Hooked

In 1882 a young doctor from Clayton West in Yorkshire had his first paper published in a major medical journal.  Dr Duncan Alistair MacGregor was not interested in making a name for himself: after completing his training in Edinburgh he had set up in practice as a country doctor, a vocation he would follow with dedication for another 40 years. But this case was too good not to share with his peers:

remarkable case of injury to the leg

On the evening of June 15th, 1881, I was hastily summoned to see a lad, aged fifteen years, who had injured his leg by falling off an outhouse. I was told that the limb was very badly cut, and that a “long worm-like thing” was hanging out of the wound.

This does not  sound good.

On arrival, I found my patient sitting on a chair, and at first sight it seemed as if there was little the matter with him, as he was laughing heartily, apparently amused at the serious view his relatives were taking of the accident.

Given the nature of his injury, it’s probable that he was in shock and/or high on endorphins.

Upon examining the right leg, I found in front a deep longitudinal jagged wound, about two inches in length, almost immediately over the lower end of the tibia, and about a couple of inches or so above the ankle-joint. From the lower end of this wound the tibialis anticus muscle protruded almost in its entirety, the belly of the muscle lying on the dorsum of the foot.

Generally known today as the tibialis anterior, this muscle lies at the front of the lower leg. When you flex your foot upwards towards the shin, or extend your toes, you’re using the tibialis anterior.

Grays leg muscles
Muscles of the anterior lower leg, from Gray’s Anatomy (1918)

This unlucky boy had managed to rip the muscle entirely out of his leg – though it remained attached.

The haemorrhage had evidently been very profuse, but had ceased when I saw the patient. Fortunately no large vessel had been injured, so, having satisfied myself on this point, I divided the tendon of the tibialis anticus at the lower end of the wound, and removed the muscle. I then cleansed the wound thoroughly with carbolised water, washing away all dirt &c., of which there was a considerable amount.

‘Carbolised water’ is phenol, the first antiseptic agent used in surgery – as pioneered by Joseph Lister in the 1860s.

When Dr MacGregor attempted to sew the edges of the wound together he found that it could not be done, owing to the amount of tissue that had been lost. Instead, he applied a lint dressing soaked in antiseptic, and prescribed bed rest.

Everything went on satisfactorily, and in less than three weeks the wound had healed up. The history of this case (which I shall now briefly give) is, I fancy, almost unique. The boy, it would seem, had been out playing with some companions, when one of their number suggested that they should place a clod of earth upon the chimney of a neighbouring house.

Boys, eh?

Accordingly they mounted upon the roof of an outhouse, from which they could easily reach the roof of the house they intended to attack. My patient’s companions all managed to reach the chimney in safety, but he was not so fortunate, for in stepping from the outhouse his foot slipped and he fell back and rolled over on to the road.  Unfortunately for him, the “roans” (or channels along which the rain flows at the lower end of the roof)…

Or ‘gutters’ as I guess most people would call them today. Anyway, the roans or channels or gutters…

…were absent, but the curved hooks which had supported them were still intact. His right leg came violently in contact with one of these supports, which pierced the flesh and hooked round the tendon of the tibialis anticus. The boy then fell, and his weight dragged the muscle completely from its origin through the wound in the leg.

The hook extracted this single muscle with the precision of an expert dissector.

The points I consider specially worthy of notice are, first, the almost complete absence of pain. One would at first sight think that getting a muscle torn out in this summary fashion would be extremely painful; but this boy seemed to suffer absolutely no pain.

No doubt about it; he was very lucky. There are numerous accounts of serious injury where the patient experienced no pain – one famous example is George Orwell after he was shot through the neck during the Spanish Civil War. The chemical cocktail that floods the brain in the aftermath of serious trauma can do miraculous things.

Second, the apparently small loss to the leg by the removal of so important a muscle. The boy I see every day, and he can use the limb, he says, as well as he could before the accident. He certainly walks perfectly, and has neither halt nor limp.

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