Part 50

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.

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 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.

(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;