Of the SUTURE of TENDONS.
WOUNDS of the Tendons are not only known to heal again, but even to admit of sewing up like those of the fleshy Parts, tho' they do not re-unite altogether in so short a Time. When a Tendon is partly divided, it is generally attended with an excessive Pain, Inflammation, &c. in consequence of the remaining Fibres being stretched and forced by the Action of the Muscle, which necessarily will contract more, when some of its Resistance is taken away: to obviate this Mischief, it has been hitherto an indisputable Maxim in Surgery, to cut the Tendon quite through, and immediately afterwards perform the Suture; but I do not think this Practice adviseable; for though the Division of the Tendon afford present Ease, yet the mere Flexion of the Joint will have the same Effect, if, for Example, it be a Wound of a Flexor Tendon: besides, in order to sew up the Extremities of the Tendon when divided, we are obliged to put the Limb in such a Situation, that they may be brought into Contact, and even to sustain it in that Posture to the Finishing of the Cure: if then, the Posture will lay the Tendon in this Position, we can likewise keep it so without using the Suture, and are more sure of its not slipping away, which sometimes happens from any careless Motion of the joint, when the Stitches have almost worn through the Lips of the Wound; on which account, I would by all means advise, in this Case, to forbear the Suture, and only to favour the Situation of the Extremities of the Tendon, by placing the Limb properly.
If it should be suggested, that, for want of a farther Separation, there will not be Inflammation enough to produce an Adhesion of the several Parts of the Wound, which is particularly mentioned as the Property of this sort of Cicatrix, though it be likewise of all others: I say, that the Inflammation will be in Proportion to the Wound, and a small Wound is certainly more likely to recover than a large one. If it should be objected, that keeping the Limb in one Posture the whole time of the Cure will bring on a Contraction of the joint, the Objection is as strong against the Suture; and now I am upon this Subject, I would advise Surgeons to be less apprehensive of Contractions after Inflammations of the Tendons, than Practice shews they are: for perhaps there is hardly any one Rule has done more Mischief than that of guarding against this Consequence; and I would lay it down as a Method to be pursued at all times, to favour the joint in these Disorders, and keep it in that Posture we find most easy for the Patient. The Risque of an immoveable Contraction in six Weeks, is very little, but the Endeavour to avoid it has been the Loss of many a Limb in half the Time.
But when the Tendon is quite separated, and the Ends are withdrawn from one another, having brought them together with your Fingers, you may sew them with a straight triangular pointed Needle, passing it from without inwards, and from within outwards; in small Tendons, about three Tenths of an Inch from their Extremities, and in the Tendo Achillis half an Inch: I have sometimes employed two Threads in sewing up the Tendo Achillis, and I believe it is generally adviseable to do so, rather than to trust to a single Suture.
Some Surgeons, for fear the Muscle should contract a little notwithstanding all our Care, advise not to bring the Ends of the , Tendon into an exact Apposition, but to lay one a little over the other, which allowing for the Contraction that always ensues in some Degree, the Tendon will become a straight Line, and not be shortened in its Length. As the Wound of the Skin will be nearly tranverse, I would not have it raised to expose more of the Tendon, but rather sewed up with it, which will conduce to the Strength of the Suture. The Knot of the Ligature is to be made as in other Wounds, and the Dressings are to be the same: there is a sort of thin crooked Needle that cuts on its concave and convex Sides, which is very handy in the Suture of large Tendons, and to be preferred to the straight one. During the Cure, the Dressings must be superficial, and the Parts kept steady with Pasteboard and Bandage: the small Tendons re-unite in three Weeks, but the Tendo Achillis requires six at least, and by violent Exercise I have known it torn open at the End of ten Weeks; though in the Instance I allude to, I brought the lacerated Tendons to a perfect Re-union, without a Suture.