SYMPTOMS. 1st. Talipes equinus. The foot is extended. The heel is shortened, and elevated. The sole of the foot is very concave and looks backwards; the dorsum convex, looks forwards; the anterior extremity touches the ground. The toes are directed forwards, their dorsal surface is turned upwards in certain cases; in others it rests on the ground. The spreading toes and metatarsal bones increase the size of the anterior part of the foot. The head of the astragalus projects on the dorsum of the foot; the same is the case with the anterior extremity of the os calcis. The posterior muscles of the leg are contracted. Progression is constrained. 2nd. Talus. Slight deformity; the foot in a state of flexion. The dorsal surface of the foot looks backwards, the plantar surface forwards, the toes upwards, and the heels downwards. The posterior part of the head of the astragalus is felt behind the tibio-tarsal articulation. The anterior muscles of the leg are contracted and shortened. Progression is difficult. 3rd. Varus. The foot deviates inwards, and is very deformed. The axis of the foot forms with that of the leg a right angle directed inwards. The dorsal surface of the foot looked inwards; concave, its inferior surface is directed backwards. The toes look inwards, the heel, a little raised, has its normal direction. The inner edge of the foot is directed upwards, the external edge rests on the ground. On the dorsal surface of the foot the tibial articular facet and the round head of the astragalus may be felt; on the external edge, the external malleolus and the cuboidean extremity of the calcaneum may be recognized, as they are very projecting. The peronei are elongated, whilst the tibial muscles, the gastrocnemii, the plantar muscles, and aponeurosis are shortened. This variety of club-foot, slightly developed at birth, often increases in intensity when the infant begins to walk. 4th. Valgus. The most rare of all the varieties of club-foot. The foot is deviated outwards; the dorsal surface is directed forwards, they plantar surface, less concave, backwards, the external edge upwards, the internal edge, convex, rests on the ground. The tibial muscles are elongated and the peronei shortened. DIAGNOSIS. Club-foot cannot be mistaken for any other disease. The surgeon called to a child afflicted with this disease should diagnose the variety of the anomaly presented to him. PROGNOSIS. This vice of conformation has no effect on the health of the children who are attacked by it; it is more or less an impediment to progression. Beyond the resources of art in the adult, it may be often cured in the child. TREATMENT. The treatment applicable to club-foot may be either curative or palliative. A. Curative treatment. The intention of this treatment is to restore to the distorted joint its form and functions, by affording it its normal relations; this aim may be obtained by means of mechanical appliances on the one part, and by means of section of the tendons and of the muscles on the other. The mechanical appliances consist of moveable apparatus, splints, pads, bandages, &c., immoveable apparatus: plaster casts, dextrine bandages, &c. They should be regularly applied in a continuous and gradual manner. In order to obtain good results from them, the surgeon should continue their use, according to the advice of Andry, even to the exaggeration of the normal position of the displaced bones. The result of mechanical means is to elongate the fibrous and muscular tissues, to modify the form of the bones; they act so much the better in proportion as the subject is younger, and the congenital vice less decided. They may produce acute pains, erysipelas, gangrene, fever, convulsions. Section of the shortened tendons, muscles, ligaments, and aponeurosis. The subcutaneous method allows the fibrous and muscular tissues to resume their normal length; it is applicable directly after birth and in the first years of existence; it constitutes an operation which is most frequently advantageous. In those instances where the deformity of the foot is slight, the surgeon should employ mechanical means. If the deformity is considerable, he should fearlessly have recourse to tenotomy. In consequence of the feebleness and irritability of the infant, some surgeons have recommended the operation to be put off until the age of three or four years, a period when the process of dentition is accomplished, and they advise waiting until this time, making use of palliative means. Others operate in the first month after birth, and find good results, for then there is much more facility for the application and the retention of the apparatus used after the operation. Towards three or four years, the children possess an indocility which cannot always be overcome, and if the apparatus is left off, all the good resulting from the operation is lost. For my part, I consider it best to operate in the first two months of existence. In talipes equinus, the tendo Achilles should be incised; in varus, section of this tendon should also be practised. In talus, the tendons, which pass in front of the tibio-tarsal articulation, should be incised; in valgus, incision of the peronei muscles should be performed. If the foot is in some measure twisted in consequence of the contraction of the plantar aponeurosis, this aponeurosis should also be divided. After the operation, the foot and the leg are maintained in such a position that the two portions of the tendon can only reunite by the interposition of an intermediary tissue which increases its length. [In club-foot, children may be operated on as early as one month, but it is perhaps best to delay it till the third month. After the division of the tendon, the foot should be kept in its previous position by means of a pad and bandagent, until about the fifth day, when extension should be commenced and gradually increased, for which purpose Scarpa's shoe answers best; if the extension is delayed as long as a fortnight, the new deposit around the severed tendon may have become quite firm. In severe cases of talipes varus, the foot may be brought straight by the division of the tendons of the inner side of the foot, and after a time the heel may then be brought down by division of the tendo Achilles.-P.H.B.] Palliative treatment. This consists in preventing the deformity from increasing, by keeping the foot straight with suitable boots, and preventing the children from walking about. CONGENITAL VICES OF CONFORMATION OF THE ARTICULA- 121 Much more rare than the deviations of the foot, the congenital vices of the hand may be thus divided: 1st. Club-hand-equinus ; 2nd. Club-hand-talus; 3rd. Club-hand-varus; 4th. Club-hand-dou! valgus. These appropriate designations are thus characterized: the equinus, 2 by the displacement of the wrist backwards, that is to say, by extreme flexion; the talus, by the displacement of the wrist forwards, which produces forced extension. The varus and valgus are recognized by the inclination of the hand in the inverse direction to the displacement. The surgeon should follow the same principles as for the cure of SAA club-foot; the section of the contracted tendons and aponeuroses should be practised when the child has obtained all its teeth; palliative treatment should be employed until the period when tenotomy should be practised. jame.. CONGENITAL VICES OF CONFORMATION OF ARTICULATIONS These deformities are rare, the observations which have been recorded are for the most part so incomplete that we shall pass them over in silence. [The frequency of congenital luxations is much greater than is generally supposed. Since the year 1826, when Dupuytren first directed attention to the subject, 180 cases, in various joints, have been recorded. In the course of eighteen years, Dupuytren met with twenty-six cases. Guérin has observed thirty, Heine had witnessed eleven cases of congenital luxation of the femur, Chelius nine, and Melicher six. Smith, of Dublin, records five cases in the shoulder joint; and Adams and Smith, and Cruveilhier have seen it in the elbow joint. Of its importance there can be no doubt, for Dupuytren has known many individuals affected with original luxation, confined to bed for years, from a mere mistake in the diagnosis. The luxations may be obstetrical, spontaneous, functional, and original. Obstetrical luxations are those produced by violence during delivery; they are principally observed at the shoulder, elbow, ribs, hip, and ankle. Spontaneous luxations are the consequences of diseases in the foetus, of which coxalgia and hydrarthrosis appear to be the most frequent causes. Coralgia is generally assigned as a cause of congenital luxation by writers on these complaints. Cases are given by Albers and Ficker where the symptoms of coxalgia were present; but Melicher states that he has not discovered any well authenticated case, where an infant came into the world with a spontaneous luxation, the result of morbus coxarius having reached its latter stage. Hydrarthosis has been cited as a cause by M. Parise in a memoir on congenital luxation. He examined the joints of 332 new-born infants, and in only three did the congenital luxation arise from an abnormal secretion of synovia.—(Archiv. Gen. de Med.; t. xiv, p. 439.) Hypertrophy of the Haversian gland. Several cases of luxation from this cause have been now recorded in medical science. Functional luxations are those the true origin of the formation of which is to be found in some cause resident within the organism of the fœtus; they result e from muscular irregularities, the dynamic cause of which resides in the nervous system; either in the nervous centres, the brain, or the spinal cord; or the the disease exists in some organ of the body implicating the peripheral parts of the nervous system; for instance, some of the abdominal viscera; the incident nerves of which are morbidly affected; these communicate in the spinal cord, with other filaments-the reflex or involuntary motor nerves-whereby the muscles of the deranged part are excited to spasmodic action. There is one variety of this species of luxation which has been rarely noticed, this is called by Melicher luxatio congenita costarum, in which the ribs are more or less compressed, the sternum and abdomen projecting, the spine inclining backwards. Original luxation embraces that particular class wherein is included the most aggravated cases of lameness and distortions; it is most apt to occur in most of the free joints, as in the shoulder, elbow, and wrist, in the hip joint, knee, and ankle. Original luxation of the hip joint was first accurately explained by Dupuytren (Repertoire Générale d'Anatomie; vol. ii), and the most important additions made to the facts stated by him are those collected by Mr. Adams of Dublin. It is Book XXIII, Chap. I.] DISEASES OF THE ARTICULATIONS. 705 distinguished from all other dislocations, especially from spontaneous dislocation, in that, 1st, it ordinarily occurs in both hips; of nine cases, however, which Chelius the points has seen, in four the dislocation was only on one side; 2nd, it is not preceded by any symptoms of coxalgia; and 3rd, it is usually first noticed in the first attempts the child makes to learn to walk, and if the attempt be continued, till the movements become wearisome. Chelius has seen congenital dislocation of the knee cap on both sides in an aged man (System of Surgery; vol. i, p. 805), and Paletta has examined alk (Exercitationes Patholog.; p. 91) a case of congenital dislocation of the patella. Smith (On Fractures near Joints, &c.) gives a lucid exposition of the congenital and is dislocation of the shoulder joint; he details five cases observed in Dublin, three of these were subcoracoid and two subacromial; of the former, two were in the left shoulder, and one in both; of the latter, one was observed on the left, the Caded other on the right side. That these dislocations are congenital and not of accidental occurrence, he thinks decided, as regards subcoracoid dislocation, in the absence of previous injury, in the joint not being the seat of pain, swelling, &c., but Symp. is especially in the perfect condition of the capsule and of the tendon of the biceps, (effugia as well as in the simultaneous existence of a pes equinus in the same patient; in the form of the head of the humerus being peculiar, and quite different from any change which he has noticed as consequent on disease or in old dislocation of the usual kind. Some attribute this congenital disease to the position of the foetus; others to an arrest of development; and a lesion of the nervous centres may be perhaps the remote cause of the deformity in some instances. This opinion is supported by the frequent occurrence of congenital luxations in idiots, and also by the fact of their being so often symmetrical; but it is difficult to believe in the possibility of effecting a permanent cure of the deformity, if we are to recognize a lesion of some parts of the nervous centres as its source in all instances. Smith details instances of congenital luxation of the right carpus backwards, as well as forwards. Congenital dislocation of the lower jaw was first noticed by Guérin (Researches sur les Luxations Congenitales; 1841) in a foetus with deficient formation of the h brain; and Smith has observed a congenital dislocation of the jaw on the left side, in an idiot from birth, and considered it as consequent on arrested development of the transverse root of the superior maxillary bone or of the articular eminence. "The following are the distinctive characters, referring only to the deformity as existing on one side, for he has never seen an instance of double congenital luxation of the jaw. 2 1. In the congenital luxation, the mouth can be freely opened and closed; in finis chronic rheumatism these motions can be performed, but not without uneasiness to the patients, an uneasiness which sometimes amounts to severe pain; in luxation. from accident, the mouth cannot be closed. 2. An involuntary flow of saliva accompanies, the accidental luxation alone, although in some cases of chronic rheumatism there is an increased secretion of that fluid. 3. In congenital luxations the teeth of the upper jaw project beyond those of the lower; the reverse is observed in accidental luxations and in chronic rheumatism. 4. In congenital luxation there is no fulness in the cheek, such as the coronoid process produces in cases of accidental luxation, and the enlarged condyle in some instances of chronic rheumatic arthritis. In the treatment of congenital dislocations, frictions and shampooing may be used as palliative remedies, and various mechanical contrivances have been employed |