Part 24

The muscles being tense and in a state of violent contraction, drew the inferior fragments very forcibly upwards; these were finally, however, by means of well directed efforts, brought into perfect contact, with the superior fragments: the difficulty now lay in maintaining this contact. The age of the patient, his strength, and the almost convulsive state of the muscles, gave reason to apprehend that a displacement was about to occur. An attempt was made to prevent this in the following manner.

The patient being laid on a bed properly prepared,

1st, The foot and the leg above the ancle, were covered by a bolster or compress, round which was passed a strong roller intended for the purpose of making extension. The ends of this roller, being left free, were carried, one on the outside, and the other on the inside of the limb.

2dly, Below the tubercle of the tibia was placed another bolster, surrounding the leg, and on this, was secured another roller for the purpose of counter-extension. The ends of this roller, after crossing under the knee, were left hanging loose one on each side of the limb.

3dly, The two rollers being thus arranged, while the assistants, still continued to make extension, the surgeon applied successively, and in the order already mentioned, the compresses, the bandage of strips, and the bolsters.

4thly, He then took two splints with notches in their lower ends, of the same breadth with the splints already described, but long enough to reach, each of them, from four inches above the knee to the distance of four inches beyond the sole of the foot. One of these was applied on the outside and the other on the inside of the leg.

5thly, The surgeon then taking hold of the two ends of the upper roller, drew them over the upper ends of the corresponding splints, while an assistant crossing the two ends of the lower roller under the sole of the foot, drew the external end over the lower extremity of the internal splint, and the internal end over the lower extremity of the external splint. Carrying them, then, up along each side, he brought them, at the middle of each splint, to meet the ends of the upper roller, to which they were firmly secured by knots, so as to make extension at the foot, and counter-extension at the knee. The two fragments, being drawn by this apparatus, the one down and the other up, could not again overlap.[36]

[36] For a view and description of an excellent form of apparatus for oblique fractures of the leg, constructed on the principles of that here described, see article III. plate III. of the Appendix. TRANS.

On the same day the patient was bled copiously; a low diet was prescribed; some diluting drinks were administered; and the whole apparatus was frequently wet with vegeto-mineral water.

Next day, fever; restlessness; blood-letting repeated; the extending rollers, having become relaxed, were tightened. Third day, evidently better. Fifth day, a new application of the apparatus; some swelling of the foot; a few small blisters on the leg; these were opened and dressed with cerate spread on linen. Eighth day, the patient easy and tranquil; a little shortening of the limb; a third application of the bandage. Twelfth day, bilious symptoms appear. Thirteenth day, an emetic given in solution; symptoms decline. Twentieth day, the fractured limb in a favourable state; the roller for extension laid aside; that formerly described employed in its place. Thirtieth day, an appearance of consolidation. Thirty-fourth day, bilious symptoms recur; further evacuations. Forty-third day, consolidation perfect; scarcely a vestige of the fracture remains. Exercise is repeated for several days. Fiftieth day the natural strength and motion of the part completely restored.

11. The general end to be answered by every bandage intended to retain a very oblique fracture of the leg, is evidently, 1st, to hold the knee up, and with it the superior fragments; 2dly, to draw the lower fragment down: from this twofold effect arises a twofold resistance diametrically opposed to the powers of displacement, which are; 1st, the slipping down of the trunk, which pushes the thigh before it, and with it the upper fragments of the leg; 2dly, the action of the muscles of the leg, drawing the foot upwards, and the lower fragment along with it.

12. But, if to these indications we compare the bandage described in the foregoing case, we will perceive that they are perfectly fulfilled by it. Indeed the splints forming a kind of pullies which change the direction of the rollers, we must count on the action of these rollers only from the part of the limb which they surround, to the ends of the splints over which they are reflected: whence it follows, that the two ends of the upper roller, reflected over the superior extremities of the splints, cannot be drawn down along each of these splints, without that part of the rollers, which reaches from the leg to these extremities, being drawn up, and with it the knee and the upper fragment. In like manner, the ends of the lower roller cannot be drawn up towards the ends of the upper one, without those portions of them which run from the sole of the foot, being drawn down and pulling the foot and the inferior fragments along with them.

13. Hence it follows, that by tying on each side, one end of the upper roller to the corresponding end of the lower one with sufficient tightness, the two indications above laid down (12) are accurately fulfilled.

14. But, in general, the common bandage is sufficient, as I have already mentioned, even in cases of oblique fractures, to prevent the ascent of the lower fragments on the upper ones. Desault never employed any others in the last years of his practice, and it was only in cases of extraordinary disposition to muscular contraction, that he ever had recourse to the second kind. By means of the common apparatus, he was able to prevent the overlapping of the fragments from forming any protuberance on the anterior and internal part of the leg.

15. We must acknowledge, however, that this apparatus is liable to the same objection with most others intended for permanent extension. The roller placed below the knee, for the purpose of counter-extension, surrounds almost all the muscles, which tend to make the inferior fragments overlap the superior ones, by drawing the foot upwards. By pressing on and irritating these, it favours, and even excites their contractions, and, by that means, gives rise to a shortening of the limb, the very accident which the apparatus is intended to prevent. This inconvenience induced Desault, in a particular case, to substitute to the preceding apparatus, that used for permanent extension in fractures of the thigh.

MEMOIR XV.

ON THE DIVISION OF THE TENDO ACHILLIS.

1. It might be supposed that a work on diseases of the soft parts, would be a more proper place for this article, than the present one, where my express object is to treat of affections of the hard parts. What induces me to insert it here is, the analogy which exists between a division of the tendo Achillis and a fracture of the os calcis, the light which the treatment of the one throws on that of the other, and the example of the celebrated Petit, who, in his work on diseases of the bones, speaks also of this division.

§ I.

OF THE CAUSES AND VARIETIES.

2. The division of the tendo Achillis is the result, either, 1st, of the action of a cutting instrument; or, 2dly, of muscular action: hence two very different modes of its production, the one by a wound, the other by a rupture. The first is not a very rare accident, because the projection of the tendon exposes it oftentimes to the stroke of external bodies: the second, though but little noticed by the ancients, has been frequently observed by the moderns, since their attention was called to it by Petit.

3. The manner in which the division is produced by a wound, has nothing particular in it; that by a rupture, takes place in the following manner. A man leaps over a ditch, but his spring or exertion is too weak; he reaches the opposite bank only with the ends of his feet: the line of gravity not falling on the ground, the weight of the body throws the feet into a state of violent flexion, the muscles contract with great force, to prevent a fall backwards, and, at that instant, the tendon is ruptured, in consequence of being drawn downwards by the violent flexion of the foot, and upwards by the effort of the muscles: hence it appears that Petit was deceived with regard to the mechanical cause of the rupture, which he considered as taking place at the moment of the patient’s alighting on his feet, when, as he said, the tendons were surprised, so to speak, into a state of too great tension. It is easy to apply the principles of this particular case to others that may happen, and where the position may not be the same; such as, when we leap on a table, &c. Sometimes slighter efforts have produced the effect; and, as Louis observes, dancers have sometimes ruptured the tendo Achillis by making a powerful exertion on the point of the foot, as well as by other motions.

4. Divisions produced in the first mode, may be situated in any part of the tendon. Those produced in the second, occur more particularly about its middle: to that part the effort or strain is most forcibly determined, and there the resistance is the weakest. The rupture of the tendon may, according to Petit, be either complete or incomplete; but, if we consider the simultaneous contraction of the gastrocnemii and soleus muscles, and the intimate manner in which their two tendons are united at a considerable distance above the heel, it will be difficult to conceive how these tendons can be ruptured separately. With regard to divisions produced by cutting instruments, the case is different: there, the weapon may pass half way through the tendon either from behind or laterally; and perhaps divisions of this kind are much more frequently incomplete than otherwise, in consequence of the great resistance of the tendinous fibres.

§ II.

OF THE SIGNS.

5. The superficial situation of the tendo Achillis, always renders the diagnosis of its division easy. It can be rendered difficult only by the occurrence of a considerable swelling, an accident that rarely happens. If there be an external wound, the depth to which the instrument has penetrated, and the possibility of sometimes feeling the ends of the tendon between the edges of the wound, are the first evidences of its division. If, on the other hand, the tendon be only ruptured, then at the moment when the rupture happens, a report is heard by the patient, not sharp, and like the crack of a whip, as is said to take place when the plantaris muscle is ruptured, but more dull and flat, according to the account given to Desault by a patient, whom he interrogated on the subject.

6. In either case, there occurs suddenly, if not an entire inability, at least, an extreme difficulty in either standing or walking: hence the patient falls, and is unable to rise again; but, in divisions that are only partial or incomplete (4), this sign does not occur. Between the divided ends of the tendon there exists a depression sensible to the touch. This depression is increased by the flexion of the foot, but diminished and even entirely removed by its extension.

7. The patient can spontaneously flex the foot, none of the flexor muscles being affected, and this flexion may be carried even beyond what is natural, because the divided tendon forms no obstacle to it behind. Spontaneous extension is also practicable, in as much as the peroneus longus, tibialis posticus, &c. which remain uninjured, are capable of producing that motion. Some have alleged that the calf of the leg must be increased in size by the swelling of the gastrocnemii and soleus muscles, in consequence of their state of contraction; but modern experience has shown, that there is but little reliance to be placed on that appearance.

§ III.

OF THE PROGNOSIS.

8. Divisions of the tendons are not in general dangerous. These organs, being insensible in their nature, are not painful when ruptured, as is proved both by experiments on living animals, and by the observations of surgeons who have had such affections under their care, more particularly of Monro, who experienced the accident in his own person. No inflammation supervenes, and if a swelling be sometimes the consequence, it is in general soon dispersed, leaving behind it nothing serious.

9. Whence arose then the exaggerated fears of the ancients respecting injuries of this kind? Doubtless from an opinion which was then entertained, that tendons and nerves were of the same nature. Hence the severe pains, the convulsions, and even death itself, which, according to them, frequently happened, and was always to be apprehended, as the consequence of injuries done to these organs. Lamotte, among the moderns, still entertained these prejudices, when, in speaking of affections of the tendo Achillis, he said, “So dangerous are they in their consequences, that they can seldom be brought to a favourable termination.”

10. Doubtless the unskilful treatment, employed by the ancients, in cases of this kind, the use of the bloody suture without proper means to retain the parts in a suitable situation, the abuse of irritating remedies applied externally, the imprudent administration of oily substances, and, still more, the motions of the patient, contributed not a little to the production of those accidents, which no longer occur in the practice of the moderns, since the nature and treatment of the disease is better understood. It has been proved, by late observations, that the division of the tendo Achillis is apt to produce some diminution in the size of the affected leg. But this soon disappears, nor does it, indeed, even occur, if, by a proper application of the bandage, a speedy union of the divided part be obtained. The patients of Desault never experienced it.

§ IV.

OF THE INDICATIONS OF CURE.

11. That I may present, in order, what I have to offer on the treatment of the division of the tendo Achillis, 1st, I will lay down, with precision, the indications of cure that arise out of this division: 2dly, with these indications I will compare the means used by different authors, by which the insufficiency of almost all of them will be demonstrated: 3dly, by showing the relation or correspondence that subsists between these indications, and the apparatus employed by Desault, I will prove that it fulfils them sufficiently, and is, therefore, to be preferred to every other.

12. To bring the edges of the division into contact, and to retain them so, are here, as in other simple wounds, the two general principles of treatment. The first of the principles presents an easy indication; it is only to extend the foot forcibly on the leg. The indications that arise out of the other, are more difficult to be fulfilled.

13. To form a proper idea of these, let us call to mind what it is that prevents the contact of the divided ends. As far as relates to the lower end, it is the flexion of the foot on the leg, and with respect to the upper one, the contractions of the gastrocnemii and soleus muscles, which are not now opposed by the continuity of the tendon. Therefore, 1st, to keep the foot permanently extended; and 2dly, to oppose the action of these muscles, are the two general indications or objects of every apparatus destined to retain the two ends of the tendon in contact.

14. But, the action of the muscles may be opposed in different ways; 1st, by keeping the muscles themselves in a state of relaxation. This relaxation may be easily effected, as far as relates to the gastrocnemii, in consequence of their insertion into the posterior part of the condyls of the os femoris: it is sufficient, for this purpose, to keep the leg half-bent on the thigh: 2dly, by a judicious and well directed compression made on the muscles. I say judicious and well directed, because it ought to bear chiefly on the fleshy portion, and not on the tendon, otherwise it will depress its divided ends, destroy their contact, and make them unite, not with each other, but with the adjacent parts, and thus produce considerable lameness. At the same time that care is taken not to depress the divided ends, these ends must not be permitted to move from side to side, a kind of displacement which may readily occur, in consequence of the hollow or depression situated on each side of the tendon. But, the only expedient to attain this twofold purpose, is, to place in these hollows, some soft substance, lint, for example, which may project sufficiently to protect the tendon behind, and to retain it laterally.

15. This compression, that ought to be made by the bandage, appears to have escaped all writers, as none of them have given it a place among their means of cure. Yet, do we not plainly perceive, that, by confining the muscles, impeding their contractions, and reducing their irritability by its long continued use, it must tend to prevent the superior end from being drawn upwards and thus separated from the inferior one? Will not compression, in this case, be similar to the effect of the uniting bandage, in transverse wounds, where the great number of circular casts which cover the limb, are particularly intended to weaken muscular action, analogous to what takes place in hare-lip, where the compresses do as much good by compressing the muscles, as by bringing together the edges of the divided lip? But further, besides reducing the force of the muscles, does not this compression serve to prevent the swelling of the limb, an effect almost inevitably resulting from its state of rest and deficiency of action? So far, then, from being, as Louis says, one of the inconveniencies of the first bandage of Petit, it constitutes one of its principal titles to a preference among practitioners.

16. It appears from what has been just advanced (13 ... 15), that the following are the three ends to be attained by every bandage, intended to retain the divided ends of the tendo Achillis in contact; 1st, the immobility of the foot in a state of permanent extension on the leg; 2dly, the immobility of the leg, in a state of semiflexion, on the thigh; 3dly, a judicious and well directed compression made on the whole leg and foot, but bearing on the tendon with only sufficient force, to keep it from moving backward or laterally. Let us compare the methods of authors with these indications.

§ V.

OF THE DIFFERENT METHODS OF CURE.

17. The treatment recommended by authors may be reduced to three general methods. The first consists in rejecting all artificial aid, and leaving the cure to nature and the position of the limb. To the second belongs the use of sutures, intended to retain the edges of the division together. The third includes the different kinds of apparatus employed for the same purpose.

18. _First method._ Chronological order places this method after the others. But this order must be disregarded by him, whose object is things rather than time. The history of the sciences calls sometimes for the approximation of distant periods, and, at other times, for the separation of those already approximated.

19. Several practitioners, in France and England, have lately proscribed the use of all external means. Pibrac and Dupouy were of opinion, that the mere precaution of the patient not to flex the foot, assisted by constant rest, was sufficient. Hoin and Gauthier mention many cases in confirmation of this doctrine. M. J. Rodbard, surgeon at Ipswich, having ruptured his own tendon about three inches above the heel in leaping over a little rivulet, instead of confining himself to bed, continued in the exercise of his profession. He walked every day, without any other precaution than that of not flexing the foot, and five years afterwards, he was able, as he mentions, “to walk, run, mount or alight from his horse, without pain, in a word, the affected leg performed its functions as well as the other one.” We have an account of a patient who was cured without a bandage by A. Petit.

20. Was there indeed a true rupture of the tendon, in all these cases, particularly in those where the patients continued to walk as before the accident? Most of the cases which we have seen prove the impossibility of either standing or walking (6). But, admitting that they were ruptures, are we authorized to pursue the mode of treatment there adopted? Certainly we are not. None of the indications formerly mentioned (16) is there fulfilled. What is there, under such circumstances, to prevent an involuntary motion from destroying the contact of the divided ends, by forcibly flexing the foot and extending the leg? The limb is not subject to any compression. Should such an accident happen, the cure must necessarily be tedious. Besides, if the ends be separated, a reunion cannot take place, except by an intermediate substance, which, by filling up the vacant interval between them, must lengthen the tendon. In consequence of this, the muscles will be impeded in their contractions, and the foot in its motions, as Desault has oftentimes observed in animals, which he left to themselves, after having divided the tendo Achillis. Thus, in a fracture of the rotula, the motion of the limb is very much impaired, when the ligamento-cartilaginous substance which unites the fragments is too long.

21. Hence it follows, that here, in like manner as in other ruptures of the tendons, art must assist nature, because without the former the powers of the latter will be insufficient.

22. _Second method._ The ancients pursued a course not less uncertain, and much more dangerous. Sutures, sanctioned by general custom, were extended to wounds in the tendons, and were even more especially employed in such cases, because the tendinous end being drawn forcibly and greatly displaced by the contraction of the fleshy portion in which it terminates, it was deemed necessary to oppose to this force a greater resistance.

23. What useful end was attained by this practice? Muscular action was left perfectly free; and the only thing done was an attempt made to resist its effect. But, in a short time the tendinous ends, in consequence of being forcibly stretched by the contractions of the muscles, either gave way at the points where the stitches were introduced, or, in case they did not give way, became swollen, painful, and inflamed, in consequence of the violent distension which they suffered: hence the serious affections produced by such treatment (9 and 10).

24. The ancients, then, were mistaken, with respect to the indications in this disease, which are, not to resist muscular contraction left free and unimpeded, but to check and prevent this contraction, by the means formerly pointed out (16). It is a principle generally acknowledged at the present day, that sutures ought not to be used as a mean of approximating divided parts, but only to keep the edges of parts already approximated in perfect contact. But, in the present case, the means of approximation being sufficient for the purpose of exact contact, sutures are altogether unnecessary. This, however, does not hold true in every case, though certain practitioners, who have too generally rejected the use of sutures, contend that it does. Finally, however, these means have been excluded from the treatment of the division of the tendo Achillis, and the doctrine of the Academy of Surgery, though erroneous in many other cases, has established, with regard to the present one, the true practice.