A STUDY OF FLAT-FOOT: 
With Special Attention to the development 
of the Arch of the Foot. 
BY 
JOHN DANE, A. B., 
BOSTrtTR, 
House Officer, Massachusetts General Hospital. 
Reprinted from the Boston Medical and Surgical Journal of 
October 27, November j and 10, i8q2. 
BOSTON: 
DAMRELL & UFHAM PUBLISHERS, 
No. 283 Washington Street. 
1892. A STUDY OF FLAT-FOOT, WITH SPECIAL AT- 
TENTION TO THE DEVELOPMENT OF THE 
ARCH OF THE FOOT/ 
BY JOHN DANK. A B.. OF BOSTON, 
House Officer, Massachusetts General Hospital. 
I. THE NORMAL FOOT. 
Anatomy. — According to “ Quain’s Anatomy,” the 
mechanism of the human foot shows a system of three 
arches, “capable of being flattened somewhat bv pres- 
sure from above, thus securing elasticity.” Two of 
these arches run longitudinally, and one transversely. 
The outer arch is formed by the os calcis articulating 
with the cuboid and the two outer metatarsals. As 
calculated by Lorenz, “ the highest point of this arch 
is at least two centimetres from the ground in a good 
ligamentous preparation. It is six centimetres to the 
hinder bearing of the os calcis, and to the correspond- 
ing base of the head of the flfth metatarsal, eight cen- 
timetres ; thus giving the arch a total length of fourteen 
and two-tenths centimetres. The hinder point of the 
outer arch [the calcaneo cuboid articulation] thus lies 
somewhat behind its middle.”2 (Fig. 1.) 
The internal arch starts together with the external 
from a common base, the tuberosity of the os calcis, 
Fig. 1. (After Lorenz.) 
1 Being a thesis presented for graduation in the Harvard Medical 
School. 
3 Lorenz, p. 35. 2 
and is made up of the astragalus, scaphoid, three cunei- 
forms, and the three inner metatarsal bones. This 
arch, while it has much the same span as the outer, is 
considerably higher. 
The third, or transverse arch, has hardly any exist- 
ence till the middle of the tarsus is reached. It is 
made up of the scaphoid, three cuneiform and cuboid 
bones from the tarsus, and the five metatarsals. 
Although all the ligaments of the foot by binding 
the several bones together help to maintain its arched 
character, certain are more directly concerned in it. 
The outer arch owes much of its stability to the strong 
inferior calcaneo cuboid ligament. This consists of 
two distinct layers: 
(1) The so-called “long plantar ligament,” which is 
superficial; (2) The short plantar ligament, scarcely 
an inch long and lying close to the bone. 
The inner arch is fastened together principally by 
the inferior calcaneo scaphoid ligament. The scaphoid 
bone and the os calcis being separated by the head of the 
astragalus, this ligament not oulv has to bind together 
two bones, but also to resist the direct downward pres- 
sure of the head of the astragalus which rests upon it. 
It arises from the sustentaculum tali of the os calcis, 
and is attached to the under part of the scaphoid bone. 
The transverse arches maintained by the plantar liga- 
ments. 
Of the muscles, four are, from the peculiar arrange- 
ment of their tendons, of maximum importance in the 
maintenance of the arches of the foot. The tendon 
of the peronaeus brevis muscle, having passed under 
the external malleolus, continues forward to be inserted 
into the base of the fifth metartarsal bone, thus span- 
ning almost the entire external arch. The peronaeus 
longus, keeping in company with the brevis in its 
course under the malleolus, passing over the externa] 3 
surface of the os calcis “ winds around the outer 
border of the foot to enter the groove on the lower 
surface of the cuboid.” * From this it crosses the 
sole obliquely to its principal insertion on the posterior 
part of the first metatarsal bone. The outer and 
middle arches are both strengthened and bound to- 
gether by this long tendon. 
On the inner side of the foot there is first, the ten- 
don of the tibialis posticus, which, after passing 
behind the external malleolus, runs forward to be in- 
serted into the scaphoid bone; in its course resting 
directly against the inferior calcaneo scaphoid liga- 
ment, which in its turn bears against the head of the 
astragalus. 
The tendon of the flexor longus hallucis likewise 
turns around the internal malleolus. From this it 
passes in a groove under the sustentaculum tali of the 
os calcis, aud runs forward in the sole of the foot to 
its insertion in the terminal phalanges of the great toe. 
Thus the arched character of the normal foot de- 
pends upon a grouping of small bones, which, with the 
exception of the three cuneiforms, show no special 
evidence in their structure of their being intended to 
form an arch held together by many strong ligaments, 
and thoroughly reinforced by the tendons of four of 
the muscles of the leg. 
II. THE PATHOLOGICAL FOOT. 
Frequency.— In the affection known in English as 
flat-foot, the arched character of the normal foot is, to 
a greater or less extent, lost by a partial dislocation of 
its bones. Hoffa, in the Munchner Po/yklinik, has 
collected the following interesting statistics upon its 
frequency:4 
3 Quain, p. 252. 
4 L.ehr; Buch. Orth. Chir., p. 679. 4 
Of the 17,619 surgical affections, 338, which equals 
.49 per cent., were flat-foot; of the 1,444 deformities, 
338, which equals 23.41 per cent., were flat foot. Out 
of 235 cases he found 10, or 4.5 per cent., were con- 
genital, and 225, or 95.7 per cent., acquired. Of the 
225 acquired cases 
11=4.9% were traumatic; 
7=3.1% were paralytic; 
7=3.1% were rachitic; 
200=88.9% were static. 
Thus it will be seen that it is the static form of ac- 
quired flat-foot that has by far the greatest surgical 
importance. This is the form that is commonly under- 
stood by the term “ flat-foot,” and over which so much 
difference of opinion, both as to cause and treatment, 
has found its way into literature. The other forms 
are easily recognized and have caused much less dis- 
cussion. 
Causation. — Unfortunately, at the very start, be- 
fore leaving the domain of physiology, the first differ- 
ence of opinion is reached. All are agreed that the 
foot normally presents two longitudinal arches; but 
as soon as we ask which of the two is normally the 
more heavily loaded, we find that authorities are not 
agreed. In 1883 Dr. Adolph Lorenz published a most 
elaborate monograph on flat-foot. In it he distinctly 
states his view of this subject as follows :6 “ The foot 
owes its arched character wholly to the outer foot 
arch, that is to say, to the exceptional union of the os 
calcis and cuboid with the metatarsals. The bones of 
this arch are wedge-shaped, (and) so put together as to 
allow very little motion.” He goes on to say that the 
inner arch is composed of more bones less firmly held 
together; “the whole arch, therefore, aims at greater 
mobility with less firmness,” and that the weight of 
5 Lorenz, p. 35. the body does not come directly upon this arch. The 
subsequent German orthopedic writers, of whom 
Schreiber and Hofi'a have published the best known 
works, have contented themselves with quoting Lorenz. 
In direct opposition to this view is the statement 
made in “ Quaiu’s Anatomy,” in the latest edition of 
which we read:6 “ The arch may be considered as 
double in front, with a common support behind. The 
internal division of the arch is that which bears the 
greater part of the weight of the body, and is most 
raised from the ground, ecc.” 
As this question of the normal weight-bearing arch 
comes out still more prominently in the consideration 
of the pathology and treatment of flat-foot, its further 
consideration will be left until speaking of those sub- 
jects. 
As upon almost all surgical diseases, there have 
been many and quite widely different opinions as to 
the cause of this affection, and yet a growing similar- 
ity. Stromeyer was one of the earliest writers, and 
he arrived at the conclusion that the first etiological 
factors in its production were atony of the planter ap- 
oneurosis and weakness of the muscles, especially those 
in the sole of the foot and the tibialis posticus in the 
leg.7 But upon dissection the aponeurosis has been 
found thickened rather than thinned. Hiiter 8 regarded 
it as a developmental deformity, an abnormal growth 
of the joint: but this is obviously incapable of explain- 
ing the cases that arise later in life; nor do we find 
the changes similar to his description upon dissection 
of the feet. 
Reisman considers it as primarily an insufficiency of 
the plantar flexors caused by over-exertion, followed 
6 Quain’s Tenth Edition, vol. ii, p. 138. 
i Beitrage zur operatven orthopadik, p. 99. 
8 Virchow’s archiv., xxv, p. 572. 6 
by a coutracture of the extensors, and subsequently 
of the pronators.9 
Henke, who next to Lorenz has probably given the 
most attention to this subject, says that it starts as a 
fatigue of the muscles of the calf and the tibialis post- 
icus, for he believes the arched character of the foot 
depends first upon them. When they cease to do their 
work the strain falls upon the ligaments of the foot, 
which, when unaided, are unable to resist it. As a 
result of the joint changes the foot is pronated and 
flexed at the talo-crural joint, and, finally, the forepart 
of the foot is bent backwards to compensate for the 
flexion. He, therefore, designates the affection as 
“ pes flexus pronatus reflexus.” 
Against this theory the only objection that has been 
urged is that it does not take sufficiently into account 
the part played by the muscles, bands and ligaments 
of the foot itself, and lays too much work upon com- 
paratively feeble muscles. With this modification the 
theory is accepted by Lorenz and his followers. To 
use Lorenz’s own words,10 “ Valgus acquisitus is that 
deformity of the foot which is caused by pressure, and 
consists of a sinking of the external portion of the 
arch of the foot, together with a sliding off of the in- 
ternal from the external arch of the foot.” This 
pressure to which Lorenz refers is that of the weight 
of the body, usually from standing ; on this most au- 
thors agree. Thus to quote from some of the latest: 
Schreiber 11 says, “ There can be no doubt that the 
etiological cause of pes valgus adolescentuim is abnor- 
mally frequent and long-continued pressure, and espe- 
cially constant standing.” Hoffa12 says, “ There is thus 
no doubt that steady loading of the foot brings flat-foot 
into being.” 
9 Langenbeck’s arcliiv., ii, iii, p. 722, 1869. 
10 Loren z, p 137. 
11 General Orthopedics, Wood’s Trans., p. 292. 
ls Loc. clt., 686. In America the same opinion prevails. Bradford 
and Lovett, in their “ Orthopedic Surgery,” say, 
“ There can be now no question that the deformity 
results from the superincumbent weight falling upon 
an ankle and foot unable to sustain it. It is the result 
of a disproportion between the body weight and the 
apparatus for sustaining it.”13 
Of all the modern English writers, Whitman of 
New York has done by far the most careful work on 
this subject, and published in the last few years a 
series of articles which take up minutely this subject 
of etiology. Having enumerated the causes already 
set forth, such as general weakness from diseases of 
all kiuds; general fatigue from long standing; danc- 
ing; running aud the like, he lays special stress upon 
“attitude,” especially the “attitude of rest,” which 
had already been noticed at length by Lane.14 He 
shows how the position of strength and action is with 
the toes well adducted; for that brings all the mus- 
cles into play to support the arch of the foot, and 
moreover, at every step the weight of the body has to 
be raised over the great toe. The least muscular sup- 
port, on the other hand, is given to the arch when the 
feet are spread and the toes turned outwards. This 
position tends not only to relax the muscles and bring 
the strain directly upon the ligaments ; but by increas- 
ing the pronation brings the weight still farther over 
towards the inner border of the foot, and aids a nat- 
ural predisposition towards a tipping over of the os 
calcis and slipping off inwards of the astragalus; in 
short, the breaking down of the internal arch. This 
it is that Lane calls the “attitude of rest.” 
This brings us back again to the question of which 
arch gives way first, and the answer seems clear. It is 
the internal arch. The weight of the body is nor- 
« p. 728. 
14 Guy’s Hospital Reports, vol. xxix, p. 256. 8 
mally transmitted through the astragalus upon the os 
calcis at a point internal to its base. This will, there- 
fore, tend constantly to roll over, and, as it were, to 
tip the astragalus off its back in a direction inwards 
and forwards. This tendency is as constantly counter- 
acted by ligamentous and muscular action. But when 
the muscles are tired and so having hard work to give 
the arch the necessary support, if the toes are turned 
out to try and relieve them, that is, if the “ attitude of 
rest” is assumed, then the weight is transferred still 
farther towards the inner border, the strain is in- 
creased, while, at the same time, the resistance is less- 
ened, and a Hat-foot is the result. 
This seems clear if we assume that it is the inner 
arch that gives way, and not the outer; for by pronat- 
ing the foot and abducting the toes we throw all the 
weight off the outer arch, which would consequently 
have no reason for breaking down so long as we 
assume this “attitude of rest” ; and yet this has been 
shown to be a great predisposing cause. Moreover, 
the outer arch is very strongly girded by ligaments, 
and its span so fully filled up by the soft tissues, that 
it practically rests upon the ground when the weight 
is thrown upon the foot. Certainly it depends the 
least upon muscular exertion for its maintenance; 
then why should it break down when the muscles are 
tired, or when they are placed at a disadvantage by 
the position of the foot ? 
Strangely, Hoffa, while following Lorenz as to the 
primary failure of the external arch, nevertheless 
quotes the English authors in regard to this matter of 
attitude as a predisposing factor, and then reprints 
their cut of a man in this position. These two things 
would seem to be contradictory. 
Anatomy. — If we turn to the pathological anatomy 
we find that the muscles of the leg are atrophied on 9 
the flexor side, while the extensors, and especially the 
pronators, are in a state of contraction. The plantar 
ligaments have been found to lie not only longer but 
also much thicker than usual, especially the ealcaneo- 
scaphoid. The dorsal ligaments are found in a state 
of fatty degeneration. 
Qf the bones, the tibia is usually unaltered. The 
tip of the external malleolus of the fibula may he 
rounded off, or even flattened out from pressure against 
the os calcis. Of all the tarsal bones the astragalus 
suffers the greatest changes. A large amount of plan- 
tar flexion at the inter-malleolar joint is quite a con- 
stant feature of the severe grades of flat-foot. To give 
this the astragalus is rotated so far forwards that only 
the posterior part of its trochlea surface lies in contact 
with the tibia. The fore portion soon loses its carti- 
laginous covering, thus diminishing the height of the 
bone considerably. 
Fig. 2. (After Lorenz.) 
The head of the astragalus projects sharply inwards 
and downwards (Fig. 2) ; the scaphoid is in its turn 
thrust so far upwards that in severe cases it may lie 
like a bridge upon the neck of the astragalus. It is 10 
also rotated in such a wav that its tuberosity becomes 
its under surface. The head of the astragalus in its 
abnormal position rests primarily upon the inferior 
calcaneo scaphoid ligament, and only articulates with 
the scaphoid at its upper inner angle. Corresponding 
to this the ligamentous facettes upon its head become 
altered, a low ridge divides the head into two ovals, 
of which the one articulating with the ligament in- 
creases with the degree of deformity at the expense of 
the one articulating with the scaphoid bone. 
During this process a low degree of periosteal in- 
flammation is often excited, which results in the throw- 
ing out of a wall upon the upper surface of the head 
of the astragalus, which increases the size of the facette 
for articulation with the scaphoid, and tends to prevent 
any further displacement. 
The changes in the os calcis relate only to its sur- 
face. It falls over inwards, and brings the external 
malleolus to bear against its upper outer surface. This 
contact develops a joint surface there, and may lead to 
the formation of a bony overgrowth. With the advent 
of flat-foot the sustentaculum tali begins to disappear, 
aud in high grades of the deformity it may be reduced 
to a mere knob. 
The same changes take place in the facettes for 
articulation with the cuboid as came on the head of 
the astragalus for the scaphoid, and the same bony 
wall is seen in advanced cases. The cuboid suffers 
merely a change of position. It is partially dislocated 
upwards aud at the same time inclined forward; so 
that it is no longer in contact with the os calcis along 
the whole of the joint-surface. 
In cases of any degree of severity there is in addi- 
tion to the changes in the tarsal bones, a “ contracture 
in adduction” of the metatarsals, which gives the foot 11 
a most characteristic zigzag line on its inner aspect 
(Fig. 3). 
Symptomatology. The earliest symptoms of develop- 
ing flat-foot are usually an undefined sense of fatigue 
upon long standing, which gradually increases to the 
degree of pain. At first this pain is dull and general 
in character, and only felt when weight is being sup- 
ported by the feet; but soon it becomes sharp and 
localized in certain definite spots, which will be found 
sensitive to pressure. 
Fig. 3. (After Lorenz.) 
Locality of Pain. (1) The first of these will be 
found over the head of the astragalus on the inner 
margin of the foot, and corresponds to the over- 
stretched calcaneo-scaphoid ligament. (2) Usually 
second in order of appearance, but occasionally first, 
is localized pain (seldom sensitiveness to pressure), 
through the heel, just under and behind the malleoli, 
which as time goes on may radiate up the leg, often as 12 
far as the knee and sometimes even to the hip. It 
seems probable that this is due to a stretching of the 
lateral ligaments that pass between the tops of the 
malleoli and the surfaces of the os calcis; and also to 
the abnormal strain upon the tendons of the leg mus- 
cles that run in this situation, and play such an impor- 
tant part in maintaining the normal arch. (3) Next 
comes pain at the calcaneo-cuboid joint, due to stretch- 
ing of that ligament. (4) And, finally, more diffused 
pain all along the dorsal aspect of the tarso-metatarsal 
articulation. 
If the foot is dipped in water and the patient al- 
lowed to stand upon a dry sheet of paper, an exact 
tracing of the sole is easily obtained. Normally the 
outer margin is nearly straight, while the inuer shows 
a sharp curve with the convexity outwards (Fig. 4, a 
and b). 
Fig. 4. a, Male, fifteen years, suffered from flat-foot and pains, 
relieved by plate, b, Female, nineteen years, ditto. 
Occasionally the outer arch may be so high that it 
also does not rest upon the ground (Fig. 5, a). As the 
arch in flat-foot becomes more and more broken down, 
this tracing is found to change. The internal line be- 
comes gradually straight, until finally when the arch 
has completely given way this line is convexed inwards, 13 
and shows a marked bulging where the head of the 
astragalus actually rests upon the ground (Fig. 6, a). 
Fig. 5. a, Male, fourteen years, non-deforming club foot, b, Fe- 
male. fourteen years, suffered from flat-foot pains; completely 
relieved by plate. 
When looked at from behind the normal axis of the 
foot is seen to be parallel to that of the leg. As flat- 
foot advances the foot assumes more and more the 
Fig. 6. a, Male, seventy years, left foot shows arch entirely lost; 
severe pain, b, Female, twenty years, feet oainful; relieved by 
plates. 
position of pronation; that is, the axis of the leg if 
prolonged falls to the inner side of the axis of the foot, 14 
the sole is turned outwards, and in high grades the 
outer border of the foot is even entirely raised from 
the ground.15 This being the case, it is hard to see how 
the outer arch can have fir«t “ broken down ” under 
weight; for if that were the case the foot would have 
certainly continued in the direction of the original 
thrust, and assumed a position of supination with an 
outward curve of its external border. 
In the pronated foot the external malleolus appears 
to have been lost. On the inner side the malleolus 
stands out very prominently ; in front of it may be 
seen a still more pronounced bulging corresponding to 
the head of the astragalus, and often a third caused by 
the scaphoid bone. 
Flat-feet are prone to sweat profusely, to have en- 
larged veins, and are uniformly cold. They have lost 
all their normal spring, they feel heavy and cloddy ; 
consequently, the patient shuffles along awkwardly 
with the toes turned out. hardly lifting the feet from 
the ground. Particular discomfort is felt on first 
using the feet after a period of rest, as on getting up 
in the morning; and~Whitman speaks of patients who 
were unwilling to sit down in his office from dread of 
the increased pain when they again stood up.16 
One peculiarity among the symptoms of the flat-foot 
needs especial emphasis. It is that the amount of 
pain stands in no direct relation to the amount of de- 
formity. Many patients whose feet show no deviation 
from the normal type nevertheless suffer acute pain. 
This pain is not only in the areas already spoken of 
as characteristic of Hat-foot; but it is entirely relieved 
by Hat-foot treatment. Figs. 4, a and b. Fig. 5, b, 
show three such feet treated by the writer at the Massa- 
chusetts General Hospital last fall. 
15 Hoff a, loc. cit., p. 692. 
18 New York Medical Journal, February 27,1892. 15 
Again, many feet that have partly or wholly lost 
their arched character are entirely free from pain 
(Fig. 7, a and b). This fact of painless flat-foot has 
Fig. 7. a, Male, twenty-one years; pain very slight. 6, Male, 
twenty years ; feet painless. 
led the Germans to make a separate class for them, 
calling it “Platte Fuss,”17 and regarding it as a failure 
of development or persistence of the infantile condi- 
tion ; and also as a racial peculiarity, instancing the 
negro and the Jew. 
III. DEVELOPMENT OF THE ARCH OF THE FOOT. 
With a view to finding out what the condition of 
the arch was in infancy and childhood a series of trac- 
ings were taken under the immediate supervision of 
the writer, of the feet of nearly four hundred children, 
whose ages range from nine days to fourteen years. 
The method employed was that already described, 
which is simply a modification of that of Konig. The 
child was allowed to dip its feet in water, and then 
stood for a moment upon a flat-sheet of brown paper. 
Wherever the feet touched, the paper would be moist- 
17 Lorenz, p. 64. 16 
ened. The edge of this moist area was quickly marked 
with pencil, and the {taper carefully dried. 
The writer here wishes to thank the officials of the 
following institutions for the uniform kindness that 
they showed in doing all in their power to aid him in 
his work : The Massachusetts General Hospital ; the 
Boston City Hospital ; the West End Nursery ; House 
of the Good Samaritan : Church Home of Orphans 
and Destitute Children ; Marcella Street Home and St. 
Mary’s Orphan Asylum ; and also to thank most heart- 
ily Mr. S. E. Bullard and Mr. Lyman Hodgkins of 
the Harvard Medical School for their co-operation in 
taking the tracings and making the experiments upon 
plates. 
The deductions from the drawings are not in accord 
with the accepted authorities. At birth the foot does 
not seem to be flat, as is the general opinion. There 
seems to be on the contrary a distinct arch in the feet of 
most infants, better formed in one foot than the other, 
and persisting until they are about eighteen months 
old. In this period the difference in the arch of the 
foot between males and females is not noticeable. 
After eighteen months there begins to be a distinct 
breaking down of the arch, which in most cases is 
wholly lost, the two feet suffering equally. For the 
next year and a half the feet remain distinctly flat, yet 
even during this period isolated tracings appear in 
which the arch is never lost. It is interesting to note 
that such are always females, and therefore presum- 
ably lighter children. 
During the next (third) year the arch is slowly re- 
built, one foot improving before the other, and the 
females considerably earlier than the males. When the 
fourth year has been well entered upon the feet have 
nearly reached the adult condition ; the two are about 
alike, and there is no marked difference between males 17 
and females. Figs. 8 and 9 are photographs from two 
sets of actual foot-tracings arranged to show the pro- 
gressive stages in the building up of the arch, one being 
the male and the other the female children.18 Corre- 
sponding squares in the two pictures are occupied, if 
not by exactly the same age, at least nearly enough 
so for all purposes of comparison. 
Briefly stated, these pictures would seem to say : 
From one to eighteen months, arch distinct; sexes 
alike ; one foot better than the other. From eighteen 
mouths to three years, arch mostly lost; exceptions are 
females. From three to four years arch building up; 
unequal in the two feet; females tending to form 
earlier. From four years upwards arch established ; 
sexes alike; both feet equal. 
Another point in which this series of tracings, as far 
as they go, seems to differ from the books is as regards 
the foot in rachitis. Instead of being flat it would 
seem to have an inner arch fully as high as the normal, 
and a much higher outer arch. This, as is shown by a 
series of four tracings in Fig. 10, gives the foot double 
concave sides, making a very pronounced pattern. So 
far as has been observed this peculiar tracing is found 
only in this disease; but the number of tracings is far 
too small to have much significance. In the few negro 
and Jewish feet that appear in the series the arch is up 
to the average for that age ; but again, they are far too 
few to be of much value. 
That tuberculosis of the vertebras does not necessarily 
weaken the resistance of the system so as to produce 
flat foot was repeatedly shown. Fig. 11, b, is a trac- 
ing from a girl of four years and nine months of age, 
who was at the time wearing a back brace for Pott’s 
disease. A few scattering cases show in a marked 
manner the production of flat foot by an injury to the 
18 Average tracing from a series of somewhat over 200. 18 
Fig. 8. Tracings of female feet; ages four weeks, three months fifteen days, one year, one year six 
months, two years, two years six months, three years, three years six months, four years, five years 
one month, six years, eight years. 19 
Fio. 9. Tracings of male feet; ages four weeks, three months, one year two months, one year ten months, 
two years, two years six months, three years, three years six months, four years, five years seven months, 
six years three months, seven years. 20 
leg. Fig. 11, a, which is a tracing from a young man 
of nineteen years, who a year and a half previous had 
his left leg broken, shows the 
right foot with its arch in a 
normal condition, while in the 
left the arch has given way. 
IV. TREATMENT. 
Non-Mechanical Treatment. 
— As most of the cases come 
on from a fatigued state of the 
system, general tonic and hy- 
giene treatment is of the first 
importance in dealing with flat- 
foot. Of measures addressed 
directly to the feet the simplest 
is the method of walking in- 
sisted upon so much by Whit- 
man. The patient should be 
made to walk with the toes 
pointing directly forward ; for 
this position gives the arch the 
greatest muscular support pos- 
sible, and compels the body to 
be raised at every step. Next 
comes Exercises. — The ad- 
mirable set of gymnastic ex- 
ercises as prescribed by Ellis,19 
which consists essentially in 
raising the body upon the toes 
and slowly rotating the heels 
outwards. In addition to this 
a broad, flat, laced boot with 
a low heel should always be worn, which should prefer- 
ably have a slight inward curve to counteract the ten- 
dency of the fore foot to evert. 
Fig. 10. Tracings of rachitic feet; ages six months, two years, three years, seven years. 
19 Lancet, September 26,1885 21 
Mechanical Treatment. — The object of all mechani- 
cal devices is to prop up the arch and so prevent the 
os calcis from rolling over inwards, and the scaphoid 
and astragalus from sinking down. 
Elastics. — Of these a large number have been sug- 
gested, such as elastic spring bands passed under the 
instep and fastened to a leather strap around the calf 
(Fig. 12) ; and short steel springs fastened to the heel 
of the shoe inside, and so arranged as to press up 
against the instep. Thomas, of Liverpool, invented a 
Fig. 11. a, Case of traumatic flat-foot, b, Tracing from a case of 
Po.t’s disease. 
method of his own. By means of an incline plane in 
the sole of the boot, running from the heel to a point 
just back of the great toe, he raises the inner side of 
the foot sufficiently to transfer the weight outwards 
away from the injured internal arch. 
Pad. — Pads of every variety of material have been 
worn inside the shoe ; but they soon flatten down and 
cease to be of much service; while, if of any hard 
material, the difficulty of getting them to fit accurately 
at first is very great. With a single exception they 
have all been discarded, and that has been retained only 
as a preliminary test. If the feet are painful and 
suspected of being flat, a pad is made up of sheet wad- 
ding folded several times upon itself until it is about 22 
four by five inches, and one inch thick. By means of 
a roller bandage this pad is held firmly in place under 
the middle of the sole of the foot, and worn inside the 
stocking. If the case be one of flat-foot, the pain will 
Fig. 12. Apparatus for elastic tension (after Bradford and Lovett). 
generally be much relieved, and we can promise good 
results from the use of a plate. 
Plates. — This, which is by far the best form of flat- 
foot apparatus, consists of a thin sheet of metal fitted 
accurately to the sole of the foot and worn inside the 
shoe, generally outside the stocking. These plate? 23 
differ among themselves : (1) In their mode of manu- 
facture; (2) In their shape; (3) In their material. 
For all kinds of plates a mould or pattern of the 
foot must be taken. Whitman 20 has a most elaborate 
method for this, by which he first takes two plaster 
shells of the upper and under surfaces of the foot, ad- 
justs these together, and then by filling up with plaster 
gets an exact production of the foot, which he sends to 
the foundry and has cast in iron. Upon this model 
the plate is forged from the best twenty guage steel. 
A much simpler method is to flow plaster-of-Paris 
into a shallow trough, and when it is about to harden 
to have the patient step in it. In this negative a posi- 
tive of the sole of the foot can easily be run. 
A most ingenious method was introduced by Dr. F. 
B. Harrington, of Boston. He first marks out on the 
foot by means of a camel’s-hair brush wet with a mix- 
ture of ink or glycerine the shape of his plate. Next 
a piece of Canton flannel is pressed against the foot. 
In this way the shape is marked out on the flannel. 
The flannel is then cut out, soaked in plaster of Paris, 
wrung nearly dry, and applied to the sole of the foot 
to harden in position. When this shell is dry it is 
taken off, its concave surface (corresponding to the 
foot) filled in with fresh plaster, and when hard sent to 
the machinist, who uses it simply as a model to which 
to fit his plate. The thickness of the flannel is equal 
to that of the stocking outside of which the plate is to 
be worn. 
The method used by the writer is similar to this, only 
sheet wax is substituted for the flannel. Such wax can 
be had at the dental furnishing stores. When put into 
hot water it becomes perfectly supple, and can be 
moulded to the foot and cut to the desired shape. As 
it cools it grows hard again, and can be greased and 
20 New York Medical Journal, February 27, 1892. 24 
backed with plaster on either side according as a neg- 
ative or positive model is wanted. The advantage 
of this method is, for ordinary plates, its speed, and 
cleanliness ; while for rubber plate negatives it leaves 
the model much smoother and allows for the extra size 
needed. 
Fig. 13. Flat-foot plates (after Hoffa). 
Shape of Plate. — Next as to shape of the plate. 
The fundamental form is simply a flat sheet of metal 
as wide as the sole of the foot, extending from the 
back of the heel to the webs of the toes and bent up 
slightly on the inner side. Fig. 13, from Hoffa, shows 
such a plate. Fig. 14, from Bradford and Lovett, 
shows one a a little less large, and Fig. 15 is a photo- 
graph from a plate fitted at the Children’s Hospital. 
Held firmly by the shoe, these plates have little ten- 
dency to slip and are quite comfortable ; but they give 
only a limited support. 
Against this pattern Whitman has urged that it is 
unnecessarily heavy, and that it interferes considerably 25 
with the free flexion of the foot while walking. To 
meet these difficulties lie published in the Boston Med- 
icul and Surgical Journal. .June 1 f, IfS«S8. the descrip- 
tion of the plate which has since gone by his name 
(Fig. 16). He takes a point, A, “beneath the base 
Fig. 14. Flat-foot plate (after Bradford and Lovett). 
of the great toe just short of its bearing centre ; a point 
B, just short of the bearing centre of the heel bone 
beneath its inner tuberosity ; C, just above the head 
of the a-tragalus, a little in front and below the internal 
malleolus.” These and a “point I), on the outer 
aspect of the foot just above and behind the tuberosity 26 
of the fifth metatarsal,” he connects with curved lines 
as shown in the figures; A and B act as the two bear- 
Fig. 15. Flat-foot plate from Children’s Hospital, Boston. 
ing points for the plate, and from them, at right angles, 
runs the lever arm D. As weight is put upon this 
Fig. 16. Flat-foot plate (after Whitman, 1888). Fig. 17. Flat-foot plate (afterWhitman, 1892). 28 
plate it crowds the lever-arm down and this forces the 
body of the plate up against the calcaneo-scaphiod 
joint, and so preserves the damaged internal arch. 
The objection to this shape of plate is its unstable 
bearing, and the great difficulty of keeping it in its 
proper place. That Whitman himself recognized this 
is shown by his last publication,21 in which he figures 
a plate considerably broader on the sole, and one that 
has a flange on the outer side of the foot (Fig. 17). 
During the summer of 1891 experiments were made 
by the writer in the Out-Patient Department of the 
Massachusetts General Hospital, and a shape of plate 
very similar to the plate last described was adopted 
(Fig. 18). The points of difference would seem to be 
but two. 
(1) The flange on the outside of the foot is made a 
little higher, and carried a little farther towards the 
heel. The reason for the change is this : In order to 
pronate the foot and turn the astragalus inwards as we 
find it in flat foot, the outer border of the os calcis 
must be both raised and pushed further from the median 
line. By increasing the size of the external flange this 
tendency of the os calcis to tip over is better counter- 
acted. 
(2) The second difference is in bringing the plate 
up sharply on the inside at the point E. This gives 
an inside bearing over the whole span of the internal 
arch, and materially increases the force of the outward 
thrust of the plate ; and especially does it work against 
the formation of the zigzag internal line made by the 
displacement of the first metacarpal bone and its 
proximal phalanx as shown in Fig. 3. 
MATERIALS. 
Steel. — Lastly as to the material of the plate. As 
21 New York Medical Journal, February 22, 1892. Fig. 18. Flat-foot plate. 
has been stated, the material used by Whitman in 
New York is hammered steel, which in addition is 30 
nickel-plated or japanned. But the plating soon wears 
off, and the steel exposed to the moisture of the foot 
rusts and breaks. This happens in six months or less. 
Besides, such plates are quite expensive, costing from 
three to six dollars apiece. 
Aluminum Bronze. — Aluminum bronze is perhaps 
the favorite metal in Boston. It is somewhat heavier 
than steel, which is a serious objection. When new 
Fig. 19. Negative mould of plaster-of-Paris used in making hard- 
rubber plates. 
it takes a beautiful polish, but when worn it speedily 
tarnishes and soon soils the stockings. It is only 
fairly firm ; after a few months the constant pressure 
breaks it down, and so destroys much of its usefulness. 
Like the steel it may snap. These plates can be made 
for two dollars and seventy-five cents each. 
Aluminum. —The metal aluminum, besides costing 
about five dollars a plate, has proved too brittle to be 
of much service for adults. For children it answers 
well, where its lightness is a great gain. It is also 
very permanent. 
Bell Metal. — For cheap plates for out-patient 
clinics some experiments were tried by Dr. Bullard. 
A mould was taken with Canton flannel and plaster 31 
in the Harrington method, which, without backing, 
was sent to the foundry and used as a core for a clay 
mould. Bell metal was used for the casting. It 
gives an excellent surface and resists corrosion well. 
So far as tested it was about as tough as the aluminum 
bronze and cost only about seventy-five cents a plate. 
The greatest objection is in its weight, which some- 
what exceeds the bronze, but for out-patients this is 
less serious than price ; therefore, the plate seems to 
promise well. 
Cast Steel. — A still cheaper plate was made from 
cast steel, smoothed on a wheel and nickel plated. Its 
cost was only thirty-five cents; but as it is rougher 
than bell metal, and more liable to wear off and rust, 
it was not thought so good. 
Rubber. — An attempt has been made by the writer 
to get a flat-foot plate of hard rubber. This substance 
combines many advantages, It is exceedingly light, 
which for women and children is a great point; it is 
uninjured by water or by the perspiration of the foot, 
and does not tarnish or soil the stocking. Moreover, 
it is not absolutely rigid, its very slight amount of 
spring proving a great comfort to the wearer. The 
method of making was this : A shell of the desired 
shape is made of wax in the manner previously de- 
scribed ; it is then greased and filled up on the back 
side with plaster. When hard the wax is removed, 
leaving a negative cast (Fig. 19). This is sent to the 
Davidson Rubber Company, who -fill in the cast with 
a thin layer of sheet rubber, and vulcanize it at a tem- 
perature of 300° C. The price is one dollar and a 
half. 
During the fall, upwards of thirty of these plates 
were put in use. The result has been only a partial 
success. For light women and for children the plate 
has answered most admirably. If made after the 32 
older patterns it proved strong enough for the heaviest 
patients ; but when the outside was carried well up as 
shown in Figs. 17 and 18, the cross-strain was more 
than the ruhber could be counted upon to stand when 
weighted by a heavy adult. Yet some few of the 
plates have even under these circumstances proved 
equal to the task. Further experiments are now 
being carried on in the hope of making the rubber 
plate still stronger. 
Iu addition to the advantages already mentioned 
rubber has one more. By holding the plate for a 
moment to the flame, the shape can be altered and an 
absolute fit can thus be easily obtained. 
Whatever form of plate is used, the good derived 
from it is strictly negative. It prevents the arch from 
further breaking down, but it does not directly build 
it up. To do this one must first build up the general 
physical condition, if it is run down ; then by teaching 
the patient a proper walk, and requiring him daily to 
practice the form of gymnastics already referred to, 
we strive so to strengthen the muscies and ligaments 
that they can again perform their proper work un- 
aided. This in ordinary cases requires from six to ten 
months, after which time the plate can safely be 
omitted. A good fitting shoe will thereafter be all 
that is required. 
Fig. 20. Apparatus for stretching flat-foot (after Hoff a). Unfortunately, all cases that come for treatment can- 
not be thus easily cured. Owing to the length of 
time that the process has been going on, the extensor 
and abductor muscles may be in such a state of con- 
tracture as to resist all our efforts to replace the foot 
in its normal position. Rest in bed and massage will, 
however, usually be sufficient if the difficulty is with 
the muscles alone. Still more serious is the case when 
the bones themselves have become much displaced and 
firmly held in their abnormal relations by the products 
of the low grade of inflammation which accompanies the 
breaking down of the arch. A few forms of apparatus 
for gradually stretching the foot back into place have 
found favor. That of Hausmann, which is warmly 
praised by Hoffa, is show in Fig. 20. 
Manipulation under Ether. —The usual procedure 
in such cases is to anaesthetize the patient and forcibly 
break down the adhesions, crowd the bones back iuto 
place, and at once restore the foot to its normal shape. 
When the deformity has been thoroughly reduced the 
foot is put up in a plaster bandage in an over-corrected 
position, that is, forced adduction and flexion. After 
four weeks’ rest this plaster is taken off and active 
treatment begun. Such treatment aims at restoring 
the free and painless motions of the foot, particularly 
those of flexion and adduction. 
The foot should be soaked in hot water and thor- 
oughly massaged before any “ twisting ” is begun. The 
surgeon should then grasp the heel with the hand of 
the same side, so that the ball of the thumb may press 
firmly against the patient’s iustep ; over this, as a ful- 
crum, the fore part of the foot is forced by steady 
pressure with the other hand. When the limit of 
action has been reached the foot should be held in the 
same position until the pain caused by the stretching 
has subsided. While the foot is still so held the pa- 34 
dent is directed to flex and extend the toes, and to 
make voluntary efforts at abduction and adduction. 
This should be done once a day for at least two weeks. 
In addition to this, the cast for the plate having been 
taken as soon as the foot is taken out of plaster, the 
patient should be taught how to walk with his plate, 
and should be directed to go through his gymnastic 
exercises by himself several times daily. 
Operative Treatment. — Of operative measures but 
three have met with much favor; first, that advised 
by Ogston,22 which aims at forming an anchylosis be- 
tween the astragalus and scaphoid bones. This is ob- 
tained by removing their articular surfaces, and fasten- 
ing the bones together by means of ivory pegs in a 
correct position. 
Second, a less severe operation has been advised by 
Mr. Stokes,23 who proceeds as follows: Having ren- 
dered the parts to be operated on aseptic, he makes an 
incision an inch and a half in length along the inner 
edge of the foot, the centre of the incision being at the 
prominence formed by the head of the astragalus. 
Near thfe centre of this incision, at right angles to it 
and a little below the situation of Chopart’s joint, is 
made a second incision, and the two triangular flaps of 
skin dissected back for about half an inch. A wedge 
shaped piece of bone from the enlarged head and neck 
of the astragalus is removed with an osteotome, and 
the foot is then put up in plaster in the corrected posi- 
tion. Both these operations are open to the objection 
of leaving a stiffened joint in the centre of the foot. 
An operation which is rapidly gaining favor both in 
Germany and in this country is that advised by von 
Trendelenburg,24 which is confidently spoken of as the 
operation of the future. It is nothing more than the 
22 Lancet, January 26,1884 
23 British Medical Journal, April 18, 1885, p. 789 
24 Arcbiv. klin. Ghir., xxxix, 4. artificial production of how leg. The tibia and fibula 
are respectively chiselled through subcutaneously a 
short distance above the ankle-joint. The ankle is 
then taken under tlffc arm and the foot forcibly placed 
in the normal position. The ankle and foot are then 
put up in a plaster bandage, in which they remain for 
from ten to twelve days, after which time the bandage 
may be taken off and the position still further corrected 
if it is found necessary. No over-correction is neces- 
sary in this form of operation. After four or five weeks 
the patient can be allowed to walk about with some 
form of light apparatus. Trendelenburg claims for 
this operation that it not only returns the foot to its 
normal position, but restores its arch as well. 
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