III. On the Pathology of Club-foot and other allied affections. -By JAMES HARDIE, M.D., Surgeon to the Clinical Hospital, Manchester. (Based on a paper read before the Medical Society of Manchester.)

HAVING lately had the fortune to obtain the parts in a case of extreme and extensive muscular shortcoming, I am induced to take the opportunity of describing the case, and of making a few remarks on the pathology of the affection. The term "muscular shortening" is used as being the best which suggests itself, so as shortly to comprehend the various abnormal conditions of the case, according to the present usually received pathology; but, as will be seen immediately, it does not, according to the views I have been led to entertain, express accurately either the cause of the affection or the condition of the parts affected.

The subject was a female child, two and a half months old at the time of death. During life, the appearance which at once arrested one's attention was the clubbed condition of both hands and both feet, the former being rigidly flexed and pronated on the wristjoints to a right angle with the forearm, and the latter being in a state of extreme varus. On further examination, however, it was observed that though both elbows could be flexed, neither could be extended beyond an angle of about 60°, and in this latter position the arms were usually held. Further, on taking hold of the legs, it was found that the knee-joints, which were in an extended position, were absolutely immovable, with the exception of a slight degree of mobility forwards. The peculiarity of this latter condition, together with the difficulty of recognising the bony prominences, made it almost appear as if the knee was somehow turned round about, and though the rationale of this was by no means clear, the difficulty of assigning the true relation of parts was so great as to make one look forward to the dissection with a considerable degree of interest, when the child (which was badly nourished and seemed to have little chance of life) happened to die. The appearance of the child was altogether most peculiar. It seems to have resembled very closely that of one of which there is a small woodcut in Mr. Adams's work on Club-Foot' (p. 203). On the occurrence of its death, I was permitted to make a careful dissection of the parts involved; and, without entering minutely into particulars, may briefly describe their general appearance.

After the removal of the muscles and tendons, the rigid condition of the wrist-joints completely disappeared. It was found to be owing, mostly, to a contracted condition of the superficial flexors

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and palmar fascia. The movements of the elbows, however, after a similar dissection, were still considerably restricted. As regards the lower extremities, in which the phenomena were much more pronounced, it was found that the ligaments and bones were also extensively involved in this distortion. With the exception of a little more looseness, the ankle-joint remained as it was, and as to the knee, after the removal of all the muscles, except the insertion of the rectus femoris, its flexion posteriorly was as impossible as in the undissected condition. While the movement forward became more free, any attempt to flex the joint was at once arrested by the rigidity and tightening of the ligaments. The position of the condyles on the head of the tibia was remarkable, and accounted for the abnormal relations of the parts observed during life. They rested on the latter quite on the anterior margin of their surface, and thus projected themselves prominently into the popliteal space. Lastly, it was found that the shaft of the tibia was much arched forwards; the fibula, however, maintaining its normal shape.

Such were the appearances met with in these limbs, and it has seemed to me that by viewing the pathology of talipes in the light afforded by a combination of abnormalities in a case such as this, a more correct estimate may be formed of its cause than by a study of such as are usually met with, viz. with the deformity limited to the parts about the ankle in one or both feet. It is assumed-what no one will be disposed to question-that the primary cause of the talipes was also that of the other deformities.

It is obvious, in the first place, from a dissection such as that described, as indeed surgeons are sufficiently aware of from the troublesome treatment so often required after tenotomy, that other tissues besides the muscles are involved in a case of talipes; and that the simple division of contracted tendons need not suffice to set the foot at liberty so as to get it into its normal position. We are led to infer, from the shortened and unyielding condition of the ligaments and other structures, that the affection must have existed for a considerable time during the growth of the child. This condition is not that of a recent and quasi temporary flexure, but has evidently been produced by the tissues growing to the form and size of a joint in a constant state of flexion. The question, however, is as to the primary cause of this condition. Has it been produced by spasmodic contraction of the muscles involved, by arrest of development of the shortened tissue, by external pressure on the child, as by the uterus, or in what manner? The generally received opinion at the present time is that spasmodic muscular contraction is the primary cause, and that the shortened condition of the other tissues is a secondary matter-the result of the persistence of this contraction. This was the view entertained by Stromeyer. Guérin, Adams, and the majority of writers at the present day also give

their adherence to it. Little considered that the deformity may either be produced by spasmodic contraction of the shortened muscles, or, in other cases, by paralysis of their opponents.

The theory of arrest of development has almost fallen into oblivion, although this is that which, in a certain sense, I am inclined to adopt. That of mechanical pressure is so obviously insufficient to explain the conditions met with, besides being, from various considerations, so improbable, that I shall dismiss it without further remark, saving this, that I by no means wish to say that it is never the cause of deformities such as these, but that it must be an exceedingly rare thing for it to be so, and that when it is, the cases can only be slight and amenable to minor treatment. I may also just mention a case in exemplification, which I met with not long ago. At birth, both feet were turned up, spread out, and flattened against the front of the leg, constituting a well-marked specimen of talipes calcaneus. I had no doubt whatever, from the appearance of the parts, that it had been produced in some way by mechanical pressure, and accordingly advised nothing more than rubbing and manipulation. In the course of a very few weeks the deformity had almost completely disappeared.

Leaving this, then, let us address ourselves to the theory of spasm versus arrest of development. Either theory might explain equally well certain conditions which often enough accompany the

I might also have quoted the theory of paralysis of the opponents of the shortened muscles. Little was of opinion that many cases are due to this, and Mr. Barwell at the present time is the principal supporter of the theory. The latter, indeed, considers this to be the cause of nearly all cases of talipes. It is supposed that during intra-uterine life the fœtus has had a convulsive attack, leaving certain muscles paralysed, or that this condition has occurred in some unexplained manner as happens frequently enough in early childhood. That the muscles on the opposite side of the joint thereupon draw the limb in the direction of their action, and being maintained in this position, an interstitial shortening commences, and the muscles and other structures afterwards grow to a size commensurate with their diminished area. This seems a most unlikely theory, and the arguments of Mr. Barwell in its favour are scanty and inconclusive. The principal is, that the most common cause of non-congenital talipes is, undoubtedly, paralysis. Most of the arguments against the spasm theory hold good against this, and I shall not, therefore, allude to it further, except to draw attention to the difficulty if not impossibility of explaining the condition of the knee-joints in my case by its means. Owing to the position of the fœtus in utero these were in a state of extension, and they were also found to be perfectly rigid, so far, at least, as concerns flexion, but unless Mr. Barwell means to affirm that, while tissues are still being developed and formed, this is accomplished on the shortest possible scale, which, of course, is known not to be the case (otherwise, to refer to nothing more, why were not the flexors of the thigh on the trunk also short in this case ?), it would have been supposed that a certain amount of extra length and looseness would still have been available. The condition of the limb certainly bespeaks a much more active agency than want of power of the flexors. As Mr. Barwell points out, it is well known to surgeons that when limbs are constantly confined to one position for a considerable time, shortening of the muscles will certainly result, but this only holds good after birth.

affection, such as its symmetry on both sides, or its being sometimes limited to a single joint, or its occasional extensive manifestation, as in the present case. There are, however, several considerations. which militate seriously against the spasm theory.

1. Beyond the simple shortening of the muscles, there is no other evidence after birth of spasm. After division of the tendons, there is no difficulty encountered by the persistence of the spastic condition. It is to be supposed, therefore, that it must have relaxed some time before birth, and we should then have expected a greater amount of mobility in the joints than is met with; or, if the ligaments should have grown into position, that the muscles should be flaccid in a corresponding degree. On the contrary, they are always the most tense of all the structures.

2. Comparing intra-uterine with extra-uterine life, there is the difficulty of imagining a condition in the latter resembling this supposed liability of muscles in the foetal state to spastic contraction. We have, in common cases of talipes, a group of muscles affected with spasm, by no means liable to be so affected in the child, at all events, not as an isolated group. It may, I think, be affirmed that such a thing as spasmodic contraction of the tibialis anticus, tibialis posticus and flexor longus digitorum, and gastrocnemius, as a separate group, without any of the other muscles being involved, is unknown as originating after birth. True, we have, often enough, talipes of one kind or another, occurring as a postnatal affection on account of muscular spasm. But in this case the whole of the muscles of the limbs are generally involved, and the resulting deformity is produced by the superior strength of a certain group. Such cases, too, are produced by organic lesion of the nervous centres, and are, therefore, permanent or very slowly recovered from. Why, we may ask, should it be different in the fœtus?

3. The great constancy with which congenital talipes occurs in the varus or equino-varus form seems quite inexplicable on the spasm theory. Opposite forms of the affection are treated of, but they are confessedly exceedingly rare; and it is necessary to look for some other cause than some obscure affection always implicating the same nerves. This, too, it must be noted, when, as in some cases, widely different parts of the nervous centres are involved in disease. Why should hydrocephalus cause irritation of the same nerves as lumbar spina bifida?

4. As regards the period of fatal life at which the condition. arises, we might suppose that instead of the fourth or fifth month, which is the time usually referred to as the period when it is first discoverable, the peculiar nervous condition might originate shortly before birth, giving rise to, let us say, a case of severe varus. this case, we would expect to find a very rigid condition of the muscles with the ligamentous structure loose and the bone unal

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tered, and, consequently, a case immediately remediable, for a time at least, by tenotomy. But I need not say that such a case is never met with. To explain the appearances met with in any case of talipes, we must always go back to a date preceding the full term of gestation by three or four months at least.

5. It might be supposed that the irritation of the nervous centres producing the spasmodic condition, would exist altogether without reference to the position of the fœtus in the uterus, so that, though its feet might be lying at one time in the usual posture, viz., resembling varus, yet owing to the occurrence of some peculiar state of the nervous system, the peronei muscles might be thrown into a state of contraction, turning the foot outwards to a state of talipes valgus. Or, again, applying the supposition to the rectus femoris, that, while the foetus is in the usual state with the legs bent on the knees, the muscles might become rigidly contracted as in the case under consideration, so as to draw the leg into an extended position. Now, although I cannot deny the possibility of the former case, it appears to me in the highest degree improbable; and with regard to the latter, admitting its possibility, it must be regarded as a strange coincidence that the presentation in these cases at birth is always a breech. It is certainly a much more feasible supposition that the straight condition of the limb was the result of the position of the fœtus: that is, with the whole of the lower extremities doubled up on the trunk at the hip joints, as is a common position in breech presentations. We may infer from this that spasm of the muscles does not occur in those on the convexity of a flexed limb, and that the character of the deformity is a thing depending on the position of the limb in the uterus.

6. It is improbable that the nervous system of the fœtus at the fourth or fifth month is developed to such a degree as to be subject to disordered action, or that the muscular system is so entirely under its control to the exclusion of the purely vegetative growth of the embryo.

7. It will be observed that in my case the flexor muscles in certain joints (the ankles, elbows, and wrists), were contracted, and the extensors in others (the knees). Analogy would make this appear improbable; and it is singular that, as before remarked, the position of the limb favoured this.

Relinquishing this theory, then, as ir-reconcilable in many respects with ascertained facts, let us see what support these give to that of arrest of development.

By "arrest of development " I do not mean that the muscles and other structures on the contracted side of the joints have at some period ceased to grow, and have remained of a lower grade of development, or have possibly undergone a degeneration of structure. Dissection of the parts sufficiently disproves any such hypothesis.