CLUB-FOOT (Talipes). The pathology and treatment of the various deformities of the foot, which are included under the above general title, come strictly under ortho-paedic surgery. Several forms of club-foot have been recognized by surgeons There are four primary forms :— (1) Talipes equinus, in which the heel does not touch the ground, the child resting on the toes; (2) Talipes varus, in which the foot is turned inwards and shortened, the inner edge of the foot raised, the outer edge of the foot only touching the ground ; (3) Talipes calcaneus, a rare form, in which the heel only touches the ground, the toes being raised; (4) Talipes valg\ts, in which the foot is turned outwards. The third and fourth varieties are so rare that they are of no practical interest, and need not be further alluded to. It is possible to confound true talipes valgus with flat-foot, a deformity which is the result of undue stretching, from weakness, of the fascial and ligamentous structures which maintain the arched form of the foot. In flat-foot the arch is lost, the patient is splay or flat-footed, and as a secondary deformity the foot is turned outwards, resembling and often confounded with true talipes valgus.

The two common primary forms of club-foot are talipes equinus and talipes varus. These two varieties are frequently combined ; thedeformity is then termed talipes equino-varus. A shortening or contraction of one group, or of allied groups, of muscles is always to be observed; as, for instance, in talipes equinus, to which the muscles of the calf are con-tracted, or in talipes varus, in which the group of muscles which turn the foot inwards are contracted, or in talipes equino-varus, in which both sets are at fault. This con-traction is due either to excessive primary irritation of the muscular group implicated, or is secondary to and the result of paralysis of an opposing group of muscles. In certain cases ths paralysis affects more or less all the muscles of the limb ; the result of this is a deformity in the direc-tion of the most powerful group. The primary cause of these diseased conditions is some irritation of the cerebrospinal central nervous system, either occurring before birth, and termed congenital, or appearing after birth, generally during theperiodof first dentition,andtermednon-congenital. As a rule well-marked cases are congenital. Such deformities are frequently hereditary. Both feet may or may not be affected. Recognition of club-foot is of import-ance, because if not treated early a change takes place in the shape of the bones of the foot, which renders treatment much more difficult, and in some neglected cases it is impos-sible to restore the foot to its normal shape.

It is to Stromeyer in Germany (1837), and to Little and Adams in England, that we owe a true understanding of the pathology and treatment of these affections.

The following broad principles, which govern the treat-ment, are now universally understood and adopted by sur-geons:—(1) A subcutaneous division, by the operation of tenotomy, of the contracted tendons; and (2) A stretching of the newly formed embryonic tissue which is deposited between the cut extremities of the tendons in the inter-space, the result of their retraction after division. This is managed by means of a mechanical appliance termed a club-foot boot. Various forms of boot have been used by surgeons ; in all the essential feature is that the foot is fixed to the boot by sticking-plaster or by straps, and the stretching is gradually accomplished by the elasticity of Indian-rubber bands, or by steel springs, or by screws. In this way the foot gradually assumes a normal appearance.

As a general rule, after it is evident that the deformity is a persistent one, the earlier the operation is per-formed the better. Only in exceptional cases should interference be delayed beyond the third or fourth month of life. If a change takes place in the bones, or if the child is allowed to walk before treatment of the deformity, the cure is rendered more difficult and more tedious. In many cases when the child is young the cutting operation will not be necessary ; the foot can be restored to its normal position by mechanical appliances alone.

Various rules have been laid down for the proper performance of tenotomy. The simple rule to begin with the most tense tendon, and to divide it where it is most tense, is of universal application. In talipes equinus the tendo achillis, in talipes varus the tibialis posticus and tibialis anticus require division. In the common form talipes equino-varus, both groups must be operated on. Very frequently the plantar fascia is shortened and has also to be divided. After the operation, which is greatly facilitated by the administration of chloroform, the foot is kept at rest with a bandage for three or four days until the small punctures are healed. The boot is then carefully applied, and gradually the foot is restored to its normal shape without causing pain, which interferes with the object in view, namely, a moulding (by stretching) of the newly-formed tissue between the divided ends of the tendons If there is distinct paralysis the appropriate remedies—friction, passive exercise, and the electric battery—may be indicated. The boot should be worn for some time after the foot has regained its normal appearance, because there is always a tendency for a considerable period to the return of the deformity. (j. o.)