I have learnt from Capt. James Patterson, C.A.M.S., of Vancouver, a large part of my present knowledge of boots, and it was he who first showed me the "foot-drill" described when dealing with claw-foot. He kindly provided me with photos, from which Figs. 154 to 157, inclusive, have been taken; and it is largely due to his work, and to the interest that he inspired me to take in "foot conditions" generally, that I am able to enter into far greater detail now than I accomplished in the first edition of this book, The boot or shoe must be three boot-sizes longer than the actual length of the foot (measured without any portion of the body-weight being placed upon it), if any degree of "shaping" at the toe is to be allowed. Two and a half sizes is enough if the toe is to be built rigidly to the shape of the foot; but this few patients will allow, as the shape of the boot will then be triangular with the base of the triangle forward. A greater allowance even than the three sizes must be made if any considerable degree of "pointing" at the toes is demanded. When we remember that a "boot-size" is usually taken as three-eighths of an inch - some boot-makers count it as one-third - it follows that most boots, and particularly those built for ladies, are made or fitted too short. Moreover, it must be remembered that the foot is usually measured without the body weight; when weight is placed upon it, the foot may show an increased length of a full size, or even more. The breadth of the "upper" also requires attention. The inner side of the boot must be straight, or even slightly sloped inwards, right away from the "waist" of the shoe up to the extreme tip. The common build of boot, where the inner side slopes outwards from the level of the first metatarso-phalangeal joint, is fatal to success. There must also be room for each individual toe to rest flat upon the ground in full extension and in a straight line with the mid-line of the corresponding metatarsal. The only place where "snugness" can be permitted at all in the fore part is just behind the heads of the metatarsals. Everywhere in front of this the foot must be absolutely free to move and, if necessary, to expand.

The sole should be flat and not, as is so common, built to slope upwards from the level of the metatarsal heads to the front end of the sole; and the slight convexity from side to side, which is so commonly seen, should be done away with.

It is evident, therefore, that most patients with foot trouble must be shod with footgear far larger than they are accustomed to wear. If it is procured ready-made the result will be bad, for the back part will fail to fit. If, on the other hand, the heel and the "waist" part of the upper are made to fit, the unwonted size elsewhere will only tend to comfort. The result of the finished article does not sound alluring. As a matter of fact a perfect boot, from an anatomical and remedial point of view, can be made to appear quite "presentable." But it will be large.

It cannot be too strongly emphasised that the ordinary plan of blocking out hollows in the sole or bulges in the upper is merely a makeshift. It may give relief, but it is usually temporary and is in no sense remedial. It is, in fact, treating a symptom and not the cause, and the general result is aggravation of the condition. Other devices, such as arch supports and "building up the instep," should be placed in the same category. Any or all may help to keep a patient in comfort, and this is saying a great deal; but they do not cure, and the patient is rarely able, even with their aid, to lead an active life or even to take full advantage of a holiday which entails much active exercise. Some are content not to do either: for them palliative measures are all that are required. A few patients - very few comparatively - are well-nigh (if not quite) incurable, and for these again, bars, supports and so forth are of the greatest service. But many a patient finds his foot trouble a handicap in life - for business or for pleasure - and for him any chance of recovering a usable foot is worth offering. Given proper footgear and given perseverance with exercises, it is often surprising to see how great an improvement can be secured.

If, however, there is any trace of osteo-arthritic change in any of the joints posterior to the metacarpo-phalangeal joints, the outlook should be regarded pessimistically. Recovery is, to all intents and purposes, impossible, and the only hope of relief - if free mobilisation fails us - is to attempt so to fix our patient's footgear that movement at the affected joints is reduced to zero.

If treatment is useless in the absence of proper foot-gear, so, too, the latter is usually insufficient to cure without other definite remedial measures in the form of exercises or foot-drill and, in severe cases, of splintage.

The flat-foot "drill" has been already dealt with so far as the earlier exercises are concerned (see Chapter XX (Re-Education In Walking).). Those that follow (designed for the treatment of claw-foot more particularly) may also be added. But the two points on which emphasis should be laid are the necessity for keeping the quadriceps taut while standing, and for sitting with the feet crossed so that "clawing" may be practised at every opportunity. The patient should be taught to mould the foot into its proper shape at least twice a day. Flat-foot of itself is not a disabling condition. Every ballet-dancer is flat-footed as judged in the rest position. In activity, however, the mobility of the foot-joints at once allows restoration of the shape of the longitudinal arch, and it is the loss of this mobility which is the cause of trouble in cases of painful flat-foot. Recovery cannot therefore take place until mobility has been restored. The patient should also be instructed to have the heels of all shoes and boots wedged so that the inner border of the heel is raised. Half an inch for an adult of about six feet and about a quarter of an inch for a child is sufficient. The wedging is often done most ineffectively. It should be so arranged that the end of the back seam is vertically above the centre of the heel when the latter is resting on the ground. The outer side of the heel should be vertical and not sloped inwards. Finally, the whole surface of the heel should be covered with rubber, and this should rest flat upon the ground when the outer edge of the sole also rests upon it. It is very common to find that the wedging has been done so that the slope of the heel renders stability insecure, or that the weight of the body rests mainly on the outer of the two sharp angular points at the front of the heel. Both are radical errors.