cannot bring the toes to the ground.

The true form is seen in congenital cases, the flexors of the foot being shortened, and the tendo Achillis being lengthened.

Talipes varus is rarely met with without equinus. In this condition the patient walks on the outer edge of the foot. Talipes valgus is met with in flat-foot. The patient walks on the inner edge of the foot.

Talipes equino-varus.-The heel is raised and the patient walks upon the outer edge of the foot. This is the usual congenital form.

Talipes equino-valgus is very rarely congenital. The heel is raised and the patient walks upon the inner side of the foot. Talipes calcaneo-varus is a combination of calcaneus and

varus.

Talipes calcaneo-valgus is a combination of calcaneus and valgus.

Treatment. In congenital cases the condition is usually manifest on both sides, and is nearly always talipes equinovarus. Congenital club-foot should be treated in infancy, and when a restoration to position can be effected by the hands of the surgeon, is treated by plaster-of-Paris bandages. If a child has begun to walk, it may still be possible to correct the deformity eventually by manipulations, by plaster-of-Paris bandages, or by club-foot shoes, but most cases require tenotomy of the tendo Achillis before the application of the shoe or the plaster. The club-foot shoe may do good service, but in many instances it is painful and is not so efficient as plaster. In severe cases, before applying the plaster, the patient is given ether; the surgeon cuts the tendo Achillis, the tendons of the anterior and posterior tibial muscles, and the plantar fascia, and forcibly corrects the deformity. In old cases with alteration in the shape of the bones, cuneiform osteotomy, or the removal of the cuboid or other tarsal bones, is indicated. In these cases Phelps advises a transverse incision through all the plantar soft parts. In talipes due to infantile paralysis the operative treatment is the same, but we should not immobilize in plaster, but rather in some apparatus which can easily be removed to permit the use of massage and electricity. In some cases of talipes calcaneus the surgeon may be forced to shorten the tendo Achillis. In paralytic cases Nicoladoni's operation is occasionally employed. This consists in dividing the tendon of the paralyzed muscle and attaching its distal end to the adjacent tendon of a healthy muscle. (For full consideration, see a work on Orthopedic Surgery.)

Pes planus (flat-foot) is the loss of the arch of the foot due to muscular paralysis or ligamentous weakness, to prolonged standing, or to trauma. Many cases are due to rickets. Spurious flat-foot or inflammatory flat-foot occurs in Pott's fracture, and in inflammation of the ankle-joint or the tendon of the peroneus longus. Static flat-foot is due to “lack of balance between the weight of the body and the strength of the foot" (Moore). All children are born with flat-feet, but the arch usually begins to form soon after birth, but in some cases it never forms. This condition is productive of much pain on standing. Flat-foot can at once be recognized by wetting the sole of the patient's foot with a colored. fluid and causing him to step firmly upon a piece of paper (Fig. 158, A, B). It can also be detected by measurement to find the middle of the foot. In flat-foot the extremity is lengthened. Flat-foot causes much pain upon walking; in fact, the individual may be completely crippled.

30

FIG. 158.-Print of a

and of a flat foot-sole (B) (Albert).

Pain is quickly normal foot-sole (A) relieved upon sitting down. Walking upon the toes is not painful.

Treatment. In static flat-foot exercise is practised several hours a day to increase the arch. Rising upon the toes again and again is valuable. After exercise the patient rests for a time, sitting tailor-fashion with legs crossed under him. Massage is valuable. A shoe should be made containing a piece of steel so arranged as to raise the arch of the foot. The patient's general health must also be looked to. In very severe cases operation may be required. Gleich shortens the foot and raises the arch by sawing through the os calcis and fastening the posterior part at a lower level. Trendelenburg advises supramalleolar osteotomy. This operation permits us to adduct the foot and put it in this position in plaster. In paralytic flat-foot, which arises from infantile paralysis, employ exercise, electricity, and massage. Pes cavus (hollow-foot) is an increase in the arch of the foot, due to contraction of the peroneus longus muscle or to paralysis of the muscles of the calf. It is the opposite of flat-foot.

Treatment. A shoe is worn containing a plate of steel in the sole, and pressure is applied over the instep. Tenotomy, cutting of the plantar fascia, or excision of bone may be required.

Hallux valgus, or varus, a displacement of the great

toe outward or inward, may occur in the young, but it is most frequent in old men. It arises oftener from wearing narrow shoes, but may be due to gout, or to rheumatic gout. In hallux valgus a bunion is apt to form over the metatarsophalangeal joint.

Treatment.-An arrangement may be worn to straighten the toe and to protect the bunion (Fig. 148), osteotomy may be performed upon the metatarsal bone, the joint may be excised, or amputation may be required.

FIG. 159.-Ham

mer-toe.

Hammer-toe (Fig. 159) is the flexion of one or more toes at the first interphalangeal joint. Shattuck shows that this condition is due to contraction of "the plantar fibers of the lateral ligaments of the joint." This disease usually begins in youth. A bunion is apt to form, and the joint may be dislocated.

The treatment is excision of the joint or amputation. Terrier's plan consists in making a dorsal flap, removing a bursa if one is found, dividing the extensor tendon, opening the articulation, removing each articular surface with cuttingforceps, suturing the soft parts, and applying a plantar splint for two weeks.2

Metatarsalgia (Morton's Disease).-A painful condition of the foot, due to jamming of a nerve between the heads of the fourth and fifth metatarsal bones. It is usually associated with flat-foot.

Treatment.-Mild cases may be cured occasionally by wearing well-fitting shoes and employing massage. Some cases require a brace. Severe cases demand resection of the fourth metatarsophalangeal joint, or amputation of the fourth toe, and with it the head of the fourth metatarsal bone.

Coxa vara is bending of the neck of the femur, the hipjoint being perfectly healthy, and the condition, as a rule, being unilateral. This condition was described by Müller in 1889. The disease arises, as a rule, between the thirteenth and twentieth years, and the commonly accepted view has been that the deformity is rachitic, but Kredel has recently reported two congenital cases. The patient develops a limp, and grows tired after slight exertion, but there is no swelling or tenderness, and little or no pain. Shortening after a time becomes apparent, and the trochanter can be detected above Nélaton's line. The extremity is adducted.

1 American Text-book of Surgery. 2 Revue de Chirurgie, July, 1895. 3 Centralbi. f. Chir., Oct. 17, 1896.

Treatment.-As long as bending is progressing employ rest. When the bone hardens perform osteotomy below the trochanters.

Flail-joints. After an attack of infantile paralysis in which the entire lower extremity of each side was involved, the limbs are limp and swing flail-like when the extremity is made to move, and the joints are much relaxed. In such cases the psoas and iliacus muscles are never completely paralyzed, and the aim of the surgeon is to utilize these muscles in enabling the patient to walk. In many cases the application of apparatus is sufficient. In others ankylosis is established by operation in the ankles and knees, so as to give the psoas and iliacus control of the legs.

XXII. DISEASES AND INJURIES OF NERVES.

1. DISEASES OF NERVES.

Neuritis, or inflammation of a nerve, may be limited or be widely distributed (multiple neuritis). The first-mentioned form will here be considered. The causes of neuritis are traumatism, wounds, over-action of muscles, gout, rheumatism, syphilis, fevers, and alcoholism.

Symptoms. The symptoms of neuritis are as follows: excessive pain, usually intermittent, in the area of nervedistribution. The pain is worse at night, is aggravated by motion and pressure, and occasionally diffuses to adjacent nerve-areas or awakens sympathetic pains in the opposite side of the body. The nerve is very tender. The area of nerve-distribution feels numb and is often swollen. Early in the case the skin is hyperesthetic; later it may become anesthetic. The muscles atrophy and present the reactions of degeneration; that is, the muscles first cease to respond to rapidly-interrupted, and next to slowly-interrupted, faradic currents; faradic excitability diminishes, but galvanic excitability increases. When, in neuritis, faradism produces no contraction, a slowly-interrupted galvanic current which is so weak that it would produce no movement in the healthy muscles causes marked response in the degenerated muscles. In health the most vigorous contraction is obtained by closing with the pole; in degenerated muscles the most vigorous contraction is obtained by closing with the + pole. When voluntary power returns galvanic excitability declines, but power is often nearly restored before faradic excitability becomes manifest (Buzzard).

Treatment. The treatment of neuritis consists of rest

upon splints, ice-bags early in the case, and hot-water bags later. Blisters are of value in traumatic neuritis. Massage and electricity must be used to antagonize degeneration. Deep injections of chloroform may allay pain. Treat the patient's general health, especially any constitutional disease or causative diathesis. The salicylate of ammonium or phenacetin may be given internally. In some cases nervestretching is advisable.

Neuralgia is manifested by violent paroxysmal pain in the trajectory of a nerve. This disease belongs chiefly to the physician, except in very bad cases. Neuralgia of stumps and scars belongs to the surgeon, and is due to neuromata, or entanglement of nerve-filaments in a cicatrix. Tic douloureux and other intractable neuralgias require careful removal of any cause of reflex irritation (stomach, eyes, uterus, nose, throat, etc.). Tic douloureux has been treated by removal of the Gasserian ganglion (page 533); removal of Meckel's ganglion; ligation of the common carotid artery; neurectomy of terminal branches (page 532); division of motor nerves; massive doses of strychnin (Dana) and purgatives (Esmarch).

Treatment of Neuralgia of Stumps.-Excise the scar; find the bulbous end of the nerve and cut it off. Senn tells us to section the nerve by V-shaped cuts, the apex of the V being toward the body, and to suture the flaps together. Senn's method will prevent recurrence. In some cases reamputation is performed. In entanglement of a nerve in a scar remove a portion of a nerve above the scar.

2. WOUNDS AND INJURIES OF NERVES.

Section of Nerves (as from an incised wound).-In nerve-section the entire peripheral portion of the nerve degenerates and ceases structurally to be a nerve in a few weeks, but after many months, or even after years, the nerve again regenerates-with difficulty, if union of the ends has not taken place, with much greater ease if the ends have united. The proximal end only suffers in the portion immediately adjacent to the section; it degenerates, but rapidly regenerates, and a bulb or enlargement composed of fibrous tissue and small nerve-fibers forms just above the line of section; this bulb adheres to the perineural tissues. Union of a divided nerve is brought about by the projection of an axis-cylinder from the proximal end or from each end and the fusion of these cylinders. The nearer the two ends are to each other the better is the chance of union.