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

by P.-J. Desault

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.