Part 25

25. _Third method._ It is to the celebrated Petit that we are indebted for that method of treating the division of the tendo Achillis, which consists merely in position maintained by apparatus. Having ascertained that the extension of the foot brought the fragments into contact, he conceived the idea of continuing this extension throughout the whole treatment, for the purpose of continuing the contact also. This was a happy idea, the simplicity of which recommended it to practitioners, and which, being once discovered, has formed the common basis of all the numerous processes devised since by different authors.

26. When we consider the action of these several processes, and compare it with the indications formerly laid down (16), we may divide the processes themselves into three general classes. Thus, some of them fulfil only the first and third of these indications, namely, the permanent extension of the foot, and a regular compression made on the leg; others fulfil only the first and second, the latter of which consists in keeping the leg constantly flexed on the thigh; while those of the third and last class, fulfil the first indication only. This manner of classing the processes, will shorten the consideration of each of them individually, since it is evident that each class is chargeable with one general inconvenience, namely, that of being deficient with respect to one or two of the leading indications. I shall examine nothing, therefore, but the disadvantages peculiar to each.

27. To the first class belongs, almost exclusively, the first bandage invented by Petit. It is formed by a long compress, placed longitudinally behind the leg and foot, and secured by a roller applied regularly on these parts. The two ends of the compress, being reflected back, are then knotted together behind the leg so as to extend the foot. This expedient is simple and ingenious, and would be preferable to all others, were it not that, besides the charge of not fulfilling the second general indication (16), it is further liable to the following objections: 1st, the compression which it makes is injudicious and ill directed, because it bears not only on the fleshy portion of the leg, but also on the divided tendon, which being more projecting and therefore more exposed, has its two ends pressed down and separated: 2dly, in some cases, it does not maintain the extension of the foot with sufficient certainty: 3dly, it does not prevent displacement in a lateral direction.

28. To the second class belong, 1st, the celebrated slipper of Petit, substituted by that author for his first bandage; this machine was composed of a slipper fixed to the foot, of a knee-piece[37] secured on the lower part of the thigh, and of a strap running from the one and fastened to the other, to extend at pleasure the foot on the leg, and to flex the leg on the thigh: 2dly, the bandage of Duchanoy, made in imitation of the preceding apparatus, and consisting of a simple sock surmounted by a roller, which running along the back part of the leg, was fastened to another roller applied round the lower part of the thigh. Besides the general objection of not at all fulfilling the third indication (16), these processes are liable also to the following ones; 1st, they fatigue the toes by the constant pressure of the slipper and the sock, as Monro experienced in his own person, to such an extent that he was unable to support their use; 2dly, the slipper is quite too complicated, and is therefore seldom at hand when wanted. The apparatus of Duchanoy, does not possess sufficient solidity and steadiness.

[37] (_Genouilliere._) I believe this was a piece of apparatus made of leather, somewhat similar to the top of a boot, and secured on the limb just above the knee. TRANS.

29. In the third class are included, 1st, the first machine of Monro, formed of a slipper similar to that of Petit, surmounted by a strap of leather, which was to be fastened by a buckle to a kind of guetre or spatterdash, fixed on the upper part of the leg; 2dly, the second apparatus of the same author, subject, like the other, to several inconveniences; 3dly, the simple apparatus of Schneider, who rested satisfied with maintaining the extension of the foot, by a splint placed anteriorly. Besides various other objections to them, these are all chargeable, alike, with the radical fault, of not fulfilling the second and third indications (16).

30. From this comparison of the indications (16) with the means destined to fulfil them, it appears that there were material defects on the part of the latter. Let us examine whether or not that of Desault was better calculated for the purpose. It is, so to speak, nothing but a modification of the apparatus of Petit (27), but such a modification as amounts to an improvement in principle, and entitles it to be called the apparatus of Desault.

31. The pieces which compose it are; a compress two inches broad, and long enough to reach from the lower part of the thigh to the distance of four inches beyond the foot; a roller five or six yards long and two inches wide; a sufficient quantity of lint; and two long graduated compresses.

32. Every thing being ready;

1st, An assistant supports the foot and leg, the former in a state of great extension, and the latter half-flexed: another assistant supports the thigh, grasping it about its middle.

2dly, If there be a wound of the integuments, a little lint wet with vegeto-mineral water is laid directly over the division of the tendon; if it be a simple rupture, this precaution is unnecessary. Under the foot, up behind the leg, and the lower part of the thigh, is then extended the long compress, which is to be secured in that situation by the hands of the assistants.

3dly, The hollows situated at the sides of the tendo Achillis, are then filled up with pledgets of dry lint, surmounted by the two long graduated compresses, which retain the pledgets, and must project a little beyond the tendon, because they are liable to be rendered flat by pressure.

4thly, The surgeon now taking the roller, makes at first several circular turns round the toes, fixing the long compress there, the end of which, being reflected over these first casts, is secured by a few additional ones which cover the whole foot, and are afterwards directed obliquely above and below the division, round which is formed a kind of figure of 8, that brings the edges of the wound into perfect contact. If there be no wound of the integuments, it is necessary to take care, lest the skin interposing between the divided ends of the tendon, should separate them, and thus prevent their reunion. Ascending, then, by circular casts, along the whole leg, and even to the lower part of the thigh, the surgeon there turns down the upper end of the long compress, and securing it by a few more circular casts, finishes the application of the roller.

5thly, The apparatus being thus applied, and the extension of the foot and the flexion of the leg firmly secured by it, the leg is then placed on a pillow or bolster, one side of which corresponding to the angle which the leg forms with the thigh, assists in keeping it half-flexed.

6thly, Should the long compress prove insufficient to keep the foot extended, or should it, by becoming relaxed too soon, render frequent reapplications of the apparatus necessary, (circumstances which rarely happen when the bandage is well applied), a splint placed anteriorly, as was the case in Schneider’s apparatus (29), completely remedies the defect.

33. On comparing this apparatus with the indications formerly laid down, in the present disease (16), we find it evidently calculated to fulfil them with great exactness. 1st, The extension of the foot is permanently secured, both by the long compress, and by the splint when it is employed: 2dly, the same compress, aided by the bolster or pillow placed under the leg, maintains the flexion of the leg on the thigh: 3dly, The muscles are effectually compressed; their action is impeded in part by the compression of the circular bandage, which does not bear on the tendon, in consequence of the bolsters of lint placed on each side of it: these bolsters prevent the tendon both from moving laterally, and from being depressed: hence it follows, that the action of the circular bandage is precisely conformable to the principles already established (14 and 15); and that the whole of the apparatus, taken together, fulfils perfectly all the indications (16); this is an advantage not to be derived from any of the forms of apparatus used by preceding authors.

34. This apparatus is in no degree complex or troublesome. Simple and easy, it requires nothing for its construction but what the surgeon can easily obtain, and what he can even himself prepare. There exists a great analogy between it and the bandages which Desault used for the reunion of transverse wounds, and for fractures of the rotula and the olecranon. A truly great man does not estimate his merit, by the number of processes which he invents; he well knows that the perfection of art consists in producing numerous effects by few and simple means.

35. We will confirm, by two cases, the principles laid down in this memoir. One of these relates to a division of the tendon, connected with a wound, and was reported by Bezard; the other by Manouri, and relates to a simple rupture of the tendon.

CASE I. J. B. Lavigne, aged thirty, as he was going down into a cellar without light, struck his leg against the edge of a sharp saw, which completely divided the tendo Achillis. The patient was immediately carried to the Hotel-Dieu. The wound of the integuments was transverse, two inches long, and had its edges but slightly separated from each other. The ends of the tendon, in contact during the extension of the foot, were separated two inches when it was flexed.

The usual apparatus was applied (32), and the limb placed on a bolster, in a position favourable for the relaxation of the posterior muscles.

In the evening, wound painful; pulse raised; a copious blood-letting; low diet. Next day, more blood taken away; antiphlogistic regimen, which was continued for several days, till the symptoms were gone: no troublesome accident occurred. Tenth day, the apparatus taken off; the wound partly healed; the apparatus reapplied, and continued till the twentieth day, when the perfect reunion of the parts rendered its further use unnecessary. From this time the patient began to walk on crutches. Thirty-sixth day, could walk well without his crutches. At this period, a small abscess occurring in his heel, induced him to remain in the Hotel-Dieu two weeks longer, when he was discharged perfectly cured.

CASE II. M. Delp, leaping with some of his young companions, ruptured the tendo Achillis, about two inches above the os calcis. Both standing and walking became instantly impracticable: the patient falling down, was taken up, carried home, and from thence to Paris, where he arrived in the evening. Desault being immediately called to him, found him affected with all the signs of a division of the tendon; such as, a hollow between its divided ends, which was increased by the flexion of the foot, diminished by its extension, &c. The usual apparatus was immediately applied, and as the patient felt but little pain, only a moderate blood-letting was prescribed. Next day, no alteration in the treatment; antiphlogistic regimen; low diet continued for some days, when the patient was permitted to return to his usual mode of living. Ninth day, apparatus removed for the first time: a slight separation of the ends of the tendon; and a wrinkle in the skin interposed between them: a new application of the bandage, taking care to free the integuments from wrinkles. Twelfth day, a relaxation of the rollers; a third application of the bandage: every thing found in a good state; but, the patient being, from sprightliness, too much inclined to exert himself, a splint was applied anteriorly to prevent the extension of the foot. Seventeenth day, a fourth application of the apparatus, which was not moved again till the thirtieth. At this period, the reunion was somewhat advanced: fortieth day, almost complete. Fiftieth day, the patient was permitted to leave his bed, and take very gentle exercise, which he continued to increase gradually, till the sixtieth day, when he was discharged cured. Doubtless the tediousness of this case was owing to the slight separation which existed for some time between the fragments.

MEMOIR XVI.

ON THE FRACTURE OF THE OS CALCIS.

§ I.

1. The os calcis, being a short and thick bone, has such a power of resistance, that it is but seldom fractured. Such an accident does, however, sometimes occur, and may arise from two causes, 1st, the action of external bodies, which is rare: 2dly, the contraction of the gastrocnemii and soleus muscles, from which it almost always proceeds. Thus, the rotula is more frequently broken by the action of the extensor muscles, than by blows received on the bone from without: there is, however, this difference between the effects of muscular contraction in these two cases, namely, that in the former, the rupture of the tendo Achillis is common, and the fracture of the os calcis very rare; whereas in the latter, on the contrary, the rotula is oftentimes broken, while the tendon of the extensors remains almost always sound. This phenomenon is explained by the difference between the thickness of the two bones, between the length of the two tendons, and between the power of the causes.

2. Be the cause of the fracture what it may, it generally occurs in that portion of the os calcis, called its great tuberosity, which projects behind the astragulus, which corresponds above and below to a large quantity of cellular membrane, inwardly to the great groove of the bone, externally to some ligamentous attachments, and behind to the insertion of the tendo Achillis.

3. It is known, 1st, by an evident inequality under the heel: 2dly, by an elevation, sensible to the touch, of the posterior fragment above its usual level: 3dly, by an almost entire inability either to stand or walk: 4thly, by severe pain being the inevitable consequence of moving the foot: 5thly, by its being practicable to increase the displacement by flexing, and to diminish it by extending the foot: 6thly, by the facility with which the posterior fragment may be moved in every direction by taking hold of it with one hand, and steadying the foot with the other: 7thly, by a swelling more or less considerable, which frequently appears around the divided surfaces.

4. The ancients gave in general an unfavourable prognosis respecting this kind of fracture. Hippocrates was apprehensive of some injury being done to the surrounding parts. Pare considered the case mortal, on account of the laceration of numerous vessels which are connected with the bone. Most of the moderns adopt these principles, not for the foregoing reasons, but on account of the vicinity of the accident to the joint of the foot. The practice of Desault cannot throw much light on this subject, as he never had more than one or two such cases of fracture under his care; but the analogy of other fractures, situated in the neighbourhood of joints and even extending into them, induces us to believe, that, if properly treated, fractures of the os calcis will terminate as favourably as those of other bones.

§ II.

5. If we attend to the signs just mentioned (3), we will perceive that they almost all result from the displacement of the fragments. But, whence arises this displacement? As far as the anterior fragment is concerned in it, it arises from, and is increased by, the flexion of the foot; and, as far as relates to the posterior one, it is to be attributed to the contraction of the muscles attached to the tendo Achillis, which is itself inserted in that fragment. Hence it follows, that the apparatus intended to prevent this displacement, ought, 1st, to keep the foot permanently extended on the leg: 2dly, to prevent the action of the muscles, by keeping them in a state of habitual relaxation by means of the constant flexion of the leg on the thigh, by making on those whose contractions are dreaded, such a regular and well directed compression as may disqualify them for contracting; and, lastly, by placing behind the posterior fragment some resisting substance, to prevent it from rising upwards.

6. If to these indications we compare Desault’s apparatus for a rupture of the tendo Achillis, as described in the preceding memoir, we will readily perceive 1st, that it perfectly fulfils that indication which relates to the anterior fragment; 2dly, that that one which relates to the posterior fragment will be equally well fulfilled by the half flexed state of the leg, by the compression made on the muscles, and by a thick compress, not very broad, laid transversely above the fragment, secured by the long roller, and afterwards by a circular bandage, which must form here, as in the case of a fractured rotula, a kind of figure of 8 around the fracture. This compress is the only modification of the apparatus requisite to accommodate it to the particular case now under consideration.

7. In applying the figure of 8 bandage here, as well as in the case of a fractured rotula, to prevent the ascent of the fragment, it is necessary to use the utmost care to free the integuments from wrinkles both above and below the fracture, lest by getting between the fragments, they might keep them asunder, and thus impede their reunion.

8. Desault used to relate in his lectures, the case of a woman whom he had formerly seen receiving a fracture of the os calcis, by falling from a great height. I cannot state the case fully, because I am not in possession of all the facts. The following one however drawn up during the first years of Desault’s practice in the Hotel-Dieu, will furnish an example of his mode of treatment.

CASE. A man, likely to be arrested by some one who pursued him, leapt from a window nearly twelve feet high. In lighting, his feet struck on a beam which lay in his way, in such a manner, that the fore part of them only was supported. He made an effort to recover his equilibrium, but as the line of gravity of his body had nothing to rest on, he fell backwards, rose in order to make his escape, but fell a second time unable to rise again.

When assistance came to him, he complained of a severe pain in his heel, and said, that on falling, he had heard a considerable report. He was taken up, and assisted in walking to the Hotel-Dieu, where he did not arrive without pain, being able to bear only on the point of the diseased foot, and suffering greatly if he attempted to put his heel to the ground.

From the signs mentioned (3), Desault perceiving that there existed a fracture of the os calcis, made arrangements for reducing it. This he did by extending the foot on the leg, and drawing down the exterior fragment from the elevation to which muscular contraction had raised it, so as to bring it into perfect contact with the body of the bone. He then applied the common apparatus for a rupture of the tendo Achillis, with the modification already pointed out (6).

In the evening venesection was prescribed: the patient experienced sharp pains at the place of the fracture; a slight swelling occurred at the ends of the toes; an anodyne was prescribed. Next day, evidently better: venesection again. Fourth day, the patient is allowed to return to his usual regimen. Eighth day, apparatus removed for the first time; fragments in contact. Fifteenth day, a second application of the bandage. Nineteenth day, bilious symptoms. Twenty-first, an emetic given in solution. Thirty-second day, further evacuations: apparatus renewed. Forty-seventh day, consolidation complete. A stiffness remained in the part for some time, but this was gradually removed by exercise.

MEMOIR XVII.

ON COMPLICATED LUXATIONS OF THE FOOT.

§ I.

1. Complicated luxations of the foot, like complicated fractures, show themselves under such a variety of forms, are accompanied by so many peculiar affections, and so many different circumstances are connected with them, that it would be difficult to lay down rules applicable to their treatment in all cases. On this subject, indeed, art is in possession of certain general principles, liable however to numerous exceptions and modifications. In the treatment of such cases, who can fix the limits between reduction, and amputation or extirpation? Who can point out, with precision, where the one ceases to be useful and becomes hazardous; while the others constitute the only resources of art? Experience and talents alone are capable of deciding on these points, and that only in the chambers of the sick. It is, therefore, less by precept than example that practitioners ought to be instructed here.

2. To furnish suitable examples on this head constitutes my only object in the present memoir, which will consist of the histories of a few cases, with such inferences and remarks as the occasion may seem most naturally to suggest. Here the practice of a great master, varying his means with the varying forms of disease, will serve as models to those who may meet with similar cases. Our experience is composed of the facts which we receive from reading, as well as of those derived from observation. Who would have a right to call himself a surgeon, if he had no other title to that name, but such as resulted exclusively from his own personal observation?

3. However difficult it may be, as already observed, to speak in general terms, on the present subject, we may yet assert with safety, that authors have greatly exaggerated the danger of complicated luxations of the foot. Terrified at the extent and unpromising appearance of the accidents, these writers have lost that confidence in the powers of nature which we never ought to abandon. They have taken up an opinion, that luxations of the foot, differing in their symptoms from other luxations, require also a different mode of treatment; that reduction, by perpetuating the accidents of the case, must prove fatal, and that amputation ought to be adopted as the only resource. Cases do certainly at times occur, where a doctrine different from this would be fatal in its effects: such are those terrible lacerations, where the foot is entirely separated from the leg, except some shreds of flesh with a few tendons among them that still retain it.

4. But, provided the blood-vessels have escaped, and any hope of circulation and life in the part still remain, the success of reduction should always be first tried; and the following examples will show, what ought to be expected from this practice, when accompanied by skilful treatment.

§ II.

LUXATION OF THE FOOT, COMPLICATED BY A FRACTURE OF THE FIBULA, TIBIA, &C.

CASE I. (The following case was collected by Leveille.) Abraham Genty, aged forty-three, a dealer in wine, as he was running along the street, slipped, and made a false step on his left foot, which turned with its external edge under him, and its internal edge upwards. He fell, luxated his foot, and fractured the fibula.

The patient was carried home, where a surgeon who was ignorant of his profession being called, did nothing but apply a cataplasm to the foot. In the evening the parts began to swell, and were extremely painful; fever supervened, accompanied with great restlessness. Third day, to a rapid increase of all the symptoms was added a delirium; blood-letting from the jugular vein was prescribed to no purpose; things continued to grow worse till the sixth day, when the patient was brought to the Hotel-Dieu, in extreme danger.