PAINFUL FEET

144 PAINFUL FEET

restricted, and attempts at flattening the arch hurt.

Treatment is by manipulation under gas. The foot is put through the full range of plantar flexion, (MR. HIGGS) and inversion. Adhesions are broken dorsiflexion, OF all minor maladies a painful foot is one of down and the painful ligaments stretched. In many the most disabling and depressing. The public is cases the pain disappears immediately mobility is not, as a rule, well advised on this subject. In the restored. Instruction in exercises and correct methods past teaching in the medical schools on "foot of walking and standing are then given and the shoes troubles " has been very deficient and many doctors are altered if necessary. feel that it is rather outside their province. Other The third group includes the thorough-going advice is therefore sought. The chiropodist, however broken-down flat-foot, in which the arch touches the skilled, can afford but temporary relief. He treats ground throughout its length. Such a foot is not in the corn but not the cause of it. The special shopsitself painful but the onset of rheumatism or arthritis devoted to foot, comfort appliances frequently fail causes symptoms. Any attempt to restore the arches to give relief, judging from the number of patients is useless, but the foot can be made more comfortable who come to hospital seeking further advice although by suitable shoes. laden with their wares. If the bonesetter is conDISORDERS OF THE TRANSVERSE ARCH sulted he usually discovers some " bones out of Transverse arch troubles. are more common in place " which he " puts back " by manipulation. -women may be of a be the if the treatment pain bruised than in men. The complaintunder Manipulation may right the balls feeling, like walking on pebbles, is due to adhesions but, since accurate diagnosis and of the or of a severe acute which occurs feet, pain after-treatment are lacking, most patients are no is when due to nerve and suddenly pressure. walking better although they remain convinced that someShort stockings which constrict the toes and shoes of thing beneficial has been done. a bad shape with too high heels are the chief factors The normal foot has strength and flexibility. which cause this troublesome condition. Treatment It must be emphasised that the muscles and not is from to take a made a cast, plaster by support, the ligaments form the natural support of the arches. If off the toes are the clawed joints. painful weight If the muscles fail the weight falls on the ligaments which become stretched and painful. Adhesions and and stiff, manipulation under gas followed by stiffness develop and the flexibility disappears.There re-education of the intrinsic muscles and faradic foot is no merit in a high arch unless it is supple and under baths will also be required. As a temporary measure muscle control. In childhood pain in the foot is a strapping the fore part of the foot or a metatarsal serious symptom, since a child under 10 years old bar gives relief. DISORDERS OF THE TOES AND HEEL practically never suffers from foot strain and the of the tarsal be due to tuberculosis bones or pain may Hallux valgus is a common trouble among women. to some unusual condition such as Köhler’s disease. It is often associated with a flat transverse arch An X ray examination is therefore essential. and is due to similar causes. The site of pain varies. It may be in an inflamed bursa overlying the prominent DISORDERS OF THE LONGITUDINAL ARCH joint, in the big toe-joint itself, or in the other metaDisorders of the longitudinal arch, a common tarso-phalangeal joints which are taking too much cause of painful feet, can be divided into three groups. weight. In selected cases operative treatment gives The first, occurring in adolescence, is due to overstrain excellent results. The modern method is to resect of apparently satisfactory arches. A typical case is about two-thirds of the metatarsal head, preserving that of the boy who has just left school and become the bearing surface for the sesamoid bones. The bone a messenger. He is on his feet far too much and after is made absolutely smooth with a file and nothing a time acute pain develops. The foot becomes stiff, is interposed between the joint surfaces. Careful everted into the valgus position, and there is spasm of after-treatment by massage and exercises is essential. the peroneal muscles. Rest is an essential in treatAn operation for removal of the bursae and exostoses ment. The boy must stop work. Manipulation of only is unsatisfactory as the valgus deformity is not the feet is carried out under an anaesthetic followed corrected and the trouble will recur. the a of rest in time this Another painful condition is a stiff big toe-jointby period plaster. During boots are wedged on the inner sides and fitted with hallux rigidus. It often occurs in adolescence and outside irons and ankle-straps. Removal of the trauma is a factor in producing it. It may follow a such as a stubbed toe, or be due to plaster is followed by physical treatment and a sudden gradual return to activity. A focus of infection must chronic strain through wearing short shoes and be sought as the condition may be complicated by stockings. Usually an infective focus, such as septic arthritis of the tarsal joints. tonsils, is also present. A traumatic arthritis is In the second group is the common foot strain thereby set up. In the early stages rest and alteration which occurs among adults. There are two types: to the shoe to support the inflamed joint are indicated. (1) an acute condition, in which there is marked In the later stages, where typical osteo-arthritic oedema and the spring ligaments are painful; and changes have occurred and the joint is very painful, (2) a chronic condition. Treatment for acute foot good results may be expected from operative treatstrain is by rest, support, gentle massage, and ment. Removal of the metatarsal head may be re-education in walking. In such a case a rigid metal disappointing through the development of arthritis support is very harmful. If any " support" is in the new joint. A safer plan is to remove the necessary one made from a plaster cast of the foot exostoses from the head of the metatarsal and excise is best and its chief function is to deflect weight the proximal half of the first phalanx. to the outer side. It is made of cork and leather, is A hammer toe gives rise to pain because of shoe the of foot. under the fits sole In and snugly light, pressure on the painful joint. Pain may also develop addition, wedges are fitted to the heels of the shoes. under the ball of the foot due to downward pressure In the chronic condition the symptoms are an aching of the corresponding metatarsal head. The deformity pain in the feet and cramp up the calves of the legs. occurs because the toe is over long and is pressed Flexibility of the foot has been lost, movement is into line with the others by the sock or stocking. S. L.

injury,

145 Once it is developed, the only treatment is operative. The toe should not be amputated. The usual operation of excision of the flexed interphalangeal joint may lead to a painful fibrous ankylosis. A better plan is to spike one bone into the other. This is done by cutting the proximal phalanx into a point and fixing this into a hole bored in the base of the second. Firm internal splinting is secured and the patient can walk without pain in a few days. A painful heel is a common complaint, especially

,in middle age.

There is often a history of lumbago It is due to plantar fibrositis and the tender spot is at the attachment of the plantar fascia to the os calcis. A spur may be present, but since this is secondary and is not the cause of the symptoms it rarely requires removal. Dental sepsis is often responsible and should be treated. A soft sponge rubber heel pad should be fitted inside the shoe. Soda foot baths or diathermy will usually help to relieve pain. or sciatica.

SPECIAL ARTICLES THE ROYAL MEDICO-PSYCHOLOGICAL ASSOCIATION THE annual

meeting of this association took place July 5th, 6th, and 7th, at Colchester and Clactonon-Sea, under the presidency of Dr. F. DouGLAS TURNER. The meetings at Colchester were held at the Albert Hall and at the Royal Institution for Mental Defectives, while a visit also took place to the Severalls Mental Hospital, at the invitation of on

Dr. R. C. Turnbull. The Gaskell prize and gold medal were awarded to Dr. Desmond Curran, and the special merit of Dr. L. Minsky’s essay was recognised by a gold medal. The bronze medal was awarded to Dr. D. N. Parfitt, and the prize dissertation was that of Dr. J. S. Sharp. The PRESIDENT gave an address on Mental

Deficiency

He said that to France belonged the honour of first attempting to do something for the mentally defective. Seguin founded in Paris the first school for educating idiots in 1837, with the primary object of overcoming inuscular incapacities, and this formed the basic principle of the training in occupation centres to-day. The first need was to awaken the senses, educate the larger muscles of the body, and infuse vitality. The

teaching

to read and write

as a

preliminary step

Dr. Turner dealt at length with the history of the movement in this country. the institution over which he presided had now an endowment fund of 50,000, and 400 acres of land, not a single bed nor a portion of a building had been provided by any local or statutory authority ; this work was the result of charitable funds. An extension had now been planned for the accommodation of a further 444 patients. It was not until 1914 that, under the" Mental Deficiency Act, the term "feeble-minded was legalised to cover the highest grades of defect. Only after long years of experience and care did early workers conclude that though great improvement was possible in these defectives, for large numbers of them life-long care of some kind was a necessity. The institution of intelligence tests gave the impression that mental deficiency was much more widespread than was actually the case, and the feeling of alarm was increased by emphasis on eugenics and heredity studies. Less than ten years ago a well-known society which was established to improve the race stated in a pamphlet : "If all mental defectives could be prevented from having children the number of defectives in the country would be halved in about three generations." To those with daily experience with defectives that was a statement which had no warrant in present knowledge. Dr. Turner’s view was that there had been no great

had been abandoned.

Though

increase in the number of defectives, but there might have been a slight increase partly due to a lowered infant mortality and partly to the greater longevity of defectives ; but he did not consider that, on the average, defectives were more prolific than were normal people of the same social standing, or that the children of such people were necessarily, or even often, defective. Popular opinion was that deficiency was a single entity or disease, whereas it was a dozen or more separate things with different causes, and therefore different remedies. THE EFFECT OF ENVIRONMENT

Dr. Turner had been greatly struck by the great effect of environment on the production of certified The legal definitions of a defective were social in character ; they did not depend on mental age or specific tests, nor on educational capacity, but on the social capacity to live in the world to which they belonged. It was a truism to say that civilisation produced defectives by making living conditions more difficult ; thus a person regarded as defective in a large city would pass muster as normal in an agricultural area. Many of these people adjudged defective were free from disease or discoverable abnormality ; they were merely somewhat short of a high standard, and this did not justify their being classed as diseased. The great hope ,for the future in this domain lay in attacking the environment. More than 10 per cent. of the patients on the books were out on licence. But all new patients must be at the central institution for a time, especially for skilled examination and care. These institutions should always be centres of research, also training schools, but he did not think the medical super7. intendent should act as adviser to the local authority. The institution should turn its back on the alarmist views prevailing in some quarters, return to the wider outlook of our forefathers, and concentrate on stabilising the defective and leading him back to the world from which he came. Among the papers contributed and discussed was one by Dr. R. M. STEWART (Leavesden Mental

defectives.

Hospital)

on

Juvenile

, _

Types

of General

Paralysis

He said that the mental symptoms in this condition were imposed on a mind which had shown an imperfect development from the earliest years of life. Since Clouston’s original description in 1877, 600 cases had been recorded. Often the symptoms were quite unlike those seen in the adult form. Owing to the

increasing tendency of general and neurological hospitals to undertake treatment of all forms of neurosyphilis, figures concerning the disease were apt to be misleading. In a recent survey of 50 cases of congenital neurosyphilis attending the National Hospital in the last ten years, 32 per cent. were found to be examples of juvenile general paralysis, and

’