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[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.