29. This truth was frequently confirmed in the experience of Desault, who had an opportunity of seeing numerous fractures of the rotula, both in the Hotel-Dieu, and in his private practice. He always observed, that, when the separation of the fragments was considerable, and the ligamento-cartilaginous substance uniting them was of some extent, standingand walking were performed with much difficulty; that the patient was exposed to frequent falls, from the want of a proper correspondence, in point of strength and motion, between the two limbs; and that, on the contrary, the less extensive the separation and the substance that filled it up were, the more free and easy were the motions of the part, which still remained, however, somewhat defective and imperfect, unless every vestige of the division was obliterated.
Paul of Egina long since observed, that, when no means of reduction were employed, though the patient might walk tolerably well on a level surface, he could not, without difficulty go up an ascent.
30. From what has been said, it follows, 1st, that in the treatment of this fracture, the perfect contact of the fragments ought to be the principal object of the practitioner; 2dly, that the kinds of apparatus employed by different authors, are but ill calculated for the attainment of this end, because they fulfil but imperfectly the indications formerly laid down (18). Let us see whether or not the apparatus of Desault be any better suited to this purpose.
31. The bandage, which he employed in this case, analogous to that for fractures of the olecranon, is composed, 1st, of one splint, two inches broad, and long enough to reach from the tuberosity of the ischium, to a little above the heel; 2dly, of two rollers, five or six yards long, and nearly three inches wide; 3dly, of another single roller, with two holes about the middle of it, a little longer than the injured limb of the patient, along the fore part of which it must be extended.
32. Every thing being arranged for the application of the apparatus,
1st, One assistant secures the pelvis, in the same manner as in fractures of the lower extremities; while another keeps the leg in a state of perfect extension on the thigh, and the thigh on the pelvis.
2dly, The surgeon, then, standing by the side of the fractured limb, extends along the anterior part of the leg and thigh the roller with holes in it, having previously wet it with vegeto-mineral water, taking care to make the two openings correspond to the lateral parts of the rotula, that, by being thus better adapted to its shape, it may not be thrown into wrinkles.
3dly, He then secures it on the top of the foot, by three circular casts of a roller placed one over the other, three or four inches above its lower end which must next be turned up over the three first casts, and made fast by two other ones. Then, while the compress roller33is secured above by an assistant, he passes up along the leg by oblique and reverse turns, according to the inequalities of the limb.
4thly, Having arrived at the lower part of the knee, he pushes the lower fragment upwards, and makes below it two or three circular turns to secure it. He then gives the roller into the hands of an assistant, and directing him who holds the long compress roller, to draw it forcibly upwards, pushes theinteguments of the knee in the same direction, lest, by becoming interposed between the fragments, they might prove an obstacle to their reunion. Passing then the fingers of his left hand through the holes in the compress-roller he places them behind the superior fragment and pushes it forcibly downwards.
5thly, When the reunion of the fragments is exact, without any space intervening, he resumes the roller, and passing it obliquely under the ham, and bringing it up again behind the superior fragment, withdraws his fingers which held this fragment down. In place of his fingers, he then applies two or three tight circular casts, covers the knee with several oblique casts in form of the figure of 8, so as to leave no opening between them, and, then, continues the bandage up along the thigh, securing by it the compress-roller extended along the fore part of the limb.
6thly, When he has arrived at the upper part of the limb, the assistant who holds the compress-roller, drawing it forcibly upwards, doubles down its end over the circular casts. The surgeon next fixing this end by several additional casts, descends again along the thigh, covers the knee by a few more oblique turns, and finishes with the roller on the leg.
33. This first part of the bandage evidently fulfils the third and fourth indications (18). The compression of the roller on the muscles weakening their action and impeding their motions prevents their tendency to draw the superior fragment upwards: while the circular casts passed behind this fragment,acting in opposition to the muscular contractions, prevents it from moving upwards in obedience to them. The long compress-roller, stretched on the fore part of the limb, being first secured below, and then drawn forcibly upwards, presses the casts of the roller against each other, and prevents those that correspond to the thigh from slipping upwards, and thus abandoning the superior fragment, and prevents also those on the leg from slipping down and withdrawing their support from the inferior fragment. As there remains no vacant space between the circular turns, their pressure is uniform throughout: no swelling can consequently supervene (20).
34. But the first and second indications remain still to be fulfilled (18): it is necessary to prevent the separation of the lower fragment, by the extension of the leg on the thigh, and to throw the muscles into a state of relaxation by extending the thigh on the pelvis, and to maintain permanently, by the apparatus, that double position, which the assistant maintains only during the operation.
35. To obtain the first effect different means have been employed; but none answers so well, to extend the limb and retain it immoveably in that state, as a long and strong splint, placed, as Desault did it, subsequently to the application of the first part of the bandage, along the posterior part of the limb. An assistant must hold the end of this splint, while the surgeon secures it in its place by the second roller (31): in this way the extension of the leg is effected.
36. To obtain the extension of the thigh, it is necessary to place on the top of each other, two orthree bolsters or little bags filled with chaff, so disposed as to form an inclined plain, considerably elevated towards the heel above the level of the bed, but which, gradually descending to the same level towards the tuberosity of the ischium, forms a supporting basis on which the whole limb may rest in a uniform manner. By this twofold extension of the leg and of the thigh, the lower fragment is kept up immoveably, and the muscles are kept in a state of relaxation.
Hence it follows, that this bandage fulfils extremely well the conditions laid down (18), and that it ought to be preferred to all the others (19...25), which answered the indications only in part.
37. Whatever may be the advantages of this bandage over the others, it must still be acknowledged to have its inconveniences. The rollers become relaxed in a short time; their compression is less active; the muscles, being less confined, contract more readily; hence the necessity of frequently repeating the application of the apparatus, a circumstance which is very troublesome, on account of the roller which composes it, and covers the whole limb. The resistance of it even when it is recently applied, is not always equal to the power of the muscles, whence the most assiduous attention is necessary, to obtain such a consolidation as to leave no trace of the fracture behind. Few persons ever possessed, like Desault, the art of overlooking nothing that might in any way contribute to the success of his treatment: from this, no less than from the excellence of his processes, arose the number of his cures. Let us confirm, by a few examples selected from among a great many, the doctrine here laid down. The following cases were collected by Julian and Bezard.
Case I.Francis Leclert, of a sanguine temperament, fell on the 7th of October, 1790, on his right knee, and produced a transverse fracture of the rotula. He was not able to rise; he was carried home, where a surgeon, on discovering the nature of his disease, advised him to be taken to the Hotel-Dieu.
He was conveyed thither on the day following, and, in the interval, a considerable swelling had occurred around the joint. The usual bandage was employed; the pains ceased immediately after its application; a copious blood-letting was directed, and a low diet was prescribed.
The whole apparatus was wet with vegeto-mineral water, two or three times a day. On the next day some light food was allowed, and the quantity increased by degrees, till in a short time the patient returned to his usual regimen. Eighth day, the swelling being almost gone, the bandage had become relaxed it was therefore reapplied. Every day the inclined plain formed by the bolsters was carefully examined, and put in order again as often as it became deranged.
Fifteenth day, a new application of the apparatus: twentieth day, an evacuation in consequence of a bilious disposition. Nothing particular occurred from this time till the completion of the cure, which took place on the sixty-seventh day after the accident: no depression existed at the place of the fracture: themotions were perfectly free; these were aided, by daily exercising the knee joint for some time.
Case II.Vincent Grenier, aged thirty-eight, making a false step, fell on the rotula, and fractured it, on the 6th of June, 1791: he was brought to the Hotel-Dieu, where Desault demonstrated to his pupils, by the usual signs the existence of the disease: a considerable swelling had already taken place. The bandage formerly described was applied: the same precaution as in the preceding case; apparatus examined every day; renewed as often as relaxed; extension maintained with great exactness. On the forty-fifth day, the consolidation was nearly effected; on the fifty-second it was complete, the joint was exercised for some time, and on the seventy-seventh day the cure being in all respects complete, the patient was discharged.
1. The history of foreign bodies divides itself naturally into two great sections; the one includes those that are introduced from without; the other such as are formed within our own systems. This latter section may be again divided into two classes; to the first class belong bodies altogether inorganic, such as the different kinds of stones; to the second, those which are truly organic, and become foreign only by being situated in places where they impede the functions, such as cartilaginous or bony productions, existing accidentally within the joints.
On the subject of the latter class, art is much more deficient than she is with regard to the former. Let us endeavour to assist her a little, by giving a sketch of the opinions and practice of Desault with respect to these productions.
2. Before his time, the surgery of France appears to have contained scarcely a record of this affection. Described only in some ancient works, such as the writings of Pare, it had been forgotten by the moderns, when numerous instances of it were suddenly met with by English and German surgeons, and soon afterwards by Desault, who illustrated and confirmed the practice of his predecessors in it, and even added something of his own.
3. All the joints may become the seat of these concretions; Haller found many of them in that of the lower jaw; Bell mentions, as a very rare occurrence, their existence at the junction of the foot with the leg. Some authors have met with them in the wrist; but none are more common, or merit more particular attention, than those that exist in the joint of the knee. To these alone shall the following observations be confined, because these alone have fallen under the notice of Desault.
§ II.
4. Concretions of the joints do not always assume the same aspect. They vary greatly as to number, size, figure, structure, &c. In general, these bodies exist singly; sometimes, however, two of them are found in the same joint, and then they may be extracted either at the same time, or in succession, as was once done by Desault. Some English surgeons have also met with two concretions, and Morgagni has found even twenty-five, in the same joint.
5. They vary also in size. The largest ever met with by Desault, was fourteen lines in its longest, and ten in its shortest diameter. Six lines diameter in every direction, was the measure of the smallest one that occurred in his practice.
6. Their figure is sometimes lenticular and smooth on both sides, sometimes unequal, rough in one part, even in another, concave on one side, convex on the opposite, sometimes marked around thecircumference and sometimes not with reddish points, and having occasionally a stem of a cellular texture and of some length, as may be seen in a paper by Theden. They usually consist of a single mass, but are in some cases divided into several lobules united by a kind of ligaments, as in the fourth case related in the Journal of Surgery. Though most frequently detached and floating in the interior of the joint, they have yet been found adhering by means of small portions of cellular substance, loose and capable of being stretched, or tight, hard, and even of a ligamentous nature.
7. If, from the external figure, we pass to the structure of these bodies, we will find them existing in three different states. Sometimes purely cartilaginous, sometimes completely bony, they at other times partake of both these states, in which case a bony nucleus is covered with a cartilaginous crust. Out of five cases, recorded by Desault, three are of the first, and two of the third kind. Many authors have met with the second kind, particularly Morgagni, who has even found in the same joint, some bodies of a bony and others of a cartilaginous nature. Hence it appears, that this variety of structure is to be attributed to the longer or shorter standing of the disease, that every concretion must pass successively through these three states, and that there is a great analogy between the formation of such bodies and natural ossification.
8. If we examine a body of the third kind cut in two through the middle, we will find it red and vascular in the centre, like an epiphysis, even when it isfloating in the joint perfectly loose and free from adhesion.
9. Bell, in his treatise on surgery, speaks of a kind of tumour, at first soft, membranous, and adhering to the internal surface of the capsule, but which, according to him, may become afterwards hard and solid, and be detached so as to float loose in the joint. But are not these tumours different in their nature from those destined to be converted into bone? Do they, in fact, ever undergo the changes mentioned by Bell? Desault having never met with any of them, was unable to offer an opinion on the subject. In the mean time, an observation made by Monro, may serve to throw some light on the question: he once saw, in one of these productions, a cellular nucleus surrounded by a covering of bone.
10. Though usually simple and free from complication, this affection may, according to some authors, give rise occasionally to a dropsy in the joint. Pare is the first who has made mention of this: he found one of these bodies in a patient’s knee, into which he had made an incision for the purpose of drawing off a collection of water. Simson, on extracting a similar body, gave vent to four ounces of water. But, as on the one hand, a dropsy of a joint oftentimes exists without these foreign bodies; so, on the other, these bodies are almost always found disconnected from dropsy. Nor is there any affinity between the acknowledged causes of an accumulation of synovia, and the presence of these bodies; so that when the two diseases do exist together, it is altogether probable, that they are independent of each other.
§ III.
11. The formation of articular concretions succeeds frequently to blows or falls received on the joint, in which case, a swelling more or less considerable in the surrounding soft parts, showing itself from the first, and remaining for some time, at length allows the foreign body to be perceived, and does not, in general, disappear during the continuance of the body in the part.
12. Sometimes no external injury contributes to the formation of the body, and then, a spontaneous swelling precedes its detection, as Desault observed in two patients, where nothing was known to have concurred in the production of the disease. Constant rest increases this swelling, while exercise and a temperate mode of life diminish it.
13. But what can be the immediate cause of these tumours? Are they, as some allege, an aggregation or crystallization of particles of matter conveyed into the interior of the joint by the synovia, in the same manner as the rudiments of a stone are conveyed into the bladder by the urine? Their organic appearance and the vessels that pervade them, are unfavourable to such an opinion. Can they be, agreeably to the conjecture of Theden, articular glands bruised by means of strokes or falls? Or are they, as some authors will have it, portions of the cartilage of the joint, detached by the same causes? How then will their spontaneous formation be explained?
But why trouble ourselves about the cause, provided we can remedy the effects? Nature conceals from us the means, and discloses to us nothing but the results. Theories are fluctuating; but experience is still the same: let us search, then, by an attention to facts, for that which we cannot learn from first principles.
§ IV.
14. The phenomena which announce the presence of foreign bodies in the joint of the knee, are sometimes clothed in a character of such evidence, that they cannot be mistaken; at other times, the nature of the disease eludes the most accurate researches: the cause of this variety may be easily perceived.
As the joint presents different depressions and eminences, and as the bodies, being usually loose and detached, may travel through its whole extent, they produce different effects, according to the particular situations which they occupy. If lodged in a depression, they are not compressed, and cannot, of course, give rise to any troublesome affection. If they bear on an eminence, such as the condyls, or the posterior part of the rotula, they are forcibly compressed, and must derange, in some measure, the functions of the joint. Hence the precise nature of the affection cannot be at all times derived from the state of the symptoms.
15. Sometimes the patient can stand and walk with perfect freedom and ease, while, at other times, a sudden pain seizing him, obliges him to sit down,or even causes him to fall, if there be nothing at hand to support him. This pain subsists for a longer or shorter time. One motion produces it, and sometimes another, made in an opposite direction, removes it. But in common it is of some continuance, and then the patient is obliged to keep his bed.
16. If the state of the joint be examined, it will be found more or less swollen, when the pain is very acute. When the pain ceases, the swelling in part disappears. It is never sufficient to prevent the fingers, when drawn along the external surface of the joint, from discovering the presence of the foreign body, when it forms a protuberance under the integuments. It is then found sometimes above the rotula, by the side of the tendon of the extensor muscles, and that is the place where it usually produces least pain; at other times, it is lower down, in front of the condyls, and by the side of the rotula. It is occasionally found immediately behind the tendon of the extensor muscles; in this case so acute is the pain, that the patient is generally unable to stand. But it is when it is situated behind the rotula, near to the projecting ridge which runs across its posterior surface, that it gives rise to the most serious affections.
17. The body passes from one place to another, on the least motion, and sometimes, as Bell observes, the patient, on changing his position during sleep, is awakened by severe pain, in consequence of the foreign body being moved by this change. It happens, in certain cases, that it disappears, and lies concealed for some time, in the back part of the joint. During this period the joint performs all its functions withfreedom and ease. Desault made this remark, in the case of a captain of dragoons, from whom, for the first time in his practice, he extracted one of these bodies, and who, for six months previously, had been able to perform all the motions of the joint freely, without pain. This person, experiencing no uneasiness, considered himself perfectly cured, when the body suddenly reappeared, in consequence of a hasty extension of the leg.
18. If the body, when projecting under the integuments, be gently compressed, it yields to the pressure, changes its situation, and, according to the impression it has received, moves either to the internal or the external side of the joint, or reciprocally from one side to the other, passing also behind the rotula, behind the inferior ligament, or sometimes behind the tendon of the extensor muscles. In these alternate displacements, it may in some cases be turned round, in such a manner that its anterior surface will take the place of its posterior one, and then resume its primitive situation. Desault met with an instance, in which the patient himself was in the habit of turning the body round in this manner.
19. Bell, in conformity to the distinction of articular concretions into cellular and solid, attributes to each division its peculiar signs. In the first case, the pains, being rather obtuse than sharp, are constant; in the second, they are extremely acute, but disappear and return at intervals. Supposing the division to be a real one, cases of the last description certainly occur much more frequently than those of the first.
§ V.
20. From what has been said it follows, 1st, that these cartilages floating through the joints, do mischief mechanically (14), by coming into contact with the articular surfaces: 2dly, that to obviate this mischief, it is necessary either to prevent their contact, by fixing the bodies in a spacious part of the joint, and thus doing constantly what nature does on certain occasions, or to extract them through an opening made into the articular cavity.
21. Hence, art can have recourse to but two methods of cure, all hope of discussing these tumours by external applications being, as Bell observes, entirely extinguished.
22. The first method was proposed by Middleton and Gooch, who having brought the foreign body into a situation where it produced no pain, endeavoured to confine it there a length of time sufficient to make it form adhesions with the corresponding part of the capsule. As we are not informed of the result of the experiments of these two physicians, we are left to our own conjectures on the subject.
23. Are these foreign bodies capable of forming adhesions? Supposing they are, will the internal surface of the capsule attach itself to them at the pleasure of the surgeon? Even admitting the existence of both these conditions, by what means can the bodies be kept stationary for a length of time sufficient for the formation of these adhesions? Will they not bedisplaced by the slightest motion? Besides, experience seems to be unfavourable to the expedient. I have already said (17) that, in a certain case, the foreign body disappeared for six months, remaining, no doubt, during that whole time, in the same place: but, if it could not, on that occasion, form adhesions, if a motion was sufficient to produce its reappearance, can we expect that art will be more fortunate in her attempts?
24. But, even admitting that the foreign body does form these adhesions with the capsule, if it should increase in size in the part of the joint which it occupies, becoming in a short time disproportioned to its extent, it will impede motion as before, and produce, by degrees, nearly the same affections.
25. From these considerations it follows, that the only expedient which can promise a radical cure is, the extraction of the foreign body. In the performance of this extraction, an incision must first be made through the integuments and the capsule.
26. This operation, simple and easy in itself, has given rise to apprehensions as to its consequences, which have long prevented practitioners from undertaking it.
It was in former times a maxim in surgery, that wounds of the joints are, if not mortal, at least extremely dangerous, in consequence of their admitting air into contact with the articulating surfaces. But observation has demonstrated the fallacy of this doctrine, and Desault in particular, has thrown great light on the subject, as I have frequently had occasion to mention in the course of this work: so that, atthe present day, it is clearly ascertained, that, if judiciously treated, these wounds are seldom productive of serious consequences.
27. Hence it follows, that the operation we are considering, when skilfully performed, never gives rise to any dangerous or disagreeable affections. Experience has proved the truth of this assertion in the practice of Theden, Simson, Gooch, Broomfield, Bell, and Desault, the latter of whom performed the operation five times with complete success. The only case in which he was less fortunate, was that of a man, in whom the wound of the integuments closed up at first without any accident, but which was succeeded by two abscesses, one in the thigh, and the other in the leg, but without any affection of the interior of the joint. This patient was subject to a wandering rheumatism, which oftentimes attacked the lower extremities, and was perhaps in the present case the chief cause of the unfavourable occurrences.
28. It is to the English that we are indebted for the first operation performed for the extraction of these bodies. An account of this is given in the Transactions of a society in Edinburgh. Since that, the operation has been frequently repeated, and more than ten instances of it were already on record, when Desault first performed it in France. His method, somewhat different from that of others, was as follows.
1st, The patient must be laid on a bed, or seated on a high chair. The first position, however, is to be preferred, because when it is adopted, the patient need not be moved after the operation.
2dly, The leg is extended on the thigh, in order to relax the anterior part of the capsule of the joint.
3dly, The surgeon then searches for the foreign body, moves it to the internal side of the joint, against the attachment of the capsule, and secures it between his thumb and the fore-finger of his left hand, while an assistant draws the skin over the fore part of the rotula.
4thly, Taking then a common bistoury, he makes, on the protuberance formed by the body, a longitudinal incision of an extent proportioned to its size, through both the integuments and the capsule, so as to lay the body bare at the first stroke.
5thly, Sometimes the body escapes immediately of its own accord, in consequence of the compression made on it by the fingers. If its passage out be not spontaneous, a small scoop or a taper-pointed spatula passed under it, answers the purpose of extracting it. But, in the introduction of these instruments, it is necessary to avoid touching the articulating surfaces with their ends, lest, by being irritated, they might swell, and give rise to troublesome accidents.
6. If any resistance be met with, enlarge the opening and the extraction will become easy. Without this precaution, the edges of the wound, being bruised and irritated by the passage of the body, will swell, inflame, and unite again with difficulty.
7. When the extraction is finished, the assistant who draws the skin towards the inside of the joint, suddenly lets it go, when it returns to its natural situation. This causes the two incisions, which corresponded, at the time of the operation, to change theirrelative situation, the one remaining internal and the other becoming external.
8. Hence arises a twofold advantage; the entrance of air into the interior of the joint is prevented, and the external and loose portion of the capsule, being drawn inwards with the skin, unites with the condyl, if it be not brought into exact apposition with the other portion of the capsule, divided near its attachment.
9. The extraction being finished, it is then necessary to examine carefully, in order to ascertain whether or not the joint contain any more of these foreign bodies. On some occasions, when this is even the case, they cannot at the time be discovered. Desault himself was once deceived on this score, in consequence of which his patient was obliged to submit to a second operation.
10. The incision in the integuments is now united by means of adhesive plaster. Over this are laid compresses and a little lint, and the whole secured by a few turns of a roller drawn moderately tight.
11. The leg being then placed on a pillow, is kept in a state of extension, by means of a splint applied, for a few days, behind the joint.
29. If we examine but for a moment the process in this operation, we must perceive, that an incision made through the skin and capsule at a single stroke, is, in no respect, less advantageous than one made at two strokes, as recommended by all practitioners, and that, it is in the following respects greatly preferable to it: 1st, it shortens the operation very considerably: 2dly, it diminishes the pain: 3dly, itexposes the joint a much shorter time to the contact of the air.
30. The object of the operator is better answered by drawing the skin outward and towards the rotula, than by either depressing it, as Broomfield did, or raising it, as Bell does. Being more loose and more easily stretched in this direction, the opening in it is removed farther from that in the capsule, which prevents more certainly the access of air to the joint, and also favours the examination of the capsule.
31. In the mean time, the operation may succeed, even although the openings in the integuments and the capsule correspond to each other. Many English and German practitioners, without previously stretching and changing the natural situation of the skin, make a common incision, which they dress afterwards like a simple wound, and are yet no less successful than others in the result of their operations. This is a further proof of the fallacy of the ancient surgical doctrine, respecting the admission of air into the cavities of joints. Perhaps Desault might have omitted this precaution, had any operations of the kind occurred in his practice during the last years of his life.
32. The operation is seldom attended with much pain. Only one patient manifested signs of this in the practice of Desault. Nor have those operations of the kind performed in England been more painful, so that it may be laid down as a principle, that in most cases no primitive accident is to be dreaded.
33. With regard to hemorrhagy, as there is no large artery near the place of the incision, there isnothing to be apprehended on that score. Oftentimes there is scarcely any loss of blood at all, as may be seen in the first case published in the Journal of Surgery. But, even admitting that a small articular branch be divided, the reunion of the edges of the wound will be sufficient to check the hemorrhagy, in the same manner as in the operation for the hare-lip, the contact of the divided integuments of the lip, puts an end to the hemorrhagy from the small arteries of the part.
§ XIV.
34. I have already said that but little is to be apprehended on the score of accidents subsequent to the operation (26). Out of the numerous operations of the kind performed lately in Europe, but few cases have proved troublesome in their consequences, and even these were influenced by some foreign circumstances. Thus, for example, one of the patients of Simson rode out on horseback a few hours after the operation, on a cold and stormy day, and thus produced a troublesome affection of the part. A similar remark may be made respecting the case formerly mentioned (27).
35. The apparatus or dressing remains untouched for the two or three first days, during which time it is necessary to wet it frequently with vegeto-mineral water. It is a certain truth, that the use of this liquid retards the suppuration of wounds, and that, when continued a due length of time, it keeps inflammation at that degree most proper for the process of healing.
36. On the removal of the dressing, the wound is sometimes so perfectly healed up, as not to exhibit the least discharge. At other times a slight suppuration takes place; but, at the end of a few days, the cure is complete. Under the care of Desault, it was always effected in eight or ten days.
37. Let us bring the doctrine just laid down to the test of experience. Five cases have been published on this point. I have selected two of them, both which occurred in the same subject, where we find the same operation twice performed with equal success.
Case I.M. Vielle, aged nineteen, was attacked about the beginning of the year 1790, by a spontaneous swelling in the joint of the knee. Inconsiderable at first, but increased afterwards by a laborious journey, it disappeared at the end of two months, discovering to the touch, near the internal edge of the rotula, a foreign body, which was hard and moveable, and which somewhat impeded the motions of the joint.
About a month afterwards, the swelling returned, and, having continued for three months, disappeared again, when the body was found at the external side of the rotula, increased in size. Sundry external applications were tried for six months without success.
Weary of this unavailing practice, the patient came, in March, 1791, to consult Desault, who discovered a cartilaginous substance of a flat and circular figure. Its usual situation was at the external side of the joint, but it could be easily moved to the internal side, and could be turned on its own axis within thejoint, nor did it occasion any pain, when suffered to remain at rest by the side of the rotula. But, when it passed behind the tendon of the extensor muscles, the patient was unable to stand, and he experienced severe pains when it made its way under the condyls or behind the rotula.
The indication was evident. Before the operation Desault prepared the patient by a proper regimen, and then, in the method already described (28), extracted a foreign body, whitish, and oval, fourteen lines in length, ten in breadth, and two and a half in thickness at its middle. It consisted of three pieces, united by a ligamentous substance, and was smooth on the side next the joint, but rough with irregular tubercles on the opposite side, and on its circumference. There was no loss of blood during the operation: the usual dressing was applied, after the most attentive examination, as to the existence of a second body.
Neither pain nor swelling supervened, and by the fourth day, the reunion was complete. In a short time motion was performed with as much ease as before the occurrence of the complaint. In the mean while, a degree of uneasiness remained in the joint; but barely perceptible at first, this uneasiness continued to increase; in about four months, symptoms of the existence of another foreign body made their appearance.
M. Vielle being now a distance from Desault, put himself under the care of his brother, who extracted a second body, in the manner already described, except that the incision was made at two strokes.
Dressing the same as in the preceding case, with this additional precaution, that the thigh and leg were covered by a roller, for the purpose of moderating the action of the muscles.
No fever, no pain; the reunion completed on the eighth day, except a small point in the centre of the wound, which suppurated slightly till the fourteenth. There was now neither difficulty in walking, nor the least sensation of pain. Since that time, M. Vielle has enjoyed the entire use of his limb.
§ I.
1.Case I.(Reported by Levacher). Catharine Belet, aged fifty-five, of a strong and vigorous constitution, fractured her leg in the middle, by a false step in alighting from a carriage. Being carried home, in a careless manner, she was visited by a surgeon, who merely reducing the fracture, but applying nothing to retain the reduction, sent the patient to the Hotel-Dieu. She was conveyed on the same day to the amphitheatre, where Desault discovered the existence of the affection by the following signs.
Pain in the middle of the leg, less severe when the limb was at rest, more so when it was suddenly moved; the patient absolutely unable to support herself on it so as either to stand or walk since the accident; inequalities sensible to the touch on the anteriorsurface of the tibia; a shortening or contraction of about half an inch; a preternatural mobility at the place of the fracture; evident crepitation, produced by the rubbing of the fragments against each other, when moved in contrary directions: a change in the direction of the lower fragment, which was bent somewhat outwards. These signs, added to the circumstance of the fall, evidently announced a simple fracture of both bones. The reduction was effected in the following manner.
One assistant made counter-extension by grasping the lower part of the thigh with both his hands, the fingers being placed behind it, and his thumbs corresponding to its anterior surface. Another made extension, not as writers recommend, at the lower part of the leg, but on the foot itself, which was taken hold of in such a manner that the fingers met on its upper side, while the thumbs crossed each other on its sole. In this way a lever of the first kind was formed, the resistance to which was the fragment to be replaced, while its centre of motion was in the joint.
Extension being directed at first in the course or line of the displacement, till the limb had attained its usual length, was then directed in such a way as to restore to the leg its natural form. By this, the fragments being brought into apposition, united exactly without the process of coaptation being employed.34The apparatus, usually employed by Desaultin such cases, was applied to maintain the reduction: the different pieces of it had been previously arranged on a pillow in the following order: 1st, four strong pieces of tape placed at equal distances from each other; 2dly, a junk-cloth,35long enough to reach from the knee beyond the sole of the foot; 3dly, a bandage of strips, similar to that described for the thigh (page246), arranged in the usual mode; 4thly, two long compresses, the lower one of which being the longest was turned back on the other; three bolsters had also been prepared; these, being formed of several pieces of linen joined together, were about one inch and a half thick: the broadest of these was designed to be placed on the anterior part of the leg; the two other lateral ones, though narrower, were a little longer, in order that, by folding back on themselves, they might be accommodated to the inequalities of the limb; 6thly, lastly, there were also prepared two splints, an inch broad, three lines thick, and of the same length with the junk-cloth.
Every thing being ready, the assistants still keeping up extension raised the leg a little, while a pillow was slipped under it, to support it equally and uniformly throughout its whole length. The leg was placed on this pillow in such a way as to correspond exactly to the middle of the apparatus which wasarranged in order on it, and was previously wet with vegeto-mineral water.
On the anterior part of the leg was then applied a long compress, extending from the knee to the upper part of the foot. Over this were lapped the other two compresses, which had been previously placed in order as part of the apparatus. These were then secured by the bandage of strips, the application of which was begun at the lower strip next to the foot, and continued successively upwards with the rest, making them cross each other at the anterior part of the leg.
On the sides were placed the bolsters which were doubled at the ancle to protect that part from the pressure it might otherwise sustain. The splints were then applied along the external surfaces of the bolsters, the edges of the junk-cloth having been previously folded round them, in order to render their pressure the more close and steady. Along the fore part of the leg was laid the largest of the bolsters, and the whole was then secured by the four pieces of tape tied on the external splint, with a degree of tightness sufficient to keep the fragments immoveable.
A compress wet with vegeto-mineral water covered the foot, and was secured by a roller, applied in such a manner, that its two ends, crossing on the back of the foot, were fastened laterally to the two splints.
The leg, being firmly fixed by this apparatus, and gently flexed by means of a pillow placed under it, was protected by hoops from the pressure of thebedcloaths. The fragments being now in complete apposition irritated the parts no longer, in consequence of which the pain ceased.
The patient being properly disposed in bed, remained tranquil and easy throughout the remainder of the day. Diluting drinks and light nourishment were prescribed.
Next day, no pain; patient composed; a slight swelling on the back of the foot; the apparatus wet anew with vegeto-mineral water. Fourth day, the bandages a little relaxed; the point of the foot turned somewhat outwards; a new application of the apparatus. Seventh day, bilious symptoms appear, loathing of food, nausea, and bitterness of the mouth. Eighth day, tongue furred, inclination to vomit; loss of appetite; a grain of tartar emetic given in solution; copious dejections; evidently better: next day, appetite returned, tongue clean. Tenth day, a third application of the apparatus, which had become too loose. Fifteenth day, fresh bilious symptoms; further evacuations; success the same. Twentieth day, consolidation evidently advancing; no deformity of the limb; fourth application of the apparatus. Thirty-second day, consolidation almost complete; the apparatus still kept on till the forty-second day, when the patient was discharged perfectly cured.
2. This case, which is in no respect different from those that most frequently occur in practice, presents us with a view of the mode of reduction, the means of retention, and the subsequent treatment, employed by Desault, in cases of the kind. The advantage of the bandage of strips, which allows the limb to be uncovered without being disturbed, isnow generally acknowledged in fractures of the lower extremities. In the treatment of these, practitioners reject entirely, at present, the roller bandage, which was recommended by Petit, Heister, and all the authors who preceded them, and which, by producing a new displacement, at each time of reapplication, may entirely prevent the fragments from uniting. The bandage of Scultet, brought into use again by Desault, the form of which has been just described, is also preferable to the eighteen-tailed bandage, which some practitioners still employ.
3. The strips which compose the former bandage, being narrower than the tails of the latter, can be more neatly applied to the leg, as they more readily mould themselves to its inequalities; the compression made by them is, therefore, more exact, more uniform, and consequently less inconvenient. If one of the strips become soiled, it can be changed without deranging the bandage. (Respecting this point, see what was said on fractures of the thigh.) This bandage being less bulky than the eighteen-tailed one, is therefore less troublesome to the patient.
4. The broad and strong splints which form a part of this apparatus, have the following advantages over those previously used both by the ancients and the moderns; 1st, they come in contact with and bear on a larger extent of the surface of the limb; 2dly, they consequently maintain the fragments in apposition with greater firmness and effect; 3dly, they prevent the rotation of the foot outwards, an accident which very frequently occurs when the fracture is complete, that is, when both bones are broken; 4thly, they remain constantly in their place, without slippingeither forward or backward, an inconvenience necessarily attendant on the other splints, which, from their roundish form, touch the limb in only one point or line.
5. To sustain the foot, Petit recommends a piece of a board to be applied immediately to its sole, and supported by two bits of tape fastened to the splints. This practice is adopted to some extent even at present: but a simple roller, applied in the manner already mentioned, is sufficient for the purpose; the tendency of the foot to turn outwards is never so strong as not to be effectually resisted by this expedient: besides, should the piece of board be placed ever so little too vertically, it retains the foot in a state of inconvenient and painful flexion.
6. The situation of the leg, gently flexed by means of a thick cushion or pillow placed between it and the mattress, is, in all respects to be preferred to the method of Pott, which is exclusively adopted by Bell. What, indeed, can be the object of this latter method? To relax, say they, the muscles, that tend to make the lower fragment overlap the upper one. But is it not evident, that most of these muscles, not being attached to the os femoris at all, cannot be influenced by this position? To obtain the relaxation of the posterior muscles, it is necessary to flex the foot; but, in such a case, the anterior muscles are necessarily in a state of tension: this completely counter-balances the relaxation of the others, and, therefore, there is nothing whatever gained. It is certainly much best to allow the leg to be in a state of moderate flexion, such as we assume when asleep, and which appears to be the most natural.
7. The apparatus just described, produces on the fragments a twofold action: 1st, by a kind of side walls formed by the splints, it prevents their displacement laterally, and from this circumstance alone, is fully sufficient for the retention of transverse fractures: 2dly, the pressure of the rollers, splints, and bolsters, if these be applied with sufficient tightness, prevents the lower fragment from mounting on the upper one, and thus preserves the natural length of the limb. Hence its advantages in oblique fractures; and, as the powers of displacement are weaker here than in the thigh, this apparatus, is in general, sufficient to counteract them.
8. It is true that cases do sometimes though rarely occur, where, in consequence, of being irritated by splinters, or the points of the fractured bone, or acted on by some other causes which make them contract, the muscles overcome the resistance of the apparatus, and make the fragments overlap. Under such circumstances, permanent extension affords here the same advantages as in fractures of the thigh.
9. Most authors, to obtain the desired end in such cases, recommend means calculated to act on the thigh. Thus, Manne proposes the use of his glaussocome. Desault, under such circumstances, effected his purpose by the apparatus described in the following case.
§ II.
10.Case II.Pierre Bejol, aged thirty-seven, of a strong and vigorous constitution, fell, as he was carrying a heavy load, over a beam which lay in hisway. His leg was fractured towards its lower part; he was lifted up and carried home, where a surgeon, by making unskilful efforts at reduction, gave him extreme pain.
A roller and a kind of round splint applied to each side of the limb, forming the whole of the apparatus, and not being sufficient to retain the fragments, soon allowed them to overlap each other nearly two inches. The pains continue; a considerable swelling appears around the fracture; the patient is greatly agitated; he is brought to the Hotel-Dieu, where, from the deformity of the limb, Desault was satisfied, at first sight, of the existence of a fracture; on a more attentive examination, it was discovered to be complete and very oblique.
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, beingleft 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
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, andwith 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.
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.
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 manleaps 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 distanceabove 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.
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 isunable 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.
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.
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 theinferior 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.
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.