them, however, were in any degree distorted. The father of these children and his brother were both of them born with double varus, and also their grandfather. In each generation there were females in this family, but amongst them no instance of distortion.

Duval mentions a somewhat similar example, showing the hereditary nature of these affections, in which three brothers were born with club-foot, whose maternal grandmother was also similarly affected. Also, two girls, whose paternal grandfather was in like manner affected with congenital varus. 1

Held mentions a family of six children, all of whom were born with club-foot; and one of the parents was also similarly affected."

"It may be remarked as a contribution to the etiology of congenital distortions, that the parents of children born with varus, for example, often present uncommon convexity of tarsus without contraction of leg muscles, and without appreciable deformity, or they, and their fathers before them, have been particularly accustomed to turn in their toes. They have what may be considered a small element of calcaneo-varus or of varus; viz., unusual concavity of sole,' probably due to some unusual tension of plantar muscles, or some undue tension of posterior leg muscles. But in accordance with the observed law in physiological pathology, that parental derangement is reproduced in the progeny in increased intensity, unless counteracted by another law which regulates the union of the sexes, but which it is unnecessary to enter upon here; the child is born not simply with an affection dependent upon slight undue tension of plantar or other muscles (as in the parent), but presents increased disorder of nervous and muscular systems, severely involving muscles of the leg, as well as of the sole, and consequent varus." 3

Op. cit., p. 111, 2d Ed.

2 Op. cit., p. 41.

3 Op. cit., note, p. 308.

Others, such as Scoutetten, Ivernois, &c. have recorded instances of hereditary varus. At the Orthopedic Hospital several instances have come under my observation of a parent and one or two children thus afflicted.

Children who are born with these distortions are fre

quently subject to convulsive disorders. And the recurrence of distortion after its entire removal, whether by operation or mechanical treatment, indicates the persistence of nervous irritation. There is an inclination to the recurrence of distortion after restoration of the limb in every instance of congenital distortion. Occasionally, it returns suddenly at the moment of an epileptic seizure, or on the child being convulsed, as in the following case.

February, 1852.-I divided the tibial tendons and the tendo Achillis of a strong plethoric infant, fourteen months old, for the removal of congenital varus. Both feet were nearly equally distorted. I had scarcely commenced the operation, when the child, crying violently, was seized with a fit; and I then learnt that, when seven months old, the child had hooping-cough, which was followed by a succession of slight fits; and that, at intervals, on coughing or crying violently, the fits recurred. The feet were after some months perfectly restored, and the supports were at length removed and discontinued. Seventeen months after the operation the child again had a fit, when both feet were drawn into the same distorted positions as at birth. The father of this child was epileptic.

An example of the recurrence of distortion from cerebral excitement is recorded by Guérin. M. Jules Guérin,

says:

"I had to treat twins who were affected with double congenital varus. I entirely removed the deformity, and the treatment had been concluded six months, when one of them was seized with a cerebral affection which brought back the club-feet; so that in three days they were just as they had been before the treatment

was commenced. I again treated and cured them; and, as though further to prove the relation of cause and effect, one year later the same child was seized with convulsions, less violent than previously, and one foot again became clubbed, that one, namely in which distortion had been greatest. On this occasion the foot was less distorted than previously. At these three periods, viz., at birth, and after the first and second cerebral attacks, the foot presented the same form and anatomical peculiarities. At birth, these children appeared perfectly healthy, and this distortion of the feet was the only trace of the intra-uterine affection which had occasioned it."1

I have observed that congenital distortions are occasionally, almost, or entirely, overcome during sleep, and that the limb regains its normal position; but that the distortion recurs at the moment of waking: but also I have observed that during sleep the muscles are frequently twitched to draw the limb back again into its distorted position. I have only observed this of the hand and foot, and only in some few instances; yet I deem the facts to be sufficiently important to be recorded. I have also occasionally observed the same relaxation of the retracted muscles to occur under the influence of chloroform.

In conclusion, it may be summed up in few words, that congenital distortions depend on irritation of the cerebrospinal nervous system, or on inflammation or destruction of parts of that system.

1

Mémoire sur l'Étiologie Générale des Pieds-Bots Congénitaux,' p. 22, Paris, 1838.

CHAPTER IV.

NON-CONGENITAL TALIPES.

ETIOLOGY, PHYSIOLOGY, DIAGNOSIS, PROGNOSIS, AND

PATHOLOGICAL ANATOMY.

THE various forms of non-congenital talipes are known by the same names as the analogous congenital distortions: there are, however, material differences, although certain points of resemblance, which render the diagnosis of these affections simple.

Non-congenital distortions depend on many causes, but chiefly on structural or functional changes in the nervous system, and on paralysis of a single muscle or of a group of muscles. For the sake of convenience they may be distributed under the following heads, viz.: paralysis, spasm, inflammation, voluntary position, and debility.

Non-congenital talipes occurs almost always during infancy; yet it occurs, also, at every period of life; but, at a later period than the first few years of existence, its occurrence is comparatively rare.

PARALYSIS.

There are three divisions into which the subject of paralysis may be distributed, namely:

1st. That arising from organic change in the nervous

centres.

2d. Myogenic, essential, infantile, or rheumatic paralysis. 3d. That arising from traumatic lesion of nerve-trunks. 1. Structural Change.—Paralysis from organic change in the nervous centres is common, both during infancy and in childhood, as well as in adult age. Hemiplegia and paraplegia result from apoplexy, cerebral and spinal, without lesion of vessels and effusion of blood-congestive apoplexy, or with effusion. When extravasation does occur in infants, it is fatal. Or, less extensive weakness may result; a limb or certain muscles only being affected.

In adults, hemiplegia with flaccid muscles, the muscles remaining loose and flabby, takes place. The muscles undergo atrophy, they degenerate, and the limb remains unused and useless. Or, from being in the first instance flaccid, the muscles become rigid: the wasted loose muscles become rigid and tense, and cause contractions of the limbs which they influence. The flexor muscles are most frequently thus affected.

Or, again, rigidity may exist, according to Dr. Todd, from the commencement of, or soon after, the attack.1 In this class of cases, nutrition is not materially altered, and wasting does not proceed as in paralysis with flaccid muscles; but, should loss of power continue, wasting takes place. Atrophy is always induced by inaction, even without disease; and it takes place in all cases of contraction, from whatever cause, when it is persistent: and not only is this

'Clinical Lectures on Paralysis,' 1854.