FLAT FOOT.
Preventive treatment in the most common or static type of this deformity is of great importance, and when the affection is detected in its initial stage it may be arrested or removed by rest or a change of occupation which will not entail prolonged standing or weight carrying. The patient should he trained to stand and walk with the inner line of the feet kept parallel, the toes not being splayed outwards but looking directly forwards. Laced boots should be worn which do not cause the great toe to be turned outwards, and he should patiently practise standing and walking on tip toe; this will strengthen the calf muscles, and may be advantageously supplemented by massage and douching, and with exercises such as walking on the outer border of the naked feet and circumduction move ments at the ankle joint.
When some deformity is present but reducible in a perfectly flexible foot cure can he effected by " crooking " the heel of the boot. This means the thickening of the inner side of the heel by inch and bringing it forward under the instep for a distance of c !3- inches. In some cases it is also advisable to raise the inner side of the sole by inch. In all cases the boots should be made to measure; they should fit accurately around the ankle; the heel should be broad hut not too low, and the front part of the boot should be wide enough to allow of complete " spreading" of the toes.
Where rigidity of the foot is present, or where complete reduction is impossible, flexibility must be restored (1) by complete rest in bed, (2) by rest in bed combined with reduction and putting in plaster, (3) or by wrenching the foot with Thomas's wrench, plastering, and rest. After
wards, the foot being reduced to deformity capable of easy reduction, treatment is carried out as above. 1\ here these methods fail some surgeons advocate tendon transplantation or the removal of a wedge-shaped piece of bone, including the articular surfaces of the scaphoid and astragalus, or a section being made obliquely through the os calcis the posterior portion of this bone is displaced forwards and downwards in order to constitute a new arch. These operations, however. are often unsatisfactory in their results.
Aletatarsalgia, or •orton's Disease, is often associated with flat foot, but even when evidence of this is wanting much relief to the excruciating neuralgic pain felt over the third and fourth metatarsal bones may be obtained by placing a pad behind the heads of the metatarsal hones and by the measures suitable for the treatment of the early stage of flat foot. The boots should be large, and should be so made that the front part of the sole under the toes lies perfectly flat in contact with the ground as the patient assumes the standing posture. The skin should be kept dry by powdering the socks with Boric Acid. A metal plate, or celluloid inset, should be moulded from a plaster cast of the foot and inserted inside the hoot resting on the sole. Rarely will bone operations he requisite, but the head of the third or fourth metatarsal should he excised if out of its normal position.