MEMOIR XV.
ON THE DIVISION OF THE TENDO ACHILLIS.
1. It might be supposed that a work on diseases of the soft parts, would be a more proper place for this article, than the present one, where my express object is to treat of affections of the hard parts. What induces me to insert it here is, the analogy which exists between a division of the tendo Achillis and a fracture of the os calcis, the light which the treatment of the one throws on that of the other, and the example of the celebrated Petit, who, in his work on diseases of the bones, speaks also of this division.
§ I.
OF THE CAUSES AND VARIETIES.
2. The division of the tendo Achillis is the result, either, 1st, of the action of a cutting instrument; or, 2dly, of muscular action: hence two very different modes of its production, the one by a wound, the other by a rupture. The first is not a very rare accident, because the projection of the tendon exposes it oftentimes to the stroke of external bodies: the second, though but little noticed by the ancients, has been frequently observed by the moderns, since their attention was called to it by Petit.
3. The manner in which the division is produced by a wound, has nothing particular in it; that by a rupture, takes place in the following manner. A man leaps over a ditch, but his spring or exertion is too weak; he reaches the opposite bank only with the ends of his feet: the line of gravity not falling on the ground, the weight of the body throws the feet into a state of violent flexion, the muscles contract with great force, to prevent a fall backwards, and, at that instant, the tendon is ruptured, in consequence of being drawn downwards by the violent flexion of the foot, and upwards by the effort of the muscles: hence it appears that Petit was deceived with regard to the mechanical cause of the rupture, which he considered as taking place at the moment of the patient’s alighting on his feet, when, as he said, the tendons were surprised, so to speak, into a state of too great tension. It is easy to apply the principles of this particular case to others that may happen, and where the position may not be the same; such as, when we leap on a table, &c. Sometimes slighter efforts have produced the effect; and, as Louis observes, dancers have sometimes ruptured the tendo Achillis by making a powerful exertion on the point of the foot, as well as by other motions.
4. Divisions produced in the first mode, may be situated in any part of the tendon. Those produced in the second, occur more particularly about its middle: to that part the effort or strain is most forcibly determined, and there the resistance is the weakest. The rupture of the tendon may, according to Petit, be either complete or incomplete; but, if we consider the simultaneous contraction of the gastrocnemii and soleus muscles, and the intimate manner in which their two tendons are united at a considerable distance above the heel, it will be difficult to conceive how these tendons can be ruptured separately. With regard to divisions produced by cutting instruments, the case is different: there, the weapon may pass half way through the tendon either from behind or laterally; and perhaps divisions of this kind are much more frequently incomplete than otherwise, in consequence of the great resistance of the tendinous fibres.
§ II.
OF THE SIGNS.
5. The superficial situation of the tendo Achillis, always renders the diagnosis of its division easy. It can be rendered difficult only by the occurrence of a considerable swelling, an accident that rarely happens. If there be an external wound, the depth to which the instrument has penetrated, and the possibility of sometimes feeling the ends of the tendon between the edges of the wound, are the first evidences of its division. If, on the other hand, the tendon be only ruptured, then at the moment when the rupture happens, a report is heard by the patient, not sharp, and like the crack of a whip, as is said to take place when the plantaris muscle is ruptured, but more dull and flat, according to the account given to Desault by a patient, whom he interrogated on the subject.
6. In either case, there occurs suddenly, if not an entire inability, at least, an extreme difficulty in either standing or walking: hence the patient falls, and is unable to rise again; but, in divisions that are only partial or incomplete (4), this sign does not occur. Between the divided ends of the tendon there exists a depression sensible to the touch. This depression is increased by the flexion of the foot, but diminished and even entirely removed by its extension.
7. The patient can spontaneously flex the foot, none of the flexor muscles being affected, and this flexion may be carried even beyond what is natural, because the divided tendon forms no obstacle to it behind. Spontaneous extension is also practicable, in as much as the peroneus longus, tibialis posticus, &c. which remain uninjured, are capable of producing that motion. Some have alleged that the calf of the leg must be increased in size by the swelling of the gastrocnemii and soleus muscles, in consequence of their state of contraction; but modern experience has shown, that there is but little reliance to be placed on that appearance.
§ III.
OF THE PROGNOSIS.
8. Divisions of the tendons are not in general dangerous. These organs, being insensible in their nature, are not painful when ruptured, as is proved both by experiments on living animals, and by the observations of surgeons who have had such affections under their care, more particularly of Monro, who experienced the accident in his own person. No inflammation supervenes, and if a swelling be sometimes the consequence, it is in general soon dispersed, leaving behind it nothing serious.
9. Whence arose then the exaggerated fears of the ancients respecting injuries of this kind? Doubtless from an opinion which was then entertained, that tendons and nerves were of the same nature. Hence the severe pains, the convulsions, and even death itself, which, according to them, frequently happened, and was always to be apprehended, as the consequence of injuries done to these organs. Lamotte, among the moderns, still entertained these prejudices, when, in speaking of affections of the tendo Achillis, he said, “So dangerous are they in their consequences, that they can seldom be brought to a favourable termination.”
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[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.
29. In the third class are included, 1st, the first machine of Monro, formed of a slipper similar to that of Petit, surmounted by a strap of leather, which was to be fastened by a buckle to a kind of guetre or spatterdash, fixed on the upper part of the leg; 2dly, the second apparatus of the same author, subject, like the other, to several inconveniences; 3dly, the simple apparatus of Schneider, who rested satisfied with maintaining the extension of the foot, by a splint placed anteriorly. Besides various other objections to them, these are all chargeable, alike, with the radical fault, of not fulfilling the second and third indications (16).
30. From this comparison of the indications (16) with the means destined to fulfil them, it appears that there were material defects on the part of the latter. Let us examine whether or not that of Desault was better calculated for the purpose. It is, so to speak, nothing but a modification of the apparatus of Petit (27), but such a modification as amounts to an improvement in principle, and entitles it to be called the apparatus of Desault.
31. The pieces which compose it are; a compress two inches broad, and long enough to reach from the lower part of the thigh to the distance of four inches beyond the foot; a roller five or six yards long and two inches wide; a sufficient quantity of lint; and two long graduated compresses.
32. Every thing being ready;
1st, An assistant supports the foot and leg, the former in a state of great extension, and the latter half-flexed: another assistant supports the thigh, grasping it about its middle.
2dly, If there be a wound of the integuments, a little lint wet with vegeto-mineral water is laid directly over the division of the tendon; if it be a simple rupture, this precaution is unnecessary. Under the foot, up behind the leg, and the lower part of the thigh, is then extended the long compress, which is to be secured in that situation by the hands of the assistants.
3dly, The hollows situated at the sides of the tendo Achillis, are then filled up with pledgets of dry lint, surmounted by the two long graduated compresses, which retain the pledgets, and must project a little beyond the tendon, because they are liable to be rendered flat by pressure.
4thly, The surgeon now taking the roller, makes at first several circular turns round the toes, fixing the long compress there, the end of which, being reflected over these first casts, is secured by a few additional ones which cover the whole foot, and are afterwards directed obliquely above and below the division, round which is formed a kind of figure of 8, that brings the edges of the wound into perfect contact. If there be no wound of the integuments, it is necessary to take care, lest the skin interposing between the divided ends of the tendon, should separate them, and thus prevent their reunion. Ascending, then, by circular casts, along the whole leg, and even to the lower part of the thigh, the surgeon there turns down the upper end of the long compress, and securing it by a few more circular casts, finishes the application of the roller.
5thly, The apparatus being thus applied, and the extension of the foot and the flexion of the leg firmly secured by it, the leg is then placed on a pillow or bolster, one side of which corresponding to the angle which the leg forms with the thigh, assists in keeping it half-flexed.
6thly, Should the long compress prove insufficient to keep the foot extended, or should it, by becoming relaxed too soon, render frequent reapplications of the apparatus necessary, (circumstances which rarely happen when the bandage is well applied), a splint placed anteriorly, as was the case in Schneider’s apparatus (29), completely remedies the defect.
33. On comparing this apparatus with the indications formerly laid down, in the present disease (16), we find it evidently calculated to fulfil them with great exactness. 1st, The extension of the foot is permanently secured, both by the long compress, and by the splint when it is employed: 2dly, the same compress, aided by the bolster or pillow placed under the leg, maintains the flexion of the leg on the thigh: 3dly, The muscles are effectually compressed; their action is impeded in part by the compression of the circular bandage, which does not bear on the tendon, in consequence of the bolsters of lint placed on each side of it: these bolsters prevent the tendon both from moving laterally, and from being depressed: hence it follows, that the action of the circular bandage is precisely conformable to the principles already established (14 and 15); and that the whole of the apparatus, taken together, fulfils perfectly all the indications (16); this is an advantage not to be derived from any of the forms of apparatus used by preceding authors.
34. This apparatus is in no degree complex or troublesome. Simple and easy, it requires nothing for its construction but what the surgeon can easily obtain, and what he can even himself prepare. There exists a great analogy between it and the bandages which Desault used for the reunion of transverse wounds, and for fractures of the rotula and the olecranon. A truly great man does not estimate his merit, by the number of processes which he invents; he well knows that the perfection of art consists in producing numerous effects by few and simple means.
35. We will confirm, by two cases, the principles laid down in this memoir. One of these relates to a division of the tendon, connected with a wound, and was reported by Bezard; the other by Manouri, and relates to a simple rupture of the tendon.
Case I. J. B. Lavigne, aged thirty, as he was going down into a cellar without light, struck his leg against the edge of a sharp saw, which completely divided the tendo Achillis. The patient was immediately carried to the Hotel-Dieu. The wound of the integuments was transverse, two inches long, and had its edges but slightly separated from each other. The ends of the tendon, in contact during the extension of the foot, were separated two inches when it was flexed.
The usual apparatus was applied (32), and the limb placed on a bolster, in a position favourable for the relaxation of the posterior muscles.
In the evening, wound painful; pulse raised; a copious blood-letting; low diet. Next day, more blood taken away; antiphlogistic regimen, which was continued for several days, till the symptoms were gone: no troublesome accident occurred. Tenth day, the apparatus taken off; the wound partly healed; the apparatus reapplied, and continued till the twentieth day, when the perfect reunion of the parts rendered its further use unnecessary. From this time the patient began to walk on crutches. Thirty-sixth day, could walk well without his crutches. At this period, a small abscess occurring in his heel, induced him to remain in the Hotel-Dieu two weeks longer, when he was discharged perfectly cured.
Case II. M. Delp, leaping with some of his young companions, ruptured the tendo Achillis, about two inches above the os calcis. Both standing and walking became instantly impracticable: the patient falling down, was taken up, carried home, and from thence to Paris, where he arrived in the evening. Desault being immediately called to him, found him affected with all the signs of a division of the tendon; such as, a hollow between its divided ends, which was increased by the flexion of the foot, diminished by its extension, &c. The usual apparatus was immediately applied, and as the patient felt but little pain, only a moderate blood-letting was prescribed. Next day, no alteration in the treatment; antiphlogistic regimen; low diet continued for some days, when the patient was permitted to return to his usual mode of living. Ninth day, apparatus removed for the first time: a slight separation of the ends of the tendon; and a wrinkle in the skin interposed between them: a new application of the bandage, taking care to free the integuments from wrinkles. Twelfth day, a relaxation of the rollers; a third application of the bandage: every thing found in a good state; but, the patient being, from sprightliness, too much inclined to exert himself, a splint was applied anteriorly to prevent the extension of the foot. Seventeenth day, a fourth application of the apparatus, which was not moved again till the thirtieth. At this period, the reunion was somewhat advanced: fortieth day, almost complete. Fiftieth day, the patient was permitted to leave his bed, and take very gentle exercise, which he continued to increase gradually, till the sixtieth day, when he was discharged cured. Doubtless the tediousness of this case was owing to the slight separation which existed for some time between the fragments.