A Treatise on Fractures, Luxations, and Other Affections of the Bones

by P.-J. Desault

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.