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Cruveilhier1 added some valuable information on the pathological anatomy of club-foot. Entertaining, however, an erroneous opinion with regard to club-hand, namely, that distortion ceased immediately after birth, he concluded that the deformity was induced by the cramped position in utero; and reasoning from club-hand to clubfoot, he asserted that position in utero was the sole cause of these congenital distortions. But his premises were false, and consequently his deductions. So far from club-hand ceasing as soon as the pressure of the uterus is removed, namely at birth, it may continue for months, and years even, without marked amendment. Had these cases been brought under Cruveilhier's observation, he would never have asserted, that "these distortions must arise from pressure in utero, because removal of pressure causes the removal of distortion."

But towards the end of the last century, viz., in 1784, a new era opened to orthopædy, when tenotomy was for the first time practised to remove distortion. Thilenius, of Frankfort, divided the tendo Achillis for the removal of talipes equino-varus. follows:

The case is recorded by him as

"A young person of this town (Frankfort), 17 years of age, who had been afflicted from her earliest childhood with lameness of the left foot, walked on the outer edge of the foot, and twisted the foot in walking. Every kind of bandage, boot, and ointment had proved of no avail. The patient limped frightfully, and the foot was bent so much forward, and the tendo Achillis was so shortened, that she walked almost entirely on the dorsum of the foot; and the surface on which she trod being always excoriated, she only limped slowly about the house.

'Anatomie Pathologique du Corps Humain,' Paris, 1829-1835.

"On the 26th of March, 1784, the tendo Achillis was divided, and at most, one ounce of blood was lost. Immediately the heel descended two inches, and the foot could be placed flat on the ground. Our surgeon, Mr. Lorenz, then bandaged the foot, and the healing process proceeded so favorably, that on the 12th of May, the large wound had completely cicatrized, without a single unfavorable symptom.

"For some time after this, emollient baths were used, and Unguent. Althææ was rubbed over the tendon; and now the girl can walk properly again, and like other people."1

Thilenius never again undertook a similar operation, and twenty-two years elapsed before it was repeated. At this time, namely, in 1806, Sartorius performed the section of the tendo Achillis, and the following is his account of the operation.

"A successful Restoration of a Contracted Foot through Division of the Tendo Achillis. By JOHANN FRIEDRICH SARTORIUS.

"On the 10th of May, 1806, I saw the son of Martin Aust, of Rozenhahn. He was 13 years of age. The right leg was thinner than the sound one, and marked by long and deep cicatrices; the tendo Achillis was remarkably tightly stretched, as was apparent throughout the entire calf of the leg; the heel was drawn up; the positions of all the bones of the foot were changed from their natural directions, so that the metatarsus was laid upon and formed an angle with the tarsus, and the whole foot described, as it were, a bow; in a word, the foot was so bent that the patient brought the dorsum, instead of the sole of the foot, to the ground. The tendo Achillis was shortened, so that I was not able, with all the force I could use, to move the foot in its normal direction forwards. The effort which I made gave the patient great pain, and the muscles of the calf were so stretched, that the tendo Achillis became exceedingly tense.

'Medicinische und Chirurgische Bemerkungen,' von M. G. Thilenius, Frankfurt, 1789. In a posthumous edition of his works, this case was omitted.

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Concerning the origin of the malady, I learnt that, until his seventh year, the patient enjoyed good health, passing through the different forms of disease incident to childhood, without any circumstance worthy of remark. During the winter of his seventh year, he fell into the water; and fearing that he might be punished, did not mention the circumstance, but continued to wear his wet clothing throughout the day. Four days after this occurrence, slight pain was felt in the calf of the right leg, which increased daily until redness and swelling, together with darting pain, fever, and thirst supervened.

"Every imaginable remedy was used, yet swelling and pain increased every day, until, about the twenty-second day, the abscess burst, and some pus escaped: similar openings subsequently formed in the neighbourhood of the calcaneum. A surgeon in the neighbourhood was now summoned, and in time cicatrization took place, but only after the abscess had been discharging for a space of six months, during which time the boy had been for the most part confined to bed. After the wounds had healed, it was found that the sole of the foot could not be put to the ground, but the toes only. At first this circumstance did not attract much attention, but it continued without alteration, and during four years the toes only were brought to the ground. Distortion increased gradually, and for a year and a half the dorsum of the foot was brought to the ground in walking; so that he was compelled to wear a laced boot with a sole on the front of the boot. His general health was good.

"I wished to try the effect of embrocations; but similar means having been employed unsuccessfully for some years, and the baths of Ems and Wiesbaden having been used without benefit, the parents were unwilling to lose more time in making repeated trials of a similar kind, but desired that the foot should be forcibly restored to its proper shape. I was not, however, at once able to make up my mind as to the propriety of such a violent proceeding, and requested time for reflection.

"On May 14th, I was at the parsonage close by, and sent for the father and son, and again inquired into all the circumstances above detailed. I was doubtful if I should attempt the cure by means of bandages and embrocations, or if I should divide the tendo Achillis, and then forcibly restore the foot to its normal position. I decided on the last mentioned plan, and, in the

presence of the clergyman, told the father, at the same time declaring that I could not be answerable for the result of the operation that the boy might lose his foot, or his life even; but that I hoped such an unfortunate occurrence would not take place; that the shape of the foot would be perfectly restored, and that he would be able to tread on the sole of the foot. The father consented to the operation, and added, that this was his only child, but that it would be better he should cease to live, than continue to be so deformed. He confided him to me, and desired me to do whatever was necessary for the removal of the deformity. The boy seemed well pleased with the determination. I took the necessary measures that bandages might be prepared.

"On May 16th, I took with me everything necessary, and performed the operation in the following manner :-I bandaged the thigh and leg, as far as the middle of the calf, with a long bandage, applied a long compress in the course of the femoral artery, and a tourniquet. A table was prepared with pillows, on which the patient was laid on his face, the dorsum of the foot resting on the edge of the table. Everything necessary for the operation bandages and dressings, were close at hand. I gave him a glass of wine, with Tinct. Opii, mxv, and proceeded to operate, seating myself with the foot before me.

“With a convex knife I made a longitudinal incision through the integuments, about four inches in length, over the middle of the tendon, raised the skin, and exposed the fascia, which I punctured and divided on a director to the same extent as the external wound. The edges of the wound were then held apart, that I might pass a small, pointed scalpel beneath the tendon; and this being done, the tendon was divided on raising the edge of the knife. Immediately the ends of the divided tendon were seen one inch apart. The patient was now placed on his back, when I grasped the foot with my right hand and endeavoured to flex it on the leg, having the index finger of my left hand in the wound between the ends of the tendon, that I might observe, on moving the foot, if the space between the divided ends were increased: but I could not move the foot more readily than before the division of the tendon, nor could I separate wider the ends of the tendon. I soon discovered, however, the reason: cicatrices had formed, which bound together the skin and tendon to the deep-seated tissues in the neighbourhood of

the os calcis. The patient was again placed on his face, and I extended the incision as far as the extremity of the os calcis, divided the old cicatrices all around, and freed the tendon from the deep-seated tissues, which resembled a steatomatous mass rather than adipose tissue. The patient was again turned on to his back; and now I could bend the foot farther forwards, and separate wider the ends of the tendon, but the foot could not be restored to its normal position. Only a small quantity of blood was lost during the operation, and one small artery alone required a ligature. Small pieces of sponge, steeped in spirits of wine, were laid in the wound during the operation, that hemorrhage might not impede its progress. The tourniquet was now removed.

"Having fixed the knee, I grasped the foot with both hands, the thumbs being applied to the sole and the fingers to the dorsum of the foot. First, I extended the ankle; then, gradually increasing the force, flexed the foot as much as possible. Now my assistants held the foot firmly on the table, and I, with all my strength, applied myself suddenly to move the limb forward, which I accomplished, but with such cracking and noise as though all the bones were broken. The patient screamed terribly: the great pain, however, was soon allayed. On examining the foot, no fracture was found."

"Graduated compresses were placed on the calf of the leg, the whole leg was bandaged, and the foot was placed in a slipper to retain it in its new position.

"I was very apprehensive of the result, as the foot could scarcely have been restored without laceration of several of the ligaments, inasmuch as the great force which was applied caused the foot to yield suddenly, with a frightful cracking noise. Moreover, I was aware of the serious symptoms which are frequently induced by dislocations of the carpus and tarsus, when combined with laceration of the ligaments.

"This was certainly not a true dislocation: but it was treated as a compound dislocation, not only on account of the wound, but also on account of the rupture of several ligaments, which must necessarily have occurred.

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May 17th.-The patient slept quietly during some hours of the night.

"19th. The pulse was frequent; there was loss of appetite, with

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