Professor of Anatomy in the Eclectic Medical College of the City of New York.

CERTAIN deformities of the foot have received special description under the name of Talipes. Those deformities may be congenital, or acquired. The latter kind may be the sequel of some exhausting disease, or nervous affection producing a paralytic condition of nerves distributed to certain groups or a group of muscles, and an irritable condition of nerves sent to an antagonizing group. The irritable muscles not being antagonized draw the foot powerfully away from its natural position, changing the relation of its parts, and sometimes giving it a form but little resembling that it naturally

has.

The contraction of the muscles is permanent, and the fascia become thickened and shortened as the person increases in years. The bones losing their normal relation to each other, accustom themselves to the new conditions as much as possible, change their articular surfaces, by making

*Read at the Semi-Annual Meeting of the Eclectic Medical Society of the State of New York.

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new ones and obliterating old ones; and by elongating some of their ligaments and shortening others. Nature tries to make as good a substitute as possible upon the new and unnatural surface trodden upon, for the soft and cushion-like sole of the foot. But changes produced by a want of balance of the forces acting on the foot, are followed by other changes, and still further departures from the natural condition, unless the balance of forces is restored, and all antagonizing ele ments overpowered or destroyed.

The heel may be powerfully drawn up by the action of the gastrocnemius and soleus, the flexor longus pollicis and flexor longus digitorum muscles, so that the body will rest on the toes or extremities of the metatarsal bones, producing that deformity called talipes equinus. There may be, or may not be a want of power in the extensor longus digitorum and proprius pollicis and peroneus tertius muscles. The person has no power to put his heel to the ground. The peronei muscles and tibialis posticus may also be at fault, and contracting strongly, change the direction downwards of the anterior row of tarsal bones, thus increasing the deformity. These conditions may be produced in children by the irritation of teething, worms, wounds in the calf, scrofulous disease in the ankle-joint, or substance of the posterior muscles, or tendon, or it may arise spontaneously.

The true method of cure is, I think, such as recommended by Dr. R. Barwell, of England, viz., stimulate by frictions, electricity, and movements of the limb, the muscles that are more or less paralyzed, and make up for a deficiency of power by supplying artificial muscles, to antagonize those that contract so strongly. He thinks that that is all that is sufficient. But while it may be in many cases, I think division of tendons of shortened muscles properly performed will hasten the cure and also perfect it.

In this form of the deformity, the tendo Achillis is the one to be divided. A small sharp tenotome is to be passed under the tendon from one side to the other, puncturing the skin only on one side, with flat side toward the tendon, and when in position, turning the edge against it, and by a slight

motion, while the tendon is made tense. by an assistant, severing its fibres. The foot is then to be put on a splint for a few days, and not too much extended, until the process of reparation is well begun. Extension may then be carried on by a gradual process, by any apparatus that will do it most. perfectly. Those are all modifications in various ways, of Scarpa's shoe, and often answer every purpose.

Dr. Barwell has proposed and successfully used artificial muscles, made of rubber, to supply the want of power in front of the leg. They are attached to a piece of tin like a small splint, held in place by adhesive plaster, which is wrapped in successive layers around the leg. The lower extremity, or insertion of the muscle, is fastened to a link firmly connected with similar plasters surrounding the foot. By this method all the natural movements of the leg are unrestrained, allowing of development of weak muscles, and freedom of movement, which very much hastens recovery.

Another deformity, called talipes varus, consists essentially of a turning-in of the foot, so that the person walks on the outer edge, or on the dorsum of the foot.

There is, 1st, elevation of the heel as in the first instance. 2d, a contraction of the tibialis anticus and posticus muscles, drawing up the inner edge of the foot, and diminished power of those antagonizing them, as the peronei and extensors. 3d, in cases of long standing, shortening of the fascia and always much malposition of the bones of the tarsus. This form is very apt to be congenital, in one or both feet, and very bad; it is the most common of all. It may be produced by position in utero, but its cause cannot as yet be accurately determined, although the mother will attribute it to some impression during the period of pregnancy. lieve this deformity, the tendo Achillis and tibialis anticus, and posticus, have to be cut, or either one or two of them, and other resistance overcome by orthopædic apparatus, or by the application of muscles to represent the peronei on the opposite side of the foot, which by opposing those in contraction and assisting the natural ones, gradually overcome the malposition. It will require considerable time

To re

and much care, with .any form of apparatus, until the natural direction and shape are restored.

Talipes valgus consists in an elevation of the outer side of the foot, so that the person walks on the inner side of it. There is a yielding and falling of the arch of the foot, so that the os scaphoides projects and touches the ground on its inner and under surface. There is weakness of action of the tibialis posticus, and sometimes anticus and flexor longus digitorum and pollicis muscles, and powerful action and shortening of the peroneus tertius, longus and brevis, and extensor longus digitorum muscles. These latter not being opposed, draw the outer side of the foot up, and the supports of the tarsus and the arch being weakened, this deformity results. This may be, and is frequently congenital, owing to position in utero. Or, it may be the result of nervous irritations, wounds, rheumatism, &c., as in the other forms.

It is corrected by severing the tendons of the muscles last mentioned, sub-cutaneously, and applying muscles to represent those that are weak. The tibialis posticus is espe cially to be supplied, and sometimes the anticus; and great care is necessary in adjusting the counterbalancing forces properly, and applying them in the right position and direc

tion.

The fourth form of the simple varieties of deformity is talipes calcaneus. In this form, which is generally congenital, there is no loss of power of the gastrocnemius and soleus muscles, but marked contraction of the tibialis anticus, extensor longus digitorum, and proprius pollicis, and peroneus tertius muscles. The dorsum of the foot is bent to a small angle with the leg, and no part of the foot touches the ground but the heel. The tendons of the last-named muscles must be carefully severed, sub-cutaneously, and the antagonizing force applied, to bring the anterior part of the foot to the ground and enable the patient to raise the heel. A shoe may be applied for that purpose, or muscles to assist the sural muscles, whichever seems most useful in accom- · plishing the purpose.

There is a variety of this form called by some talipes cavus, in which there is moderate action of the anterior muscles, weak action of the sural muscles, and strong action of the peroneus longus, which draws down the front part of the foot, while at the same time the heel droops and the patient walks on the posterior part of the heel, the prominence of the heel being quite absent, and the hollow of the foot being quite deep. In this case the peroneus may need to be cut, but additional force must be given to the action of the sural muscles and anterior tibial and peroneus tertius muscles, by adding artificial ones, as well as by the application of the galvanic battery and the use of such other measures as will best accomplish that end. There are other deformities in which these simple forms are mixed, and hence are called compound forms. They are talipes equino varus, talipes equino valgus and talipes calcaneo valgus. They are produced by a combination of the causes producing the simple forms, and have to be studied well in order to adapt the proper and necessary treatment.

Sometimes a deformity will be met with, in which the foot from inflammation about the ankle joint, will, on recovery, be kept at right angles with the leg, without the ability to change that relation. This is a very troublesome deformity, occasioning lameness the same as the others. The peronei, anterior tibial, and common extensor, and perhaps other muscles will be found rigid, and these and all such must be divided. Flexion and extension of the foot should be practised several times a day, and in this way it will be gradually corrected. Where there is in any of these deformities, marked shortening and contraction of the deep fascia, as the plantar fascia, it must be severed at the most available point, before the deformity can be overcome. Pedal deformities are very common, and where it is possible should be begun to be counteracted in infancy, where it is congenital, before the bones of the tarsus become ossified or become fixed and rigid in one position. In other cases it needs a great deal of patience and diligent perseverance to correct the unnatural contractions, break up adhesions and support