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.