus, which becomes twisted and articulates more or less faultily with the external and internal malleolus; it becomes flattened and rotates so that the head of the • astragalus becomes prominent on the inner border of the foot. The lesser process disappears and there may finally be complete destruction or separation of the cartilage.

The scaphoid becomes displaced laterally and twists upon its sagittal axis so that the, tuberosity points downward toward the sole. The change in the relationship between astragalus and scaphoid leads to irritation of the periosteum and osteophytic deposits, which may in turn cause limited motion between these bones.

The os calcis seems to be turned outward; its anterior surface may show two, or even three articular surfaces; its cartilages may become eroded, and it may finally become ankylosed to the astragalus.

The cuboid is pushed upward and its upper portion becomes prominent; its artic

ular surface is no longer parallel with the os calcis, and on this account the inner edge of the latter may press upon the calcaneo-cuboid ligament.

The plantar fascia becomes relaxed. longer, and thicker. The dorsal ligaments are thin and show degeneration, while the tibialis anticus and posticus muscles are weak and degenerated and their tendons are stretched.

Symptoms.-The most common and most important symptom is pain. It is felt most severely when the foot is used, and has no especial localization. It may be felt in the bones of the weakened arch, the dorsum, in the heel, under the malleoli, beneath the tendo Achilles, in the calf, knee, thigh, hip, and even in the sacral and lumbar regions. The onset of the foot-pain is generally quite characteristic. After a night's rest the patients have generally forgotten the fact that they have feet, but the first few steps out of bed bring back the pain as uncomfortable as ever. The agony of this continuous pain, has in many cases, caused men and women, otherwise healthy to give up active life. Early or milder cases may not suffer actual pain at all. There may be only a sense of weakness, strain, or insecurity about the feet and ankles. The feet may be cold, cyanotic, numb, swollen, and frequently perpsiring. Lesser has ob served that most cases of local hyperidrosis of the feet are in the flat-footed individuals. The ankle is frequently "turned out;" sprains become common; the muscles of the calf become spastic; the toes may become dorsal or plantar flexed and the ball of the foot (metatarsal heads) painful.

The severity of the subjective symptoms, above described, bears absolutely no relation to the severity of the objective symptoms. and vice versa. It is a common occurrence to find patients whose sufferings are intense and yet upon careful examination to find few or even no objective symptoms to ac count for them. The actual symptoms of pain in such cases are due to a dispropor tion between the burden of the strain and the ability of the foot to sustain it. The pain is most severe when the arch is fall ing." It is in these cases that the diag nosis is difficult, and the patients are ofte dismissed with the recommendation to take a course of baths for rheumatism at some famous bath resort.

Various authors have divided flat-foot into various degrees or stages depending upon the severity of the symptoms.

One classification is:

1. Cases in which the arch only sinks of bearing weight.

2. Cases in which the arch is constantly sunken.

3. Cases in which the arch has become convex.

4. Fixation in the position of No. 3.

Objective Symptoms.-The gait of the patient has become slipshod and shuffling; the whole body, especially the shoulders, sways from side to side as in knock-knee; the feet turn outward and are pronated, so that in walking the patient first strikes his heel and then rolls the weight of the body off the foot at the inner side just above the head of the first metatarsal. Calluses and

bunions are common in this particular area. The knees are not fully extended in walking and also never well flexed. Often a slight knock-knee has developed. The shoes are bulged downward at the arch and worn away at the inner side of the sole. The arch of the foot has sunken down, to a greater or lesser degree, from an almost imperceptible amount, to a degree where the arch "digs a hole in the ground." The amount of the surface of the sole bearing against the ground is increased as can be shown by an imprint, and the range of motion of the foot is decreased in every direction, especially in supination, until in severe cases the foot becomes quite fixed in the adduction and pronated position. There are certain points about the foot which are usually quite tender upon pressure; the head of the astragalus, the scaphoid bone, the dorsum of the foot at its highest point and just below either malleolus. There may also be pain and tenderness beneath the tendo Achilles.

The internal malleolus, head of the astragalus, and the scaphoid lie in a straight line and form a convex bulging anterior to and below the malleolus.

Diagnosis. Where any of the typical objective symptoms are present or where the typical pains are complained of, the diagnosis presents no difficulties. Only those cases in which there are typical pains and few objective symptoms, or where these are out of all proportion to each other, or where the flat-foot is combined with or masked by other processes, can there be any difficulty

in the diagnosis. It is always best to take a careful imprint of the bare foot carrying the entire weight of the body, upon paper prepared in various ways, so as not to overlook that class of cases where the arch has become slightly weakened.

Differential Diagnosis.-1. Static flat-foot must be differentiated from all other forms of flat-foot in which the static conditions do not play the most important role; also from all diseases and conditions which can cause pain in the lower extremities and feet, the disappearance of the arch, and the deformity or change in gait. It must be differentiated from rheumatism, acute

polyarticular rheumatic arthritis, arthritis deformans, tumors, malignant or benign, syphilis of the astragalus or scaphoid, circumscribed swellings and edema, abnormal bursae, sprains and traumata of the foot.

Treatment. The treatment is necessarily divided into, first, the relief of the symptoms, and second, the cure of the flat-foot. The first is easy; the second, difficult or impossible.

The symptoms can be promptly relieved by strapping the foot and ankle with adhesive plaster so as to take the weight off the scaphoid and astragalus. The foot should scaphoid and astragalus. be actively supinated while the adhesive is being applied. The relief gained by thus supporting the arch is but temporary and should never be used for more than a few days or weeks until the proper braces or shoes can be secured.

For the more permanent relief of symptoms in mild cases or those whose feet can bear very little correction over an "active" brace, a balanced shoe with some form of arch support and stiff shank built in, as advised by Dr. Cook, of Hartford, Conn., will be found efficacious.

Braces or arch supports will relieve symptoms, and can be worn in any appropriate shoe. Metallic arch supports should be made by a competent trace-maker after a pattern of the foot furnished by the physician. The type and form of metallic arch support to be used depends upon the training of the physician, the practice of the brace-maker, and need of the case.