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.