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MEDICINE AND SURGERY.
Art. I.-An Essay on Tenotomy, with illustrative Cases. By
S. B. RICHARDSON, M. D., Lecturer on Anatomy and Surgery, &c., of Louisville, Ky.
The operation of Tenotomy in the treatment of club-foot, which has met with such encouraging success recently in the hands of Stromeyer, of Hanover, and Bouvier and Duval, of Paris, (professed orthopedists of the continent of Europe) must be regarded by all who are familiar with the subject as a beautiful illustration of established physiological and pathological principles, and an undoubted advancement in the treatment of a very extensive but hitherto neglected class of individuals, found in every community.
In the legitimate employment of the term, it may be stated in the outset, that tenotomy must be regarded as a discovery, of such extensive application and importance, as to take rank with those great and acknowledged improvements in medical and surgical science, which have shed such brilliant lustre upon all that appertains to medicine, during the present age.
Like most true discoveries the merit of its origination cannot be awarded to the labors of a single individual, but it will be found upon a careful inquiry into its history, that the facts which led to its deduction were made known long anterior to designed tendinous section itself.
How encouraging should a fact like this be to those who are laboring in the field of observation, and thus become the benefactors of science, it is needless to insist. It rarely, in fact, falls to the lot of any one observer however qualified, to develope a single new principle in any department of knowledge. We are free to assert that every Newton will be found to have had a Gallileo, a Kepler, and other observers as his predecessors, and the remark will be found to apply not less appropriately to medicine than to astronomy and natural philosophy. Science, too, must be regarded, in some sense, as a unit, although artificially divided and sub-divided for convenience of study. It is not in the nature of true knowledge, but in the limited capacity of the human mind, connected with the comparatively brief period allowed for observation, that these artificial arrangements in too many examples, dismemberments,) have been made and must be allowed to continue. What the God of nature has intimately associated should not in any case, cannot be dissevered except with the most injurious effects. Extra-professional scep
ticism among the learned as well as the uninformed is known to exist to some extent every where, in reference to the verity of medicine as a science—with how much truth, let those, who are immediately interested, give the answer, and abate the odium if found in any degree to exist. Some medical men, too, at no very remote date, and who have received the exalted appellation of medical philosophers, are known to have regarded the term science applied to medicine, as an unallowable assumption.
By these remarks, we do not wish to be understood as embracing or countenancing the sentiment just referred to; on the contrary we have too much attachment for, and confidence in practical medicine to detract one iota from her just merits, and the noble stand which she has recently assumed, and is destined to occupy (if rightly studied) as an exact science. It must in candor, however, be admitted, that medicine has not kept pace with those sciences par excellence entitled exact. This is doubtless referrable to more causes than onechiefly however to the neglect of the inductive or Baconian (may it not be entitled Hippocratic ?) method of investigation, and the multiplicity of phenomena presented in vital manifestations, coupled with the heretofore almost inextinguishaable thirst for theorizing, and system building, in medicine. The perception of this has led many distinguished physicians of the present age on the continent of Europe and elsewhere, to abandon the false route into which so many have strayed and wasted their energies, and to return to the path of patient observation,-admitting that there is not as yet a sufficient number of well established facts to serve as a basis for a theory, or, more properly, to evolve one or more controlling principles that are to organic what gravitation is to inorganic matter.
Without any farther preliminary remarks, we proceed to the subject which claims our immediate consideration.
When in the progress of pathological investigations it was ascertained, that club-foot essentially depends, on a permanently shortened or contracted state of certain muscles and tendons, connected with the movement of the foot upon the leg, and in some instances the toes upon the foot, the failure of every description of machinery to remedy it was easily accounted for. It was not less palpable, from what is observed in accidental rupture of the tendo achilles, as well as from direct experiment upon inferior animals, that nearly all obstacles to the extreme flexion of the foot upon the leg is overcome by a section of the tendons of the extensor muscles.
I have in my private cabinet a peculiarly interesting specimen of that variety of club-foot technically styled Talipes valgus, which I fortunately obtained for dissection whilst engaged in investigating this subject, in the capital of France. It is not apparent upon a careful inspection of it at the present time, that inflammatory irritation had ever invaded any of the elements or tissues which enter into the constitution of the foot and leg, nor was this the case when the preparation was made, now about two years ago—unless the thickening and induration of the skin and cellular substance, and the production of adventitious burse mucose corresponding with the new points of pressure upon the side or top of the foot, may be regarded as possessing this character.
The deformity, then, in the preparation before me, in which the points of the toes are thrown outward and backward, the inner margin of the foot downward, and the sole looking backward, is connected with a permanently shortened and rigid state of those tendons whose physiological action
tends to incline the foot and toe in this particular position. Hence arises the principle or rule by which the deformity in any of its species or varieties may at once be recognized ; viz: Those muscles with their corresponding tendons, whose individual or combined action, when strongly contracted, tend to its production in a normal condition of the parts, are concerned in producing or maintaining the deformity in question. Deformities of the foot (which may be congenital or acquired) have the generic appellation of Talipes referring to the ankle, or pastern of a beast, or more classically, perhaps, Kyllopodia.* Of this, three varieties are distinguishable. Ist. That in which it is turned inward, (vara,) 2d. That in which the foot is turned outward, (valga.;) and 3d. That in which the foot, from the extreme extension, is turned upon itself, and rests upon the ground by the superior surface of its phalangeal extremity, (equina) called, also, phalangeal club-foot.
It was suggested long ago, that these deformities were caused primarily by an irregular conformation of one or more of the tarsal bones, by a defect of equilibrium in the action of the muscles which move the foot, or an abnormal insertion of one or more of their tendons. To these I will take the liberty of adding an ingenious supposition of M. Duval, of Paris, which I received from him in a conversation upon this subject. This gentleman is well known as a practical orthopedist of distinction in that capital, and by his numerous me. moirs delivered before the French Institute, and the Royal Academy of medicine, upon subjects connected with his speciality. He holds that the primary cause of these deformities resides in the cerebro-spinal axis, and that they are in * From kullos, crooked, and pous-podos, foot.