holding the foot rigid, causing the patient to walk with that characteristic flat foot gait, slouchy, stiff, stumping along on his heels. The subjective symptoms at this stage are pain in various parts of the feet or in the calf muscles. The pain increases during the day, as the patients stand on their feet, and they feel better in the morning after the night's rest. The patient has difficulty in walking up and down stairs; after a period of rest during the day, the foot, upon using, is very stiff and painful for several minutes.

TREATMENT. In mild cases passive movements of the foot should be carried out to the full limit at morning and night, at the same time actively exercising the muscles by standing with the toes together and the heels far apart, then rising on the toes. Besides this, the patient should wear a proper insole to support the arch. In more severe cases, where there are dislocation of the astragalus and muscular spasm, it is necessary to reduce the dislocation and overcome the spasm. This may be done by forcible correction under an anesthetic and the application of a plaster of Paris bandage in the

overcorrected position. After the plaster of Paris is dry, the patient is encouraged to walk about as best he can. The bandages are removed after from three to five weeks. Casts of the feet are taken and steel plates carefully modelled upon these casts. Another method is by the use of the Krukenberg pendulum apparatus (see illustration). This gradually reduces the dislocation, relieves the spasm, and within a short time effects a complete cure, the patient actively assisting in the cure. After exercising from ten to fifteen minutes in the machine, the patient at once experiences great relief from pain and spasm and the foot will readily follow all passive movements. A valuable therapeutic measure is the application to the foot of rubber adhesive strapping. The foot is inverted as much as possible. Two broad strips of plaster are placed on the outer side of the leg, passed under the foot, and held tightly on the inner side of the leg. Narrow strips of plaster are now passed in a figure of eight fashion around the ankle. This dressing gives good support for from ten to fourteen days and may then be renewed. A simple but ofttimes efficacious remedy is the building up of the shoes to of an inch on the inner side.

FLAT FOOT OF CHILDREN

595

FLAT FOOT OF CHILDREN

Children do not naturally have flat foot. On gross inspection we find the inner border of a child's foot touching the ground. It is apparently flat, and if we take an impression of the foot we find that almost all of the sole makes its imprint. If, however, one closely examines the foot, one will find in place of an arch a thick pad of tissue which gives the idea of a flat foot. This pad is a protection to the normal arch, which is always present. And when we say that the arch is formed in later childhood, we simply mean that this protective pad has disappeared, its function having been served, for now the muscles and ligaments have become firmer and the arch strong enough to bear the weight of the body.

Typical cases of weak foot, however, sometimes present themselves, and we find them in rhachitic children or those whose muscles in other parts of the body are weak or where a child is growing rapidly and the muscles are not able to keep up with the growth.

Flat foot is often associated with knock knee. The symptoms are pain in the arches and calf so that after a little exertion the child tires easily and cannot walk far. There is rarely muscular spasm. On examination we find a thin foot with the normal pad of tissue under the arch missing and the bony structure easily palpable. The head of the astragalus is prominent under the internal malleolus and on the patient's standing we find the arches sunken.

The treatment for these cases is by a perfectly fitted Whitman flat foot plate and massage of the foot, with exercises for strengthening the muscles, for only in cases where a positive diagnosis of flat foot is made should any appliance be worn.

The promiscuous use of corset shoes, ankle supporters, high counters, and elastic anklets is distinctly harmful in that they tend to further weaken the foot by interfering with its function, and are to be discountenanced.

CHAPTER XXIV

OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM-Concluded

MASSAGE, SWEDISH MOVEMENTS, VIBRATORY STIMULA.. TION, AND HOT AIR TREATMENT

REMARKS ON MASSAGE AND SWEDISH MOVEMENTS

The Value of Massage and Movements. It is often an important question to decide whether motion or rest should be employed in the treatment of disease. As a general rule it may be stated that rest should be made use of in all acute conditions of disease when the normal activities are in excess, whereas motion should be employed in all chronic conditions when the normal activities are deficient or in abeyance. Again, there are many cases, both acute and chronic, in which the rest of some part could be combined with motion of other parts of the body.

We speak of two kinds of motion, active and passive. The active motions comprise those which originate in the will of the patient and are executed without assistance. The passive comprise all movements executed and controlled by an alien power, independent of the will of the person operated

upon.

The familiar forms of massage are rubbing, kneading, tapping, rocking, and stroking. Vibratory massage is another valuable form of motion. When the patient is more or less vigorous, the simple, or active motions may be employed; when the patient is debilitated, the passive movements or a combination of both are more effective.

Movements systematically employed may be strengthening movements, such as flexion, extension, torsion, etc.; or stimulating movements, as by percussion and vibration; or quieting movements, as by rotation and friction; or purgative movements, such as kneading, pressing, and active movements on the bowels.

Some movements have a special effect on respiration; others on the circulation. Movements may be so applied as to affect any organ or portion of the body, increasing vital action when it is deficient and decreasing it when it is in excess. Movements cause an increased flow of blood to the muscles and soft parts, thereby increasing the circulation and removing accumulations of waste products. They cause absorption of exudations, transudations and infiltrations, and often effect a separation of adhesions in tendon sheaths and joints.

Movements relieve congestion of the brain, lungs, intestines, uterus, liver and kidneys by increasing the flow of blood to the muscles. directly stimulate the sympathetic nervous system.

They

MASSAGE AS AN AID TO THE CIRCULATION

597

From the foregoing remarks it must be evident that some ailments can be cured more quickly by this method than by any other, but in the majority of cases, massage is simply a part of the general management. In some cases it should be resorted to only as an after-cure or as a means of exercise.

Massage and movements are useful in disturbances of the nervous and circulatory systems and of the respiratory organs, in neuralgia, rheumatism, muscular weakness, gout, paralysis, writer's cramp, insomnia, anæmia, chlorosis, chronic heart disease, cold hands and feet, dyspepsia, constipation, spinal curvature, flat chest, round shoulders, sprained ankle, stiff joints, fracture, etc.

Massage Treatment of the Digestive and Pelvic Organs

Abdominal massage is performed in many ways according to the indications. It may be confined to the superficial structures or may be directed to the deep seated viscera. The principal movements for this treatment would be friction, kneading, and vibration.

Friction is given by placing both hands over the abdomen, following the direction of the ascending colon and transverse colon on the right side. and the descending colon on the left. Such treatment is given a number of times in frequent succession to patients who suffer from indigestion, dyspepsia, and constipation.

Kneading is confined to the superficial structures of the abdomen. The operator takes hold of the flesh and lets it roll through his hands, starting from the middle and working toward both sides.

Vibration massage is used with very good results in cases of chronic dyspepsia and catarrh of the stomach. The manipulation should never take place immediately after a meal.

Generally speaking, abdominal massage promotes peristalsis of the stomach and intestines, facilitates the passage of food and fæces, and takes the place of active exercise in all cases of enforced idleness. In fact, all palpable viscera may have the benefit of massage and vibratory massage treatment. Therapeutic palpation and massage of the pelvic organs, in both male and female, are regularly employed and give excellent results in chronic congestion and indurations in which operative treatment is not called for.

Massage as an Aid to the Circulation of Blood and Lymph

Daily muscular contractions by means of exercise aid the circulation of the blood and lymph by causing a pressure on the arteries, veins, and lymph channels. The act of breathing also exerts a suction pump action on the circulation, drawing the blood toward the heart. Muscular contractions produce a pressure on the walls of the veins whereby the blood is forced toward the heart. It has been shown that effleurage stimulates the superficial muscles, produces dilatation of the superficial vessels and insensible perspiration, excites the skin reflexes, and, acting through the cutaneous nerves, increases the rapidity of the circulation and the heart beat. Massage forces the lymph out of the muscles, increases the velocity of the blood current through the part operated upon, and temporarily decreases the size of a limb while increasing its muscular power.

With the aid of massage and movements, a better distribution of the blood is affected. Through this the nourishment of the whole body is improved. The heart also will thus receive its due nourishment, and retain or regain its power to force the blood regularly to all parts. An irregular

action of the heart may disappear, the blood will pass more easily and with less obstruction through the lungs, and respiration will become deeper and easier.

Treatment of Stiff Joints by Massage and Movements

The greatest care is required in the treatment of joints, since it is quite possible to provoke fresh inflammatory action by rough handling. When massage is carried out without violence and with good judgment, it gives better results than any other form of treatment. The pain and discoloration will in a very short time disappear, the tension diminishes as the products of inflammation are carried off, the fever temperature falls, the natural outlines reappear, extravasated blood is dispersed, and adhesions between the torn and bruised surfaces are effectually prevented.

Treatment of Sprains by Early Massage

It is a well known fact that massage is of the greatest value in both acute and chronic cases. The earlier the patient receives treatment the sooner will he enjoy its good effects. Immediately following the injury the parts are very tender; perhaps the whole limb is swollen, the joint distended with blood and very hot to the touch.