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thirst, headache, and pain in the foot: he had passed a sleepless night. The bandage was removed, the wound looked well, and was inclined to heal: another bandage was applied, in such a manner that it should not require to be moved to expose the wound.

"21st. The upper half of the wound had nearly cicatrized; but some pus escaped from the lower portion.

"26th. The pain was less, cicatrization was advancing.

"June 14th.-Except about the fourth of an inch, the wound had closed.

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'July 18th.-I examined the limb, and found that anchylosis of the ankle was complete. The wound had not yet quite healed.

"27th.-Cicatrization was complete. He was allowed to walk about the room, which he did, bearing his weight on the foot without pain." 1

Thus, this "successful restoration," of Sartorius, terminated in anchylosis. The case was less favorable for operation than that of Thilenius. It may well be matter of surprise that it terminated so favorably, when the treatment is considered.

Michaelis, surgical professor at Marbourg, operated, November 18, 1809, on a young man, sixteen years of age, for talipes equinus; and before the following October he had performed eight operations; namely, three for talipes equinus, one for varus, three for contracted knees, and one on a woman, thirty years of age, four of whose fingers were much contracted.

Michaelis was led to believe these contractions of limbs were curable, from considering the operation for torticollis, as well as by reflecting on Bell's operations, in which he divided Poupart's ligament. He did not divide the tendon in its entire extent, as had previously been

1 Siebold's 'Sammlung seltener und auserlesener Chirurgische Beobachtungen,'

band iii.

done by Thilenius and Sartorius, but in part only, and ruptured the remaining portion, so as to restore the position. of the limb.1

Delpech, in 1816, next divided the tendo Achillis for talipes equinus, in a boy nine years old. Suppuration took place, and exfoliation of the tendon; abscesses also formed in the course of the thigh and in the groin, and several * months elapsed before the limb could be used. It will be seen, on reading the case recorded by Delpech, that his mode of operating was a vast improvement on that which had been practised before his time: it was a subcutaneous operation, and may fairly be said to have been the commencement of subcutaneous tenotomy. The rules which he laid down, some years after, for the division of tendons, are absolutely those which guide the surgeon at the present day.

The Case of DELPECH, in which he divided the Tendo Achillis.

"In the month of March, 1816, I saw the son of a magistrate of this town (Montpellier), 9 years of age, for a deformity of the right foot, which had existed from birth. The foot was in a state of extreme extension, so that the toes appeared to point backwards; and when flexion was attempted, it was found to be impossible. It was, however, less difficult to increase the state of extension. When this was done, the motion was observed to be in the tarsal and metatarsal joints, rather than in the ankle-joint. The muscles of the leg and thigh were atrophied, but the length of the two lower extremities was equal. When the foot was placed on the ground, the toes and the heads of the metatarsal bones alone were in contact with the ground; but in walking, the foot inclined inwards, so that the fourth and fifth metatarsal bones formed the basis of support. The tendo Achillis was very tense.

1 Ueber die Schwächung der Sehnen durch einschneidung, als einem mittel bei manchen Gliederverunstaltungen,' in Hufeland und Himly's 'Journal der practischen Heilkunde,' v, Stück, 1811.

"This deformity was said to be congenital, but also that it had greatly increased since the period of infancy. The leg and thigh became daily more attenuated, and this increased as the deformity increased. No attempt had been made to remove this distortion; because to some it appeared incurable, and others expressed a hope that equilibrium, which they supposed to be destroyed, would be restored as age and development advanced.

"The age of the patient, together with the nature and extent of the malady and its long duration, held out no hope of success by those means which had been used efficaciously in other cases. The age when growth is most rapid, when nutrition is most active, and when extension is most easily borne, had already past. Also, it is infinitely more difficult to restore the shape of the foot when it is thus distorted, than when it deviates laterally.

"I have noticed, in every instance of rupture of the tendo Achillis which has come under my notice, that, notwithstanding the most methodical treatment, re-union is not immediately obtained between the divided ends, but that first a swelling is formed, which decreasing, gives origin to a prolongation or neck, which is smaller than the normal tendon. This cannot be otherwise accounted for than by the formation of an intermediate substance, which unites the ends of the tendon and occupies a certain portion of its length.

"It appeared to me that, with care, the length of this intermediate substance might be increased by gradual but continued extension, if it were applied before the substance had acquired all that firmness of which it is susceptible; besides, it is well known that neither the rupture nor the section of tendons, especially of the tendo Achillis, is attended by any serious result.

"With these impressions, I proposed that the tendo Achillis should be divided near the heel, leaving the skin which covers it in situ, and thus without exposing the tendon to the air or to the contact of dressings and bandages.

"It was quite certain that anchylosis had not taken place, that the tibio-tarsal articulation was more than sufficiently free, and that no obstacle would be presented to flexion of the foot, after section of the tendo Achillis.

"And the section being made, the foot might be held in the same amount of extension as before the operation, by a suitable apparatus; by means of which gradual but constant extension could

be made, at the same time that the condition of the limb and the changes that might be taking place would be apparent to the surgeon; and also, through this means, the foot might be retained in the desired degree of flexion, until the intermediate substance had acquired that firmness of which it was capable.

"Re-union having taken place (and this could scarcely be doubtful), it was possible that extension might not be applicable, or it might not be practicable on account of the pain attendant on the operation. Should this be the case, the operation of dividing the tendon would prove useless, but, at least, it would not be dangerous; and the condition of the patient was such as to justify some risk. I was little apprehensive, however, on this account, for in solutions of continuity, it is always easier to obtain an imperfect union than a linear cicatrix.

"But it might also happen that the intermediate substance would not allow of the necessary extension; that it might break and not re-unite; or being fully extended, it might not gain that amount of consistence which is required of tendon. In either of these cases the result would be, that the use of the muscles of the calf would be lost; but the operation would not be altogether useless: the foot might be brought forward and fixed in that position, so that the sole of the foot should be in apposition with the ground. The gait would be imperfect, but less so than before. But it appeared to me that with attention unfortunate results of every kind would be avoided.

"Lastly, I have always observed that, when the shape of the foot has been restored by mechanical means and simple extension, the retracted muscles, as well as those which were relaxed, gain considerably in development. But by dividing the tendon, the muscle would be left in its retracted condition, and its nutrition would not be affected.

"After mature reflection, I considered the scheme to be practicable, and proposed it, mentioning, at the same time, my doubts to the parents of the boy. The proposal was talked over with several medical practitioners, who treated it with scorn; but, at the end of a month, it was determined that the operation should be undertaken: an apparatus was therefore prepared.

"May 9th, 1816.-I operated in the following manner :-The patient being laid on his face, the knife was passed from side to side

in front of the tendon, so as to divide the skin on both sides to the extent of one inch parallel to the tendon. The knife was then exchanged for a convex bistoury, with which the tendon was divided transversely from before backwards, without injury to the covering skin. Having satisfied myself that the foot could now be flexed on the leg, I proceeded to fix the limb in the apparatus, at the same angle at which it was held before the operation.

"The pain was slight after the operation, and the patient would have slept well, had not the hand of a servant been placed on the limb to prevent movement.

"On the second day there was slight pain around the wounds, but the child was otherwise comfortable: this state of things continued until the tenth day.

"On the tenth day the wounds were exposed, without removing the apparatus, when a small quantity of pus escaped from them. After this, the ends of the tendon could be felt more distinctly; they did not appear to be separated by an interval; they were slightly swollen and painful. A pledget of lint was placed on the point of division of the tendon, with the intention of preventing another collection of pus, and to prevent the chance of ulceration of. the integuments, which would have occasioned adhesion of the skin to the tendon.

"On the twelfth day, a considerable quantity of pus, together with shreds of tendon, escaped from the wound. After this, swelling of the tendon ceased, and the quantity of pus was diminished.

"About twenty days after the operation, namely, at the end of May, the wound on the inner side of the leg had closed, and that on the outer side had nearly healed.

"June 6th.-Twenty-eight days after the operation, the re-union appeared to be sufficiently complete to permit extension to be made, without risk of breaking the new substance. Extension was continued until June 9th. The intermediate substance had acquired one and a half inch in length, and cicatrization of the wounds was now nearly complete. In a few more days the foot was brought to a right angle with the leg, and it was maintained in this position one month, whilst solidification was advancing; at the end of which time, the tendon appeared to have gained all that length, fineness, and compactness of substance, of which it was capa

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