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ON

CLUB-FOOT

AND

ANALOGOUS DISTORTIONS,

INVOLVING THE

TIBIO-TARSAL ARTICULATION.

CHAPTER I.

INTRODUCTION.

ORTHOPÆDY, a term derived from 6o0os, straight, and

ὀρθὸς,

Tadior, a child, was introduced into the language of science by Andry. "From these two words I compose," he says, "the term orthopedy, to express in one word the design which I propose to myself, of inculcating the means of preventing and correcting in children deformities of the body."1

Orthopaedic surgery, at the present time, comprises the treatment of congenital and non-congenital distortions of the trunk and extremities; such as curvature of the spine,

'L'Orthopédie,' par M. Andry, Conseiller du Roy, Lecteur et Professeur en Médecine au Collége Royal, Docteur Regent, et ancien Doyen de la Faculté de Médecine de Paris, tome i, p. 2, 1741.

distortions of the neck, the globe of the eye, the hands, feet, &c., whether produced by abnormalities of skin, muscle, fascia, bone, or ligament; and also those which result from chronic affections of joints, and terminate in partial displacement of the articular surfaces, or in muscular retraction.

Mention is made of some of these affections by Hippocrates.

"In all the works on ancient surgery, I verily believe," says his translator, "there is not a more wonderful chapter than the one which relates to Club-foot, § 62. In it he has not only stated correctly the true nature of this malformation, but he has also given very sensible directions for rectifying the deformity in early life. Now it appears to me a lamentable reflection, as proving that valuable knowledge after being discovered may be lost again to the world for many ages, that not only did subsequent authorities, down to a very recent period, not add anything to the stock of valuable information which he had given on the subject, but the important knowledge which he had revealed to the profession came to be disregarded and lost sight of, so that, until within these last few years, talipes was regarded as one of the 'opprobria medicinæ.'” 1

In the 62d chapter of the Book "On the Articulations," he says:

"Most cases of congenital club-foot are remediable, unless the declination be very great, or when the affection occurs at an advanced period of youth. The best plan, then, is to treat such cases at as early a period as possible, before the deficiency of the bones of the foot is very great, and before there is any great wasting of the flesh of the leg. There is more than one variety of club-foot, the most of them being not complete dislocations, but impairments connected with the habitual maintenance of the limb in a certain position."

The Genuine Works of Hippocrates,' p. 560, vol. ii. Sydenham Society's Edition.

Directions are then given for the application of bandages to remove the deformity, wherein is expressed, as has been well said by M. Jules Guérin, all that is required to be done for the reduction of varus. After the bandage has been

applied,

"A small shoe made of lead is to be bound on externally to the bandaging, having the same shape as the Chian slippers had. . . This, then, is the mode of cure, and it neither requires cutting, burning, nor any other complex means; for such cases yield sooner to treatment than one would believe. However, they are to be fairly mastered only by time, and not until the body has grown up in the natural shape." 1

It is clear from this chapter that the nature of the affection, and the mechanical treatment necessary for the removal of the distortion, were understood by Hippocrates; and, as Dr. Little has remarked, a doubt may be entertained, in consequence of the allusion to cutting in the last sentence quoted, whether he ever practised or witnessed the section of tendons for club-foot.

For 2000 years and more, nothing of importance was added to the knowledge collected by Hippocrates on this subject, and handed down to us by Polybus. The subject of club-foot occurs, however, in the works of several authors; as for instance, in those of Ambroise Paré, Lyon, 1641; M. A. Severinus, Francof., 1643; Arcæus, Amst., 1658; Fabricius ab Aquapendente, Lugdun. Bat., 1723.

Arcæus describes the process by which distortion is to be removed, and figures an apparatus and a boot, by means

Op. cit., vol. ii, p. 634.

of which he was accustomed to treat this deformity. (Vide figs. A and B.)

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Du Verney, in his work, Traité des Maladies des Os,' 1751, devotes a chapter to the subject, "Des Pieds bots." He recognises muscular retraction as the cause of club-foot, and describes the distortion as due to the influence of the muscles and ligaments. He writes of varus and valgus, "these distortions depend entirely on the unequal tension of the muscles and ligaments; for those muscles which are extremely tense draw the parts towards them, while their antagonists yield, being relaxed.”

Blumenbach, Naumberg, and others, advanced and supported incorrect ideas of the disposition of the tarsal bones, and of the causes of club-foot.

In the eighteenth century, Venel, of the Canton of Berne; Wanzel, of Tubingen, who was himself cured of club-foot by Venel; Ehrmann, of Frankfort; Jackson, in England; Brückner, in Gotha; Tiphaisne and Verdier, in France, treated these affections empirically.

At the commencement of the present century, Scarpa,

the illustrious professor, of Pavia, published his work on club-foot, in which he maintains the opinion entertained by Hippocrates, that the tarsal bones are not dislocated, but twisted on their smaller axes: he contends that the primary disturbance is in the osseous system, and that consequent on this displacement, the muscles are elongated or retracted, according to their position. He describes and figures an instrument for the removal of varus, which is still in use for that distortion.

Palletta,

de loxarthro,' states his belief, that the malleolus internus being wanting, or in part deficient, is the primary cause of varus.

"In nonnullis interior malleolus aut deficere, aut certe brevior esse videbatur, ut propterea pes adducentium musculorum actionem sequeretur. In plerisque autem, in quibus malleolus certe non desiderabatur, caussa, ob quam pedes interius converterentur, videbatur in aucta musculorum adducentium actione consistere, qui pedem ad naturalem figuram restitutum, mox in interiorem partem contorquebant." 2

Rudolphi is perhaps the first who arrived at a more correct view of the causes of varus. He saw that club-hand and club-foot were analogous distortions, not dependant on extrinsic causes, and frequently occurring in young children from irritation and spasmodic action. He says:

"I presume that club-hand and club-foot in the foetus arise alone through morbid nervous influence acting on the muscular system. Those who believe in an extrinsic, mechanical cause, as pressure, through an unnatural position, cannot be aware that distortions of this kind have frequently been found in the embryo as early as the third or fourth month."

1 Memoria Chirurgica sui Piedi torti Congeniti dei Fanciulli,' Pavia, 1806. 2 'Exercitationes Pathologica,' cap. x, art. 5, 1820.

3 Grundriss der Physiologie,' 1823.

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