Page:The American Cyclopædia (1879) Volume IV.djvu/731

 CLUB-FOOT CLUNY 719 resting on the ground and the sole turned up- ward. This is usually congenital, and accom- panied by deformity and stiffness in the other joints of the limbs, and depends on contraction of the flexors of the toes and the muscles of the calf. A fifth form is described, in which the toes are turned upward, the dorsum of the foot ap- proaching the anterior surface of the leg, and the person walking on the heel. Club-foot consists essentially in a contraction, rigidity, and atro- phy of the muscles of the calf, the deformity taking place in whichever direction the mus- cular equilibrium is the most easily disturbed. Various causes have been assigned for congenital club-foot, such as vicious positions of the foetus, and mental and physical affections of the ma- ternal system, such as are generally supposed to cause arrests of development. Convulsive diseases in infancy often cause permanent con- traction of the muscles and consequent club- foot. Before the time of Scarpa it was sup- posed that there was in club-foot a dislocation of the bones of the tarsus and metatarsus ; he maintained that there was rather a torsion of the scaphoid, cuboid, and os calcis, which would carry with them in the same direction the rest of the foot. The deformity may de- pend on an abnormal conformation of the as- tragalus and cuboid bones, with deviation of the anterior bones, this being especially the case in congenital club-foot ; and in some rare forms there may be dislocation of the astra- galus, though in most cases this bone preserves its normal relations to the tibio-tarsal articula- tion. In varus, the scaphoid and cuboid and heel bones are rotated outward, and the liga- ments which bind the last two are generally relaxed; in congenital cases all the bones are small and the muscles wasted, and the limb is cold and feeble, indicating imperfect nutrition and innervation ; the tibialis anticus and pos- ticus, the flexors of the toes, and the muscles of the calf, being stronger than the peroneal muscles, increase the torsion as age advances, and the tense tendo Achillis draws the tube- rosity of the os calcis obliquely upward. In talipes equinus the astragalus is more or less dislocated forward, and may be felt under the skin at the top of the instep ; when the foot is rolled backward, the bones of the tarsus are more or less separated on their dorsal surface, and the joints below are proportionally ap- proximated; the dorsal ligaments are thin and elongated, while those of the sole are shorten- ed and thickened. In valgus, the deviations of the tarsal bones are the opposites of those in earns. In children the prognosis is more fa- vorable than in adults, on account of the flexi- bility of the muscles and the suppleness of the joints. Until the latter part of the last century the only means employed for the treatment of club-foot were various kinds of bandages and apparatus for- extension ; these were incon- venient, painful, expensive, requiring years of trial, and useless except in the simplest cases and in early childhood. The indications for 200 VOL. iv. 46 treating club-foot are fulfilled by the division of the tendo Achillis, or any other contracted tendon or tense fascia, and an apparatus for extending the foot at right angles with the leg. The tendo Achillis had been for many years frequently divided in veterinary practice, but was not interfered with in man for the cure of club-foot until about the year 1782 ; though an acknowledged operation in surgery, it was not practised in France until 1816, when Delpech performed it with indifferent success; it had become almost forgotten when Stromeyer re- vived it in 1831 ; since that time the operation has become improved and simplified, and the apparatus for extension rendered efficient by Duval, Bouvier, Gu6rin, Roux, and the best surgeons of Europe and America. Tenotomy, as the operation is called, has been performed at all ages, from a few weeks to 50 years, and has been applied not only to the tendo Achillis, but to the flexors of the toes, the plantar fascia, and any of the tendons surrounding the ankle joint which seem to aid in producing the de- formity. The operation is so simple, so free from pain, so easily performed, so little liable to unfavorable consequences, and generally so speedily efficacious, that it seems unpardonable, unless in a few exceptional cases, for a surgeon to submit his patient to the plaster moulds, starched bandages, and other immovable ap- paratus of the old method. The divided ten- don heals by a callus, which, when recent, may be extended to any desired length ; the wasted antagonist muscles, being relieved from tension, gradually recover their power. At first the knife was passed under the tendon, piercing the skin largely on both sides of the limb, and extension was not applied until the fifth week, when the divided ends had con- tracted adhesions and lessened the chance of a favorable result. Stromeyer improved upon this by making a single puncture of small size, and by putting on the apparatus in the course of the second week. The tenotome is gene- rally blunt-pointed, the skin being pierced by a lancet ; it is introduced on the inner side of the limb, and is made to cut the tendon, pre- viously put upon the stretch, from before back- ward, or toward the skin, without wounding the latter ; this subcutaneous operation is pain- less, bloodless, and, from the exclusion of air from the wound, not liable to be followed by inflammation ; extension should be applied as soon as it can be done, without causing too much pain. CLUNY, or Clngny, a town of France, in the department of Saone-et-Loire, 12 m. N. W. of Macon; pop. in 1866, 4,253. It has several churches and schools, manufactures, a govern- ment stud, and some trade in cattle, horses, tim- ber, and grain. The town sprang up around a Benedictine abbey, founded in the 10th century, which in the llth and 12th centuries acquired great celebrity. Popes Gregory VII., Urban II., and Pascal II. had all been inmates of this abbey, which was inhabited at one time by