Phelps (Amer. Medicine, Apr. 6 and 13, 1901).
Astragalectomy is an operation that would never be required if the family practitioner could be brought to the comprehension that the treatment of club-foot should be commenced before the infant is twenty-four hours old,— almost. as has been remarked by one observer "during the third stage of labor." It seems strange that any ed ucated physician can willfully neglect the golden opportunity of molding such distorted bones during the first three months of life when the osseous struc tures are soft and when growth is so rapid that, if neglected, irreparable de formity of the bony structures must re sult. During these months constant manipulation and simple forms ot re tentive apparatus will accomplish won ders. De Forest Willard ("International Clinics," vol. iii, Twelfth Series, 1902).
Pes Equino-varus.—In simple yarns the foot is turned inward. The cases, however, usually have the heel more or less drawn up, and the affection is then designated equino-varus. The affection is usually congenital, both sides being generally affected. The acquired form results from disease of the bones or else paralysis—sometimes cerebral, but oftener spinal. In the congenital form treatment should be instituted as soon as the affection is discovered. The worst cases met with are neglected cases or those in which treatment has been ineffi cient. It is natural for the feet of an fant to turn inward rather than outward; therefore an outward deformity is more apt to attract attention than is the tion we are now considering. The fact that the feet are turned in a little more than is usual or that they are kept more persistently inward than they ought is a circumstance apt to be overlooked. The child does not attempt walking for several months and therefore careless parents allow the deformity to continue until it interferes with the child's efforts to walk. The infant's foot is largely cartilaginous, and on that account is more readily molded into proper form than when the child is older. It is on this account that treatment should be commenced as soon after birth as pos sible. This softness of the infant's foot also prohibits the use of severe measures; its shapelessness also renders it impos sible to apply apparatus in the form of shoes, and even other appliances are only retained for any length of time with difficulty.
Talipes equino-varus is always an avoidable condition, and the relapses are generally due to carelessness on the part of patients and friends and sometimes on the part of the practitioner. Robert Jones (Med. Press and Circ., July 3, '95).
Equino-varus occurs in locomotor ataxia and in Friedreieh's disease, but is the result, not of bony changes, but of abnormal muscular action. The primary disease is so serious and disabling that the question of treating these secondary affections is not often a practical one. Mechanical treatment may, however, be considered with three objects in view: 1. To give firmness to the foot and ankle and direct the sole to the ground. 2. To give lateral support to a Chareot knee. 3. To stiffen the knees by the use of automatic joints, in order to prolong the period for which locomotion was pos sible with the aid of crutches. A. B. Judson (N. Y. Med. Jour., Nov. 26, '93).
Treatment.—In the treatment of con genital equino-varus in infants of from one to three months of age the main re liance must be placed on manipulations or stretchings. This stretching consists
in endeavoring to straighten and replace the foot in its normal position by manual force. It is to be done by the mother or nurse three times daily. The following is the method of performing it: The leg is grasped, close down to the ankle joint, by the left hand; the anterior por tion of the foot is then twisted or ro tated outward with the right hand, so as to first overcome the condition of varus present. This having been clone the foot is flexed on the leg so as to stretch the tendo Achillis. In other words, the foot is first twisted outward until the ball of the big toe is in line with the internal malleolus and side of the leg and then flexed on the leg to bring down the heel. This is to be done several times at one sitting morning, noon, and night. In very young infants this is to be the only treatment instituted. If the infant is a little older and robust, and the foot well developed the stretching can be done morning and night and on its comple tion a bandage may be applied. Flannel is best: from the toes to the knee. This has a distinct influence in correcting the deformity. If the child is older—say about the age of three months and even, in some cases, earlier—the bandaged feet may be placed in ordinary right-angled splints made of tin or felt. These should be padded with a little cotton and the bandaged feet placed in them. The heel should be brought down as well as pos sible by pressing the sole of the foot down on the splint and holding it there with one hand while the bandage is ap plied with the other. It facilitates mat ters to have one person hold the foot in position in the splint while another ap plies the bandage. As the child in creases in age another method is useful. It consists in first bandaging the foot and leg in several thicknesses of flannel bandage (leaving the toes exposed for observation) and then applying over all a plaster-of-Paris bandage. The foot is to be held in the corrected position while the plaster sets. Too much should not be attempted at the first trials and one should see the child soon after the application of the bandage to see that the latter is not too tight. The toes constitute a fair guide: if these are pink ish and not blue and swelled one may be assured that the circulation is satis factory. This bandage should not be left on longer than a week. On its re moval the foot is to be bathed with whisky and alum or alcohol. Repeated applications of the plaster - of - Paris bandage will in a short time cause such improvement that if the child's foot is sufficiently developed some sort of per manent appliance may be tried. The most common appliance is a shoe fast ened to side-irons, which are hinged at the ankle. An elastic band goes from the foot to one of the side-irons and tends to flex the foot on the leg and thus bring the heel down. The shoe is laced down to the toes and a strap passes over the instep to hold the foot in place while the shoe is being laced. This brace should be removed daily, the feet bathed, and the brace reapplied and worn at night as well as during the day. In se vere cases better command of the foot will be obtained by continuing the side irons above the knee, a joint being in serted at the latter point.