the past, to excite ambition and stimulate imagination, the nature of his subject, binds him to the rugged path of science. To be useful, must be his highest aspiration. To revel among the flowers of rhetoric, to mount on strong pinions towards the heights of eloquence, even to sport by the wayside with the gems of literature-all this would be impertinent, even if his humble powers would warrant such an attempt. The advancement and effective proof of a simple fact in Medicine or Surgery is more correctly in his line of duty on this occasion than the happiest display of erudition or literary accomplishment. Accordingly, I have chosen for my subject at this time," The Inutility of Tenotomy in the Treatment of Congenital Varus."

The propriety of tenotomy in cases of deformity, as a general question, has been warmly argued between surgeons of high distinction from an early period, the operation alternately rising and sinking in popularity like other fashions in medicine. Of late years within our memory, there has been a period in which such operations were carried to an unwarranted excess, and frequently with very unfortunate results; there followed an interval of years during which its enemies proved victorious to a considerable extent, and it fell into, perhaps, unmerited neglect. Recently this discussion has been renewed with more vigor, and we are in danger I think of going once more into the former extreme. The dispute is probably, like that of the two travelers, as to the color of the chameleon, the truth being determined rather by surrounding circumstances or the nature of the deformity in each class of cases, than by the intrinsic merits of the operation. I am far from wishing to be understood as an opponent of tenotomy in all deformities, even while presenting both argument and practical evidence against its employment in congenital varus; to which my attention will be confined at present as closely as possible.

Presuming that all are acquainted with the history of tenotomy in varus, from the time of Thilenius, in 1784, to the present moment, and with the counter evidence and reasonings of the equally

distinguished friends of the exclusively mechanical treatment of this deformity, your Essayist takes ground that in Congenital varus, the division of tendons or muscles, only complicates the case, and prevents at least for a time, the application of instruments proper for the reduction of the deformity;-instruments, be it remembered, that are always requisite, whether tenotomy be performed or not:-for no sane surgeon will dare to assert that, unaided, muscular contraction can restore the displaced parts to their normal position, even after all opposing tendons are divided; and I hold that this restoration may be far more perfectly effected by the proper mechanical agents, without the operation. Much has been said of the proximate cause of this deformity; but I am not aware that any fact has been discovered, or that any thing even plausibly hypothetical on this point has ever been advanced, but we do know, unfortunately too well, the actual condition of the foot, in such cases the peculiar malformation and serious distortion of the hopes of the tarsus, metatarsus and ankle, with the corresponding arrangement of the muscles and tendons. From these well established data, your essayist is irresistibly forced to the conclusion that the muscles have no effect in producing the deformity, but that they merely accommodated themselves to the altered condition of the osseous structure, resulting from unknown and abnormal actions on the partially developed limb, while the child is in utero, whether those actions be mechanical-from aberrations in the contractions of uterine fibre, or temporary malposition of the fœtus, or physiological, from errors in the process of nutrition. It is well known that the very great change in the form of the foot results from alteration in the shape and relative positions of the astragulus, the os naviculare, and the internal, middle, and external cunieform bones; and that in consequence of this change, the weight of the child, when placed in an erect attitude, is brought to bear upon the os cuboides, (which is often enlarged,) and upon the heads of the fourth and fifth metalarsal bones. At birth, as Dr. Horner very

properly remarks, though the skeleton is sufficiently solid to preserve the shape of the individual, yet it remains very imperfect in many particulars. The ends of the long bones are still cartilaginous, and all parts of the carpus and tarsus are nearly in the same condition, presenting only very delicate and minute centres of ossification, bearing but slender proportion to the entire dimensions of the several bones; which therefore present, as yet, no sufficient points d'appui for the vigorous action of muscles, even if the tender infantile fibres were capable of such action. Now I contend that, under such circumstances the muscles can have nothing whatever to do with the production of the formidable alterations of structure and position that constitutes the varus; and if correct, in this, what possible good result can follow the division and subsequent reunion of muscle or tendon? I hold that there is none. Even adult muscles slowly accomodate themselves to considerable permanent extension; as is evidenced in the History of irreducible luxations with elongation of the limb; and it is not to be believed that the tender fibres of an infant can offer any effective opposition to a gentle, but persistent action of mechanical force. The obstacle to the restitution of the bones to their proper relative position in this deformity, is not to be found in muscular resistance, but in the actual changes of form in the osseous and ligamentous structure; and these are to be counteracted not by tenotomy but by the gradual remolding of tissue, effected by time, under the influence of mechanical pressure, and certain well known physiological powers, such as we sometimes see developed in the formation of new joints after dislocations of the shoulder or hip.

In varus the articulations, ligamentous connections, and the bones themselves are changed, not only in position but in form; and our special duty is to bring gradually the parts to such relations as will restore them as nearly as possible to their capacity for the performance of their normal functions, through the agency of the plastic powers of the vital organization which we see so remarkably exemplified in the production of the very malformations that

we seek to remedy. This very cursory review of the subject being premised, and your patience demanding brevity, it would seem desirable now to enter at once upon the consideration of the proper method of treating this deformity, and the appropriate time for its commencement.

I have made it a rule in my own practice to commence the application of apparatus as soon after birth as the parts are suf ficiently developed to bear the application of the splint intended to produce eversion of the foot without producing abrasion; and I have found the proper age to vary from six weeks to three or four months; but even at an earlier period a systematic and cautious course of treatment is not to be neglected. From the first, the nurse should be taught to bring the foot repeatedly and carefully to the median line of the leg, by gentle manipulation; for this will be found to facilitate the after operations, and ultimåte success in a remarkable degree.

The first instrument to be employed in changing the relations of the parts was called by its inventor, the late Heber Chase, M. D., of Philadelphia, "the Everter." [See Figs. 1 and 2.] It consists of a brass splint, moulded to the general form of the outside of the leg, and well padded to its lowest extremity, which terminates just above the external malleolus, to which is appended a projecting flat rod of soft steel, provided with three fenestra, longitudinally arranged, for the accommodation of straps. This bar is connected with the brass splint by a malleable neck, round in form, and one inch in length, which permits it to be easily bent in any direction, at the will of the surgeon. This neck is prevented from pressing on the external malleolus with which it corresponds in position, by the thickness of the padding of the splint. This splint is applied to the limb, from opposite the head of the fibula to the malleolus, and it is secured in that position by a roller. The neck of the instrument is then bent till the flat steel rod is brought to an angle with the splint, somewhat more obtuse than that formed between the leg and distorted foot. [See Fig. 1.]

And the latter is everted and held in a line with the steel bar, either by a few turns of narrow roller, or what is prefer able, soft leather straps passed through the fenestra. The foot should be examined from day to day, and the instrument re-adjusted when necessary; and, as the resulting change of position of bones progresses, the direction of the steel bar should be gradually altered, until the foot is brought into a straight line with the spine of the tibia. It then becomes advisable to keep things in statu quo for two or three weeks, to favor the required absorption of the soft bones of the outside of the foot, while the reparatory process is going on upon the inner side. The eversion should then be steadily continued until the foot is rotated outward, to an angle of thirty degrees, as shown by instrument. [See Fig. 2.]

In the management of very delicate children, where the parents are extremely anxious to have the treatment to be commenced, at a very early age, I have used with very happy effect, an instrument of my own projection. It differs from "Chase's Everter" in having substituted for the flat steel bar of that apparatus, a second brass splint, adapted by padding and moulded to the form of the outside of the foot, together with about half the plantar and dorsal surfaces of the tarsal and metatarsal regions in their deformed condition; the two splints being connected by a flexible neck as in the former contrivance. [See Figs. 3 and 4.] This instrument is at first arranged at an angle rather more obtuse than that of the foot and leg, and is secured to the limb after adjustment, by means of a roller applied over a well regulated padding, both to the foot and leg. The foot is then from day to day, cautiously brought into line with the spine of the tibia, as in the foregoing plan of treatment; but without the same forcible action on the smaller bones affected by the unnatural torsion that gives character to the deformity. Some weeks are allowed, as in the former case, for the natural processes of absorption and the remodeling of bone; and then rotation of the foot outward is continued until the eversion is complete, and the foundation of a proper pedal sup