Part 49

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.

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.”