Psychotherapy

It was not unusual to see patients who had consulted many physicians and taken all sorts of internal and external remedies for the rheumatism that they supposed was causing their discomfort, yet who had nothing more than flatfoot. Their condition had become so bad that some of them had actually given up occupations that required them to stand. Merely following the advice to wear flatfoot braces in their shoes relieved these patients almost as if by magic. There was no need to measure them particularly; all they needed was an ordinary set of flatfoot braces. Some of them needed only a pair of good shoes, but the metal braces were advised to make sure that there would be a firm support for the arch of the foot. No wonder the "magic shoe-maker" had such success in New York a few years ago.

Nearly always the shoes worn by dispensary patients are of the worst kind, considering the condition. The patients' feet are often cold, and they think this is nature's demand for heavy shoes, so they buy heavy shoes and large sizes so as to be sure they will not hurt their feet. This clumsy footgear allows the arch to drop still further because no proper support is furnished, and the foot-trouble becomes more poignant. Then working people nearly always wear older shoes on rainy days, and this makes two elements for discomfort instead of one. The yielding arch is already a source of discomfort which is more noticeable in rainy weather because any affection around a joint is more bothersome at such times. The support that a new pair of shoes affords to the arch is lacking when what are so aptly termed "sloppy weather shoes" are worn, and the consequence is that the patient is particularly miserable in damp weather.

Unfavorable Disease Suggestions.—Of the cases in my experience of so-called rheumatism in the legs, over one-half are due either to flatfoot or to the incipient yielding of the arch which is called weak foot. Rheumatism is most commonly held accountable for the condition, though gout comes in for its share of blame with quite as little justification. Occasionally some even more serious pathological condition is appealed to. I have seen the tendency to passive congestion in the feet with slight swelling around the ankle consequent upon the yielding of the arch called kidney trouble in spite of the fact that there was nothing in the urine to justify any such diagnosis. I have even known the coldness of the feet, which is likely to be a symptom of the disturbed circulation consequent upon the yielding of the arch, attributed to heart disease. As we shall see, most of the curious deformities of the old that make locomotion so difficult and so painful are due to a breaking down of the arch just after middle life and then to a progressive deformity of the foot. The mechanics of the support of the body are sadly interfered with when the arch yields, for bones are pushed out of place and ligaments and tendons are lengthened in order that the foot may accommodate itself to the new conditions. In nearly all these cases the patients are prone to say that they are sufferers from rheumatism. This diffuses and inveterates the notion which is a source of many unfavorable suggestions, that rheumatism is a curious progressive crippling disease which begins insidiously but advances remorselessly and eventually leaves its victim a prey to deformity.

Gout and Flatfoot.—Bunions consist originally of an enlargement of a bursa over the proximal end and the inner side of the big toe in order to protect the bone and joint from friction. If the irritation is continued, the proximal end of the first phalanx may enlarge, though usually this is preceded by a series of attacks of more or less acute inflammation of the bursa, when the bunion is said to "become sensitive." I have seen these attacks called gout so often that I feel sure that much of the gout reported in this country is nothing more than bunions. There is true gout, and it is probably almost as frequent with us as it is in England, but many of the so-called cases are really flatfoot associated with development of the bunion that so commonly occurs as the arch yields.

I was once asked to see a physician's wife who was thought to be a sufferer from gout. Long ago Oliver Wendell Holmes said that, as the shoemaker's children are likely to wear the worst shoes of the village, so the doctor's family is likely to take the least medicine, that is, be subjected to the least formal medication. The physician had seen the more or less acutely swollen and red enlargement of the base of the big toe, and heard his wife complain of the severe pain associated with it, and had suggested the possibility of gout. After rest in bed and the administration of salicylates and colchicum, the pain subsided and the redness and much of the swelling disappeared. This was a typical illustration of one event following another without causal relation. The succession of events was taken as a therapeutic test of the diagnosis of gout, and the patient was advised to regulate her diet so as to prevent the further accumulation of urates or uric acid in her blood. She was warned about eating red meat, about taking acid fruits, and about the acid fermentation of starchy vegetables. The main result of eating only white meat is apt to be simply a limitation in the amount of meat eaten, because white meat is less savory and after a time palls on the appetite. In the same way fruit was largely eliminated and sweets were taken out of the diet and vegetables were limited.

As she did not escape recurrent attacks of soreness in her bunion, while at the same time there were achy feelings in her foot, she took up the careful study of the dietary for gouty patients which she found in the books in her husband's library. So many things have seemed possibly deleterious for gouty people that it is not surprising that after a time nearly everything worth eating except a few cereals and milk and eggs had to be eliminated and she began to suffer from inanition. Then, after a time, came constipation, due to the insufficient amount of residue in her intestines, and this, partly by physical action but largely by mental suggestion, still further diminished the appetite for food, and a loss of over twenty pounds in weight was the result. The weakening of the general muscular system consequent upon this loss emphasized the trouble with the foot and the painful condition at the base of the big toe became more marked.

The supposed necessity for more exercise in the open air led her to walk long distances and in order to prevent her feet from hurting her, as she thought, she wore roomy shoes, distinctly too large. This is one of the common mistakes of people whose feet bother them, and it is just the wrong thing to do, since a snug, well-fitting shoe provides both support and protection. It is not surprising that the attacks of sub-acute bursitis became more frequent and more painful.

It was then that I saw her, and, as I feared to disturb the family harmony by suggesting that the whole trouble was a bunion and flatfoot, I compromised by saying that, while there might be some gout, there was undoubtedly flatfoot, and if she would wear the proper sort of shoe and stop limiting her diet so strenuously, and cease suggesting to herself that she had a progressive gouty affection that would lead to deformity and decrepitude, she would soon be much better.

It required tact to make her look favorably on this advice, after all that she had gone through during months of limited diet and enforced exercise. Though not quite convinced, she was ready to try the new method. She began to be better as soon as she was fitted with a pair of shoes that supported her arch and as soon as her increased nutrition began to make itself felt. At the end of two weeks she was able to give up the remedies for constipation that she had been using for nearly a year, while at the end of four weeks she had regained ten pounds of weight and felt much better.

Several years have passed since I saw her professionally and occasionally I hear from her only to be told what a great measure of relief it afforded her and how much better she has been as a consequence of a few simple directions with regard to her feet. I have seen at least a dozen of cases of so-called gout in educated people which followed almost exactly the same course and yielded promptly to the same treatment. The hardest symptom about these cases to cure is the cherished mental conviction that they are the victims of constitutional disease, either gout or rheumatism, to which all their symptoms are attributed. They are cases for psychotherapy more than any other form of therapeutics and need for a considerable period to have repeated assurances of the entirely local character of their affection.

Bunions and Flatfoot.—The etiology and preventive treatment of a bunion has always seemed to me to bear a closer relation to a flat foot than to anything else. The flatfooted man has nearly always a tendency to bunions. The explanation of this is not difficult if one traces the relation between the tendons that run around the arch to the big toe. The usual etiological explanation, however, is that in youth short shoes were worn which initiated a tendency to divert the big toe inward toward the other toes. But there are many reasons against this explanation. Anyone who tries will find that it is practically impossible to wear shoes that are so short that the big toe is crowded back. Women are more apt to shorten their shoes than men, yet women suffer both from flat feet and from bunions much less than men. The reason for this seems to be that the forward position with the elevation of the heel of the shoe supports the arch and gives the shoe a shape more fitted to the normal foot than is found in the masculine flat-heeled shoe. Besides, this form of shoe maintains its shape better, and then, too, women are not so prone to wear old so-called comfortable shoes as are men.

The mechanism of the formation of the bunion in many cases seems to be, that the large toe, instead of lying straight along the inner edge of the foot, is pushed or pulled toward the other toes. If this process began from the wearing of pointed shoes, especially if such shoes did not have a straight line on the inside, conditions within the foot would soon tend to emphasize it. If the adductor hallicis once gets the habit of contracting rather strongly, as it is likely to do through the irritation set up by the yielding of the arch, it will be hard for its opposing muscles to counteract it. More important than this, however, is the fact that the tendon of the flexor longus hallucis runs along the inner border of the foot and is particularly affected by the yielding of the arch. For it works at a decided mechanical disadvantage under the new conditions and is stretched in such a way as to pull forcibly and constantly upon the big toe, necessarily turning it more and more outward as the arch continues to yield. The dropping of the arch makes the distance from the heel to the toe longer than before and the tendon pulls the toe as far outward as possible to compensate for this, as the distance to its insertion is thus made somewhat shorter.

The yielding of the arch lengthens the foot and puts the tendons of all the flexors on the stretch. All of them have a tendency to bend the toes, and as this action is constant, gradually the tendons of the extensors become over-stretched and these muscles are not capable of exerting their full force in overcoming the action of the flexors. The flexor longus digitorum has a tendency to cause a bending of the small toes, and as it also runs across the foot it pulls the toes somewhat inward, that is, toward the big toe. This crowding leads to hammer toes and over-riding. The big toe, however, is maintained in a state of extension by its firm, full contact with the sole of the shoe and with the floor when walking barefoot. The one direction in which it can yield rather readily is outward toward the other toes because this shortens the distance between the end of the toe and the heel. The pressure put upon the flexor longus hallucis will have a tendency to cause this, for it is over-stretched by the yielding of the arch and keeps constantly pulling on the big toe until that member has a distinct flexion outwards.

This makes the metacarpo-phalangeal joint prominent and then nature proceeds to protect it by a water cushion, a special bursa due to the formation between layers of connective tissue of a pocket in which some serum is constantly present. One can scarcely admire enough this provision of nature by which she protects prominent bony points whenever they are subject to much irritation or to such use as would cause injury to important structures below. If continued pressure continues to be irritating, however, the water cushion proves unavailing and an inflammation of the overlying skin occurs with occasionally a spreading of infectious agents from the surface into the serum pocket below. This serum is such a good culture medium that an acute abscess is likely to form—the acute bursitis of the surgeons.

Rarer Foot Troubles.—Besides bunions, a number of other deformities of the feet occur as a consequence of the yielding of the arch. All the toes are likely to bend rather acutely, and the points of them are pressed against the shoe, while the knuckles, so to speak, are made prominent and are more likely to be subject to corns than would otherwise be the case. Besides, the displacement of the big toe toward the little toes leads to a crowding of the toes together, and this gives rise to soft interdigital corns and to a lowered resistive vitality which may be the predisposing factor to slight infections of various kinds that will make the patients miserable. Such affections may appear negligible, a matter for the chiropodist, and not deserving the physician's attention; but they mean so much for the comfort of the patient and the prevention of exercise through sore feet reacts so deleteriously on the general health that these minor ailments become important and merit careful attention. Dr. Emmet tells the story of the old family servant, always grumpy and complaining, who, when he had the many blessings of life pointed out to him, confessed that the Lord had been very good to him, but said, "The Lord knows He takes it out of me in soft corns."

Hammer Toes—Clam Toes .—Nature has provided a wonderful mechanism in the arch of the foot and the anatomical relations of the toes to support the weight of the body firmly, gracefully, and comfortably; yet any yielding of any part of it leads to a disturbance of its delicate mechanical relations and, consequently, to ever-increasing deformity. Hammer toes are typical examples of what such a disturbance may lead to. One of the toes becomes pressed downward between two others. This over-stretches the extensor muscles and tempts the unbalanced flexors to contract. As the extensor muscles become, after a time, unable to work in the constantly bent toes, they atrophy to some extent and then the flexor muscles pull the toe farther and farther down until there is no possibility of its being straightened at all. Now, if the flexor tendons are cut and the toe straightened the atrophic extensor muscles will not hold it in that position, and when the flexors grow together the old condition will reassert itself. In the meantime, muscle changes in the neighboring toes have also taken place. With no resistance on one side of them, they become bent sidewise over the hammer toe, and so their muscles on one side are overstretched and on the other side become contracted. After a time it is impossible to correct this series of deformities which are being constantly increased and emphasized by the weight of the body above.

Present-day Shoes.—In recent years we have heard much more than heretofore about foot troubles. As the old-fashioned shoes were carefully made by skilled shoemakers to fit the feet of one individual and not to conform to some supposed ideal pedal extremity, they supported the feet much better than do the modern cheap machine-made shoes. These custom shoes lasted a long time, and, after they were once molded to the foot, the wearer was not disturbed for many months by the process of having to become accustomed to another shoe. The many advertisements in quite recent times of foot powders and other artificial relief for the foot show that people are suffering much more than before, or, at least, are less able to bear the discomfort. These powders, however, are not likely to do good in the long run, since they tempt the wearers to stand the discomfort against which they do furnish a certain amount of soothing. It is much better, however, for the sufferer to find the cause of the discomfort and to remove it if possible, for otherwise it will lead to constantly growing displacement of bones and muscles and may eventually even bring on actual and ever-increasing deformity.34

Prophylaxis.—The most important means of prophylaxis in these cases is to have patients who must assume the standing position for some hours each day, exercise their legs rather vigorously. If teachers, lecturers, and the like, have to stand for a long time, it is important that on the way to and from their occupations they should not have to stand up in cars nor assume cramped and uncomfortable positions. It would be better for them to walk rapidly for several miles rather than ride in a standing or a constrained position. If they are convinced of the necessity for exercise, there is much less likelihood of the development of the severer discomfort that is sometimes very discouraging. It is particularly difficult to make women understand this; yet, once they have found how much relief is afforded by vigorous exercise, they are likely to overdo it and thus run the risk of incurring ills quite as serious as those consequent upon not taking enough. In nervous people the nagging discomfort of a yielding arch will sometimes (just as eye strain does) produce reflex headaches, constipation, lack of appetite, and apparently predispose to the frequent recurrence of migrainous headaches. I have, in not a few cases, seen these conditions relieved by rational treatment of the foot condition.

Circulatory Disturbances Due to Flatfoot.—An interesting direct consequence of flatfoot is the disturbance of the venous circulation, which is likely to bring about some swelling of the feet and nearly always considerable coldness and numbness, particularly in the winter and, above all, on damp days during cold weather. The swelling of the feet makes the patient think—sometimes at the suggestion of his physician—of kidney trouble or heart trouble, and sometimes it is hard to persuade him that there is nothing serious the matter with these important organs. The disturbance of the circulation further leads to numbness, to some anesthesia, and to paresthesia. Corns and especially callouses grow more readily between the toes, and patients who are prone to read about such ailments may conclude that they are suffering from hypesthesia and hyperesthesia due to some serious progressive organic nervous disease. I once had a woman patient discourse learnedly to me about these things who was sure that she had the beginning of some incurable spinal disease. Locomotor ataxia was the least she might expect from her description of her feelings. What I found was flatfoot. Raising her arch cured her.

The cold feet and the numbness, to call them by simple Saxon names which will not disturb patients, may sometimes keep them awake. In the chapter on Insomnia we suggest that the best thing for this is to secure a return of the circulation either by exercises, or by wearing a flatfoot brace during the day, or by putting the feet in water as hot as can be comfortably borne and keeping them there for a quarter of an hour. Of these means exercise is the best. Raising up on the toes after the shoes are off and coming down on the outside of the foot strengthens the muscles, pulls the bones of the arch firmly together and encourages the circulation. For beginning flatfoot this is a curative measure and it is the natural mode of treatment for the coldness and numbness of the feet. Rubbing, also, is good for the feet in order to restore the circulation, but patients are inclined to rub downwards while they should rub upwards in order to help the hampered venous circulation. The thin-walled veins are more likely to be compressed by any disturbance of tissues than are the firm-walled arteries, and it is to help the veins that our remedial measures must be directed.

Secondary Consequences.—The secondary consequences of flatfoot are interesting. It is surprising how many people who frequently suffer from sprains of the ankle have some yielding of the arch as a predisposing factor to that condition. Two classes seem to suffer frequently from sprained ankle—those with yielding arches and those with high insteps. Apparently there is weakness in the excess in both directions. Very flatfooted people apparently do not suffer so frequently from sprained ankles as those in whom there is only an incipient yielding of the arch. They seem to have learned to walk more circumspectly. Perhaps, too, their well-known tendency to toe outward lessens their liability to turning on their ankle. The effects of sprains of the ankle in people with weak foot last, as a rule, longer and leave more weakness after them than they do in ordinary cases. This, of course, might be expected, but it is surprising how often the significance of beginning flatfoot fails to be noticed even by the physician. I have seen rather frequently cases of so-called chronic rheumatism in which there is a series of stories of sprained ankle because of the assumed weakness of the ankle from supposed rheumatism, when the whole case can be summed up in a yielding arch.

Exercises.—If the arch has not yielded much, it is often unnecessary to prescribe flatfoot braces or arch supports of any kind, unless perhaps at first. After the first soreness has passed off, exercises may be employed to strengthen the muscles. As we have said, the patient should rise on his toes and then come down slowly on the outside of his feet. He may be instructed to sit with his feet—not his legs—crossed, the feet resting on their outer edges. He may be shown how even various slight movements of his toes, almost without moving his shoes at all, will strengthen the muscles that pass around the arch, which, thus strengthened, will hold the bones of the arch firmly together and prevent further yielding. There is, at the present day, a tendency to recommend too freely the wearing of flatfoot braces or arches. After all, these are only crutches and should not be worn unless absolutely necessary. If the arch can be strengthened—as it can be in many cases—so as to bear the body weight without discomfort, then this is much the better treatment. If the arch is restored the feet are in a more natural condition, while artificial support leaves the muscles without that exercise which will preserve their functions. Flatfoot braces may be necessary, but only if absolutely necessary should they be advised, and palliative measures, such as exercise, manipulations, and rubbings, should be given a fair trial after the unfavorable suggestions as to his foot condition have been removed from the patient's mind.

Significance of Foot Troubles.—We have devoted much space to foot troubles—more, perhaps, than will seem justified to the minds of many physicians. We have done so, however, because of the firm conviction that the feet are the source of more discouragement and depression of mind than any other part of the body. Life very often takes on another aspect when foot troubles are relieved. In the old, progressive deformities of the feet consequent upon mechanical disturbance are probably the source of more discomfort, and by their interference with exercise and outing, the cause of more ill-feeling and even disturbance of health than any other single factor. Even life may be shortened by the confinement or limitation of movement consequent upon bad feet. Above all, the idea that any constitutional trouble, or hereditary disease, is at the bottom of their affliction must be removed, and then these patients are encouraged to live their lives more fully and with more happiness for themselves and others. Hence this long chapter.