The deformities described above are gene rally congenital, hut they are also occasionally produced after birth by accidental causes; though in this case there is no difference in the nature of the distortion or in the anatomical condition of the parts, yet they are less fre quently cured, because the same carelessness or bad management which has too often occa sioned the accidental form of the disease to creep on unheeded, makes the parents indiffe rent as to the cure, while the deformity, which has not mismanagement for its cause, is imme diately remarked on the birth of the child, excites alarm in the mind of the parent, and means are early adopted for its removal.
This part of our subject leads us to notice a deformity, of not uncommon occurrence, but one which has met with little notice from writers, although the inconvenience and suffer ing occasioned by it, great in degree, and, as far as we have known, permanent in duration, will entitle it to the consideration of the sur geon. We allude to that state of the foot wherein the arch is lost, and the foot rests flat upon the ground. It is met with generally, but not always, in those children of the lower classes who are obliged, in their early youth, to engage in laborious occupations, and parti cularly in lifting heavy weights, before the powers of the system are developed, though we have known it to occur where none of these causes could be traced. It happens generally, not in the very weak, nor in the firm and robust children, but in those who have the promise of developement on a large scale, and are rapidly growing. It comes on insidiously, and is rarely detected until too far gone to admit of a complete cure. The marks of this disease are an evident alteration in the shape of the foot. The dorsum has comparatively lost its con vexity, the concavity of the sole is entirely gone; the scaphoid bone projecting below un naturally, and the inner malleolus falling con siderably inwards. The relative position of all the rest of the foot appears natural. The pa tient complains of pain and tightness at the upper part of the instep passing through to the sole upon attempting to elevate the heel while standing. Indeed, in aggravated cases, he cannot lift himself at all upon the metatarsus, while every step upon an uneven surface is accompanied with pain. The anatomical cha racters of this distressing disease consist, as far as a close examination of the living parts can detect, for we have had no opportunity of dis secting them, in a relaxation of that ligament which passes between the os calcis and navicu lar bone, and on which the fore part of the astragalus rests and moves. It will be quite
evident, from an examination of these parts and their connexions, that this supposition is sufficient to account for the symptoms that are apparent, and the idea is borne out by the fact of the point of the scaphoid being further sepa rated than natural from the tubercle of the os calcis, which may be readily ascertained by the touch. We conceive the remote cause to be a certain degree of inflammatory action in the elastic ligament just mentioned, produced by over-exertion, before the part had acquired its full developement and strength. The morbid action being continued by the continuance of the irritation, the elasticity of the ligament is impaired, and it can no more support the weight laid upon it ; it consequently yields, and is stretched. This view receives some support from the fact of the tenderness upon pressure constantly found in this precise spot, and from the relief afforded to the more dis tressing symptoms by the application of leeches and counter-irritations.
Another deformity of the foot occasionally met with is exactly the reverse of the prece ding ; this is too great a convexity of the arch, by which the foot is considerably shortened, and the bearing, anteriorly, taken from the under side of the heads of the metatarsal bones, and thrown partly upon the bases of the first phalanges and upon the metatarso-phalangeal joint itself. From the tense state of the plantar fascia we must suppose that this structure is shortened, and indeed we have been inclined to consider this contraction of the fascia as in some degree a cause of the deformity, which Dupuylrcn has proved to be the fact in the parallel case of contraction of the fingers, by shortening of the palmar fascia. With this view, in a case of deformed foot which lately came under our notice, we divided the fascia plantaris, and certainly with considerable tem benefit. We have not been able to ascertain why the relief was not permanent, as the patient lives at a distance; but it might not improbably arise from his returning to work too soon, and leaving off the extension of the foot which had been adopted.
(A. 1'. S Dodd.)