Since congenital club-foot is of a very different nature to that of paralytic origin, the treatment of the latter being carried out on the same lines as that of any other paralytic deformity, a few remarks may be made here on the gymnastic treatment of this not uncommon defect. There are many different theories relating to the origin of this deformity, but the most likely is that the cause of club-foot is found in a bad position of the feet of the foetus in its early stages; and thus it is that many cases can be said to belong to the intra-uterine weight deformities. Should the development of a foetus take place while either one or both feet are in a faulty position it is quite evident that the skeleton as well as the soft parts belonging to it will take that form which is most convenient and will therefore develop into bad shape and proportions. The longer this faulty position has lasted the more the tissues accommodate themselves to it, and the greater is the resistance offered by those faulty parts to any power that is present to place the limb in its normal position.

The theory of the treatment of congenital club-foot seems quite easy to understand. It is of great importance that correction should be used in the earliest stages, also that suitable appliances should be used to fix the foot, in order that further growth may take place with the foot in a normal position, whereby the skeleton and soft tissues are compelled to return to their normal form and proportions.

It has already been shown how impossible it is for gymnastics and massage to be of sufficient force to correct a moderate form of this deformity when the patient is older; yet this theory does not apply to the case of infants. The tissues of an infant have not become so fixed that they offer a very strong resistance to this form of correction. Ossification of the cartilage of small bones like those of the foot has scarcely begun.

One often finds that even a high degree of congenital talipes equino-varus can, by energetic manual treatment alone, be corrected by degrees, though possibly not at the first attempt. It is important that manual correction should be attempted immediately after birth, and the cure of every case of congenital clubfoot should be possible by this means, since fixation in the corrected position can be easily achieved by means of bandages, the resistance of the tissues being so slight.

Experience shows that one generally sees congenital club-foot after the child has begun to walk, either in its original stage or worse. The reason for this is that, however simple the treatment is for infants, those in charge of the child seldom carry it out correctly or for a sufficiently long period. In the end it is generally necessary for a medical gymnast to carry out the treatment. Social and practical inconveniences are often causes which prevent a lengthy treatment, the most important thing being the great expense of massage and gymnastics, so that it can easily be understood why many congenital cases are left till too late, for the older the child the greater are the difficulties in treatment. These difficulties become so great that even severe surgical operations fail to give a satisfactory result.

Under these conditions it is necessary for a child born with clubfoot to be at once ordered energetic medical gymnastic treatment. I will here give a few practical hints as regards this particularly easy treatment.

The aim is, naturally, to reduce the foot to its normal shape. For this it is necessary to give manual correction daily, preferably several times a day, and with great energy and patience this can often be accomplished. One must not make the mistake of thinking that the correction is easier than it really is. It is quite simple at first to correct the whole anterior part of the foot so that the whole anterior part of the sole looks downward as in the normal walking position. The condition with regard to the heel is quite different. Part of this faulty position consists of the equinus position of the heel with contraction of the Achilles tendon, and sometimes even the equino-varus position of the heel. It is more difficult to correct the posterior part of the foot than the anterior, which is more supple than the heel, and is not so difficult to grasp as the undeveloped heel of the infant.

Now if the anterior part of the foot is fully corrected, but the heel left in equino-varus position, the deformity is bound to recur, as is proved by experience and by the study of anatomical and mechanical conditions. The bad position of the anterior part of the foot recurs, and no result is achieved. If, however, the medical gymnast treats the heel as primary from the first, it is more possible, in spite of the slight development of the os calcis, to correct the faulty position by means of stretching the shortened Achilles tendon. In order to do this successfully I strongly recommend the following method : - The child lies on his back with the sole of the foot (at least the anterior corrected part of it) against a hard surface, e.g., the edge of a table. By flexion of the knee it is possible to imitate the natural support of the foot as when standing, and by using the leg as a handle one is able to correct it by natural means, the foot being fixed against the hard surface. This is a much easier method to bring about an effectual correction than by trying to correct the foot directly by fixation of the leg. The exaggerated flexion of the knee, especially with fat children, may present difficulties, but this can be prevented by the gymnast placing a book or piece of wood against his own chest with the sole of the foot on it and pressing the whole of the sole against it. By this or similar treatment it is quite possible in nearly every case, if the conditions are favourable and the treatment given long enough, to correct this deformity. Generally it is necessary to over-correct. Between the treatments it is important that the corrected position be maintained; with infants this is done by means of bandages and with older children (more than four months old) by the use of suitable irons. In this, again, the same difficulty is present, namely, that to maintain the correction of the anterior part of the foot is much easier than that of the posterior part. But with a little practice, even with the use of only soft bandages, one soon learns to adjust the bandages in such a manner that the greater part of the correction is maintained. Others beside the gymnast must learn to bandage in the same manner in order that the care of the child in regard to washing and baths in the usual way is not unnecessarily interfered with.

If this gymnastic treatment be continued until the child can walk a good result is to be expected. If the child places his foot on the floor in a correct manner when he begins to walk, standing and walking will be good corrective exercises for him. If, on the contrary, there is any remainder of an incorrect position, which always depends on insufficient correction of the heel, the tendo Achillis especially not being sufficiently stretched, the treatment must be continued and combined with the use of suitable mechanical support. It may, however, be so difficult to stretch sufficiently the contracted tendo Achillis that it is often necessary to employ partial or even total tenotomy with subsequent plaster bandages. For older children this is frequently absolutely essential, and then the treatment is not always entirely successful, and a more severe operation is often necessary. Yet the principle of the treatment remains the same, namely, to make the sole of the foot touch the ground in walking long enough to force the bones and soft tissues to take by degrees the shape necessary for normal function. In order to guard as far as possible against return of the deformity, whether in the case of an infant's club-foot corrected manually, or in the case of older children or adults corrected by stronger surgical orthopaedic methods, it is necessary to use orthopaedic apparatus, besides continuous treatment by massage and gymnastics, for a longer or shorter period, as circumstances permit. Orthopaedic apparatus of various kinds suitable for this deformity are to be found, from the very simplest and cheapest surgical boots to the most complicated and expensive, but also more effective, supports.

When the treatment of older children and adults demands the use of massage and gymnastics alternately with plaster bandages, one uses, besides forced correction, active muscle exercises, specially emphasising the evertors. The evertors are usually very weak, especially in one-sided cases, so much so that it has often been suggested that the cause may be poliomyelitis or similar disease occurring in foetal life. With infants active muscle exercise cannot of course be used.

The treatment of congenital club-foot is of a very variable nature, according to the nature and stage of the illness. Lastly, I must remind my readers that the best result is to be gained, as in many other instances of orthopaedics, by energetic, methodical, and conscientious co-operation between the medical or surgical specialist and the gymnast.

The above brief description of the treatment of a few different orthopaedic cases ought to be sufficient to give the reader interested in these laborious, tedious, but often satisfactory orthopaedic cases some idea of how to judge to what extent massage and gymnastics can be of use, and also in what way they should be used. It is important on the one hand to take care not to over-estimate one method of treatment so that another necessary treatment is set aside, but, on the other hand, to see clearly of what inestimable help rationally applied medical gymnastics and massage really are in the treatment of orthopaedic cases; in certain cases this mechano-thcrapeutic treatment, if used with sufficient understanding of the underlying aim, really works wonders. If these remarks in the smallest degree prevent the reader becoming dogmatic or one-sided and fanatic in his contest for "the system," for one or another "method of treatment," they have fulfilled their aim.