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by which unhealthy forms of inflammation were avoided, and adhesion was promoted.

In 1838, Stromeyer published his 'Contributions to Operative Orthopaedic Surgery," in which the following occur as his rules for the performance of subcutaneous operations.

"When it can be done, the tendons of the resisting muscles must be divided; but when the tendons can be divided only with great difficulty, then the muscles themselves. The section should be made beneath the skin, when this is possible, and the skin itself should not be divided. Small instruments of different shapes are to be chosen for this purpose; generally, a moderately curved, sharppointed knife is the most useful. The limb should be so held, that the tendon to be divided may be made to stand prominently forward; and the knife being passed behind the tendon, and the exit for the point of the knife being gained on the opposite side, the resisting tendon is to be divided rather by pressure against the edge of the knife, than by onward movement of the blade. The yielding skin follows on the blade of the knife, so that the two small wounds are only of the same breadth as the blade. I have very often divided the tendo Achillis with a single puncture of the skin; but this is unimportant, the two small punctures healing as quickly as one only. Usually, it is known when the tendon is divided, by a peculiar cracking noise at the moment of division. Section of the tendon with the point of the knife is not always safe; partly, because the point is not sufficiently strong, but, also, because other structures may be wounded should the patient not remain quiet. Probepointed knives are quite useless. When tendons are many to be divided the sections should, if possible, be made at the same time, for extension is then accomplished with greater facility than when the operation has to be repeated." 2

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After Stromeyer had led the way, and by his assiduity and skill had overcome difficulties and silenced his opponents, a crowd followed in his train. Some were content

'Beiträge zur Operativen Orthopädik,' Hannover, 1838. 2 Op. cit., p. 18.

to perform the section of the tendo Achillis; others, again, saw in this new operation a mode of treatment applicable to deformities in general; of whom Dieffenbach was amongst the first to appreciate the subcutaneous section, and subsequently one of the boldest and most successful in its employment.

In the month of October, 1835, Vincent Duval performed, for the first time in France, Stromeyer's operation of division of the tendo Achillis.

In 1836, Dr. Little, who was himself afflicted with distortion of the foot (equino-varus), had, in June of the same year, the tendo Achillis divided, by Stromeyer, in Hanover, and the shape of the foot restored. Before he left Hanover, he himself performed a similar operation, in July, 1836; and subsequently, in Berlin, Dr. Little enlarged his experience by treating, together with Dieffenbach, numerous cases of distortion.

Dieffenbach's account of Dr. Little's return to Berlin, as "Apostel der Tenotomie," after having been operated on by Stromeyer, in Hanover, is worthy of its author.

“A month had elapsed," writes Dieffenbach, "since Dr. Little had taken a letter from me to Dr. Stromeyer, in Hanover, when suddenly my door was opened, and the individual who had left me a cripple, entered with a vigorous, rapid step. I cannot tell which was greatest, my astonishment or my joy, but I think the latter. Without delay, I examined his foot, and found the shape normal, the sole in contact with the ground, the arch of the foot less; the calf of the leg had begun to be developed, and the entire lower extremity had gained its normal length. A miracle could not have struck me more forcibly; and I must confess that I was never in my life so taken by surprise at the successful result of a surgical operation as by this; and I esteemed Stromeyer, who had done it, even luckier than Little, who had been benefited by it."1

Ueber die Durchschneidung der Sehnen und Muskeln,' p. 80, 1841.

In Berlin, Dr. Little wrote his inaugural dissertation, and selected for his subject talipes varus.1 He returned to England the same year, and we find, " February 26th, 1837, divided the tendo Achillis ;" and rapidly established that reputation which he now enjoys.

Delpech, in his master work, 'De l'Orthomorphie,' may well be said to have raised the structure-Orthopædy ; it has, however, since his time, been greatly extended and simplified; and, amongst others, Dr. Little has contributed largely to its present advanced position.

It would be presumptuous in me to speak in terms of praise of the philosophical works of Jules Guérin. I would express an earnest desire that he may be induced to complete his valuable series of works, and that he may give to the profession, more in detail than he has hitherto done, the results of his labours. The name of Guérin will always remain prominent in orthopædy, and his writings a guide to warn against many shoals.

The decennial period 1830-40 is indeed rich in contributors to this branch of surgery. Such names as Bouvier, Ammon, whose work3 merits the highest praise, Phillips, Held, Scoutetten, &c., enrich this period.

It is remarkable that subcutaneous tenotomy should not have been practised until 1831, as the subcutaneous division of muscles was introduced so long ago as 1670, by Roger Roonhuysen, and after him performed by Florian, Minius, Solingen, Meckren, Tulpius, Ten Hoof, and others, until the present time.

1 'Symbolæ ad Talipedem Varum Cognoscendum,' Berol., 1837.

2 A Treatise on the Nature of Club-Foot,' p. 196.

3 De Physiologia Tenotomiæ experimentis illustrata,' 1837.

CHAPTER II.

CONGENITAL TALIPES.

PHYSIOLOGY, DIAGNOSIS, AND ANATOMICAL PATHOLOGY.

THE term talipes, from talus and pes, was first used as a generic term by Dr. Little, and is applied to all those distortions in which the foot deviates from its normal direction, with and without partial displacement of the articular surfaces of the tarsal bones.

The following are the principal varieties of talipes; namely, varus, or inversion of the foot; valgus, eversion of of the foot; equinus, phalangeus, vel digitus, elevation of the heel; and calcaneus, depression of the heel. Of these several varieties there are many degrees: there are also compound varieties of distortion, which are composed of two of the above mentioned forms of talipes; as, for instance, equino-varus, equino-valgus, varo-equinus, calcaneo-valgus, calcaneo-varus, &c.

Each of these forms of distortion may be congenital or non-congenital.

Talipes varus is by far the most common form of congenital distortion of the foot. In a resumé of cases, which had occurred at the Royal Orthopedic Hospital, in 1851,

it appears that, of 765 cases of congenital talipes, 688 were varus, 43 valgus, and 19 calcaneus.1

It

Equinus is an exceedingly rare congenital affection. does not once occur among the above-mentioned instances of congenital talipes; and moreover Mr. Tamplin says, "I have never met with pure talipes equinus congenital." It does, however, occasionally occur as a congenital affection; several authors relate cases which they have individually treated, and I have once seen an undoubted instance of congenital equinus.

Of non-congenital distortions, equinus, equino-varus, and valgus, are the most common: the latter is very frequently met with in a slight degree. In its more aggravated form, as it is usually seen at the Orthopedic Hospital, valgus is not the most common distortion of the foot. Of 1218 cases of congenital and non-congenital talipes, recorded by Mr. Lonsdale,3 the varieties occur after the following

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At the Orthopaedic Hospital it is observed that double and single club-foot occur almost with equal frequency. Thus, of 688 cases, above mentioned, 363 were double

1 Medical Gazette,' Lecture by Mr Tamplin, 1851.

2. On the Nature and Treatment of Deformities," p. 21, 1846.

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