lis 



dis(;ovi:hy 



the Uniwrsily of I'aris. His book on children's 

 deformities rea-ived this title (from opOu':, straight, 

 and Trai&iin-, a child), and in this he anticipated modern 

 views in his belief in carefully selected exercises for 



SPRING FOR DEALING WITH I-OOT-DROP. 

 (Reproduced by pcnnission of the Oxford Medkal Publications.) 



the prevention as well as cure of certain deformities. 

 He would thicken the sole of a shoe, attach a weight 

 to a crooked shoulder or massage a hunchback, as 

 a logical outcome of his belief in the evils wrought 

 by a faulty posture. In France, in fact, was born a 

 realisation of the importance of muscle action in the 

 shaping of bones. Delpech was next on the scene. 

 He was the scientific bedside observer ; and from a 

 study of his patients he was driven to the conclusion 

 that deformities such as club-foot must be attributed 

 to unbalanced muscular action. So we find him in 

 1816, at Montpellicr, performing the pioneer operation 

 of tendon-cutting, or tenotomy, by which he released 

 the deformed part from the unbalanced pull of the 

 more active muscle (the tendon or " leader " being 

 the means of its attachment to bone). 



From its extreme simplicity, its great value, and 

 the frequency of conditions in which such an obstacle 

 to free movement is present, the operation with 



various modilications is still extensively employed. 

 To-day, however, we must regard tenotomy in most 

 cases merely as a remedy for conditions which were 

 avoidable or preventable in the first place. Con- 

 tinued overaction of one set of muscles, with weakened 

 muscles opposing it, brings about permanent shorten- 

 ing of the active set, and stretching with still further 

 weakening of the less active ; a vicious circle is estab- 

 lished, and finally a fixed deformity of the joint is 

 produced. Clearly the process should be recognised 

 at its first inception, before definite secondary changes 

 have occurred in muscles and neighbouring structures, 

 and the onset of deformity should be prevented by 

 support of the weaker muscles with splints. 



A toe-raising spring is illustrated in Fig. i, such as 

 has been extensively employed for the prevention of 

 deformity following foot-drop, a condition which 

 occurs through injury of the nerve which suppUes the 

 toe-raising muscles. If such a case of foot-drop be 

 left without support, the heel becomes more and 

 more drawn up till eventually it gets fixed there by 

 the shortening of the active calf muscles, and at this 

 stage tenotomy above the heel must be an essential pre- 

 liminary to any attempts to cure the toe-raising muscles. 



To return to Delpech, we find that he had many 

 imitators, and Stromeyer of Hanover was able, by 

 adopting his idea, to relieve squint by division of 

 certain eye muscles. 



German surgeons next made a great forward step with 

 the introduction of osteotomy — the division of bone 

 by saw, or by hammer and " osteotome " (like a 

 chisel with double bevelling) — a procedure by which 

 the fragments may be made to unite in any desired 

 alignment. It provides a means of placing the lower 

 limb in a useful position, when, for example, hip 

 disease has culminated in a fixed updrawn thigh. 

 And other similar circumstances arise, the commonest 

 being, perhaps, bending of the bones under the body- 

 weight from rickets. 



To-day an alternative procedure (osteoclasis) for 

 children of three or four with the bent legs of rickets 

 consists in simply breaking the bone across by hand 

 without incision. But it is, of course, less exact. And 

 though it appeals to some parents as being " blood- 

 less," it is quite inadmissible when the " bend " has 

 occurred near a joint. So-called " bloodless " methods, 

 in fact, must be reserved for suitable cases, and each 

 case must be judged on its merits. While it succeeds 

 with the dislocated hips of little girls, it involves the 

 gravest risks in old-standing shoulder dislocations. 

 We may consider, then, that since the advent of 

 Listerian Principles in Surgery, there is no reason 

 whatever for avoiding the knife when better results 

 are thereby obtained than by other means. 



Consideration of the normal functions and require- 



