ble: it had gained two inches in length; and this new portion of tendon was half the thickness of the tendon in its normal condition.

:

"A shoe was now worn, and the patient allowed to take exercise he could stand on one or both feet, could walk and run without other deviation of the foot than a slight outward inclination.

"Such was the state of the patient, when derangement of the digestive organs supervened, and abscesses formed in the thigh, above the knee, and in the groin. He was sent without delay to Cette, where he used sea baths, which brought about the complete cicatrization of the wounds which had been made at the time of the operation; those, also, which were occasioned by the abscesses, as well as the tumefactions which resulted from them; and his health was in a short time completely re-established.

"At the present time, he is in the enjoyment of good health, and astonishes those who knew him previously, by the firmness and rapidity of his movements. He wears a proper support, which I intend he should continue to wear several years."

Thus, the first and only operation performed by Delpech of tenotomy for the removal of distortion, was a subcutaneous operation. And, unlike his predecessors, he allowed re-union to take place before he commenced to make extension. It is much to be regretted that he who could write the following rules should not have had courage to resist the clamour which was raised against him, and practise that he had so well devised.

The rules of Delpech for the subcutaneous division of

tendons.

"1st. The tendon to be divided should not be exposed: its section should be made by entering the knife at a distance from the tendon, and not through an incision in

'Chirurgie Clinique de Montpellier,' par le Professeur Delpech, tome i, p. 192, 1823.

the skin parallel to it. There is danger of exfoliation of the tendon without this precaution is taken.

"2d. Immediately after division of the tendon, the divided extremities should be brought into contact and so held by a suitable apparatus, until re-union is accomplished.

"3d. As re-union can only take place by an intermediate fibrous substance (organisation inodulaire), gradual and careful extension should be made, to give the required length to the shortened muscles, before solidification takes place.

"4th. Extension being complete, the limb should be fixed in this position, and there kept until the new substance has acquired that firmness of which it is susceptible.1

The author of these rules may well be said to be the originator of subcutaneous tenotomy. Fifteen Fifteen years after the operation by Delpech, and three years after the publication of 'L'Orthomorphie,' Stromeyer first divided the tendo Achillis. Stromeyer was well acquainted with this work of Delpech, and approved of the rules therein inculcated. As Dr. Little has well said, "To Stromeyer is due the honour of establishing the division of tendons on a secure and permanent basis, and of ensuring its reception as a standard operation in the art of surgery." But, however great may be the merit of Stromeyer in reopening the question of tenotomy, it must not be forgotten that Delpech dictated what Stromeyer performed. The following case, the first in which Stromeyer divided a tendon for the removal of distortion, will show how well he had studied Delpech,

'De l'Orthomorphie,' tome ii, p. 330, 1828.

2

Section of the Tendo Achillis for the cure of Club-foot.

George Ehlers, aged 19, the son of a schoolmaster in Hanover, was affected, in his fourth year, with distortion of the left foot, from some unknown cause, which subsequently gradually increased in severity. At first, therapeutical means and bandages were tried with some degree of success; but the affection made such rapid progress, that this mode of treatment was found to be useless. Excoriations and deep-seated suppuration, inducing caries of the fifth metatarsal bone, resulted from these attempts to redress the limb. This treatment was consequently discontinued, and the boy, then 14 years of age, was provided with a wooden leg. With this he walked about tolerably well, using at the same time a stick or a crutch.

"In October, 1830, I was consulted.

"On the left side there was a severe form of club-foot; the toes were bent inwards and downwards, the outer edge of the foot was immediately beneath the axis of the leg, and the whole foot was forcibly extended through the action of the gastrocnemius muscle, so that the foot formed a continuous line with the anterior surface of the leg. Above the external border of the foot, were the rudiments of two callosities, which had been formed at an early period by pressure. A cicatrix, one inch long, and adherent to the bone, was observed above the fifth metatarsal bone. The motion of the foot was very limited. The leg was atrophied, and the calf very small, and drawn high up, and was only to be distinguished by moving the foot. From wearing a wooden leg five years, the leg had an outward inclination. The length of both legs was the same, allowance being made for this inclination. The muscles of the right

leg were well developed.

"On the 28th of February, 1831, in the presence of Dr. Dommes, and some of my surgical pupils, I proceeded to operate. The patient was seated on a table before me, leaning towards the right side; an assistant fixed the knee, and another flexed the foot, and rendered the tendo Achillis tense. I passed a small, curved, pointed knife behind the tendon, two inches above its insertion, the back of the knife being towards the tibia, and its cutting edge so close to

the tendon, that this was divided in introducing the knife, with a cracking noise. My intention of making the outer wounds as small as possible, to prevent the entrance of air, and to avoid suppuration and exfoliation of the tendon, was perfectly accomplished, for the point of the knife only passed to the opposite side, without producing a bleeding wound; and the point of entrance of the knife was only as broad as the blade itself. A very small quantity of blood escaped from the wound. The retraction of the tendon was inconsiderable. When the foot was flexed, however, the ends of the divided tendon were three quarters of an inch apart, without the shape of the foot being appreciably improved; but when the foot was extended, no interval remained, the divided ends being in contact. The wounds were dressed with court plaster, &c.

very

"On the third day, the wounds had healed, the ends of the tendon were slightly swollen and sensitive, and there was slight ecchymosis about the inner malleolus. Movement of the foot did not influence the upper end of the tendon. On the sixth day, reunion had taken place, so that movement of the foot now stretched the upper portion of tendon. There was less swelling of the tendon, but considerable pain.

"On the tenth day, pain had almost ceased. Union was at this time so complete, that the patient could move his foot, and bring the muscles of the calf into action. The interval between the portions of tendon was now scarcely to be recognised. I thought that the time had now arrived when extension of the intermediate substance ought to commence; and consequently I applied the apparatus. When it was applied, the foot formed a very obtuse angle with the leg. Extension was in the first instance made very gradually, lest the adhesions should be broken, and also because more pressure caused pain; but at the end of a week more extension could be borne without pain. At the expiration of the eighth week, the foot formed a right angle with the leg; so I allowed the patient to have a boot, with an iron stem along its outer side, having a joint at the ankle, and a screw attached to it, to decrease the angle formed between the foot and the leg. With this boot, and the assistance of a stick, he could walk about the room. From long disuse, the leg at first swelled; but by using it daily, at first in the house, and afterwards in the garden, he gained strength and steadiness so rapidly, that in a fortnight from his first attempt he could walk a mile and

a half. The length of the new tendon could not be distinctly made out; it was thinner only where the section had been made.

"At the end of two months the foot was at a right angle, and its outer edge horizontal. At the end of six months the position of the knee was entirely restored; and at the expiration of a year my patient was enabled to lay aside his boot and iron, and use an ordinary laced boot, in which he could walk securely without a stick, and so well that no one would have suspected the former condition of his foot, for he trod firmly and without effort, and brought the toes well forward, even when walking quickly.

"In the course of the following summer the foot was excoriated by wearing a new, tight boot; but there was no inclination to the return of distortion, and no tendency to retraction of the new substance. I therefore considered that the cure was complete." 1

In a note appended to this case, Stromeyer observes:

"I determined the more readily to perform this operation, as, in September, 1830, whilst in Hamburg, at a meeting of the Association for the advancement of Science (Naturforscherverein), I was present at an amputation of the leg of a young girl afflicted with club-foot. Some of the most eminent German surgeons were present, and agreed on the necessity of amputation of the leg; yet the deformity was less than in my patient."

I have given these early cases of tenotomy in extenso, which now for the first time appear in an English dress, to show how slowly the advance was made from the "large wound" of Thilenius, and the frightful operation of Sartorius, to the more philosophical proceeding of Delpech, and the subcutaneous tenotomy of Stromeyer. Nearly fifty years were necessary for this purpose. But this triumph having been accomplished, the attention of the surgical world was directed to this new principle in surgery,