93. If this bone should be much shattered, and the injury nearly
confined to it alone, it may be removed in the following manner: Make
a semilunar incision down to the bone from the posterior angle of the
inner malleolus, across the sole of the foot to the external malleolus,
the convexity of the flap being forward. This flap being turned back,
the tendo Achillis is brought into view, and is to be separated from
its attachment or cut across above it. The point of junction between
the calcis and astragalus having been ascertained, the ligamentous
fibers are to be cut through and the joint between them opened, when
the knife is to be carried from behind forward, in order to divide the
interosseous ligament between them. Some ligamentous fibers passing
between the calcis and cuboid bones are then to be cut through, when
the os calcis may be dissected out without difficulty. The posterior
tibial artery and nerve will be divided.
This bone was first removed for disease of its substance by Mr.
Hancock, and the operation has been done several times since by Mr.
Greenhow and others with success.
94. When the bones of the leg are not injured, although those of
the tarsus are so far destroyed as to render amputation necessary,
the operation introduced by Mr. Syme for removing the foot at the
ankle-joint will be well adapted for this injury, provided the soft
parts have not been so much destroyed as to prevent the formation of
the covering flap or flaps. His directions are:--
“Pressure should be made on the tibial arteries by the finger of an
assistant or a tourniquet applied above the ankle. The only instruments
required are a knife, the blade of which should not exceed four inches
in length, and a saw. The foot being held at a right angle to the leg,
the point of the knife is introduced immediately below the malleolar
projection of the fibula, rather nearer its posterior than anterior
edge, and then carried straight across the bone to the inner side of
the ankle, where it terminates at the point _exactly opposite_ its
commencement. The extremities of the incision thus formed are then
joined by another passing in front of the joint.
[Illustration]
“The operator next proceeds to detach the flap from the foot bone,
and for this purpose, having placed the fingers of his left hand over
the prominence of the os calcis, and inserted the point of his thumb
between the edges of the plantar incision, guides the knife between
the bone and nail of the thumb, taking great care to cut parallel with
the bone and to avoid scoring or laceration of the integuments. He
then opens the joint in front, carries his knife outward and downward
on each side of the astragalus so as to divide the lateral ligaments,
and thus completes the disarticulation. Lastly, the knife is carried
round the extremities of the tibia and fibula so as to afford room
for applying the saw, by means of which the articular projections are
removed, together with the thin connecting slice of bone covered by
cartilage. The vessels being then tied, and the edges of the wound
stitched together, a piece of wet lint is applied lightly over the
stump, without any bandage, so as to avoid the risk of undue pressure
in the event of the cavity becoming distended with blood, which would
be apt to occasion sloughing of the flap. When recovery is completed,
the stump has a bulbous form, from the thick cushion of dense textures
that cover the heel, and readily admits of being fitted with a boot.
“The advantages which I originally anticipated from this operation
were--_first_, the formation of a more useful support for the body
than could be obtained from any form of amputation of the leg; and,
_secondly_, the diminution of risk to the patient’s life, from the
smaller amount of mutilation, the cutting of arterial branches
instead of trunks, the leaving entire the medullary hollow and
membrane, and the exposure of cancellated bone, which is not liable to
exfoliate like the dense osseous substance of the shaft. From my own
experience, amounting to upwards of fifty cases, and that of many other
practitioners who have adopted amputation at the ankle, I now feel
warranted to state that these favorable expectations have been fully
realized, and that, in addition to its other advantages, this operation
may be regarded as almost entirely free from danger to life.”
This operation has not answered, in some of the hospitals in London,
the expectations entertained of it from its success in Edinburgh, the
flap formed from the under part, or heel, having frequently sloughed.
This, Mr. Syme declares, is the fault of the operators, and not of the
operation, sufficient attention not having been paid to make the flap
of a proper length, and no more, and to preserve the posterior tibial
artery intact, until it has divided into its plantar branches. He
insists, with reason, that the operation should be done exactly as he
has described it in the following explanation:--
“A transverse incision should be carried across the sole of the foot,
from the tip of the external malleolus, or a little posterior to it,
(rather nearer the posterior than the anterior margin of the bone,)
to the opposite point on the inner side, which will be rather below
the tip of the internal malleolus, but can be readily determined by
placing the thumb and finger at opposite sides of the heel. If the
incision be carried farther forward, a considerable inconvenience is
experienced from the greater length of the flap; and I believe a great
deal of the difficulty that has been attributed to the operation has
arisen from this source--the operator getting into the hollow of the os
calcis, cuts and haggles, in striving to clear the prominence of the
bone, with the desperate energy of an unfortunate mariner embayed on
a lee shore in a gale of wind. Another incision is then to be carried
across the instep, joining the ends of the former. The next point to be
attended to is, that in separating the flap of skin from the os calcis
you must cut parallel to the bone. This is of the greatest importance,
since when the flap is detached from the bone, its only supply of
nourishment must be the branches which run through it parallel to the
surface; and if, instead of keeping parallel to the surface, you cut
on the flap as a butcher does when he skins a sheep--you will, by
scoring it in this way, necessarily cut across these branches. I have
reason to believe--nay, to know--that the sloughing which has occurred
in some cases has been due to these defects in the performance of the
operation; the flap having been cut too long, difficulty has been
experienced in separating it from the calcaneum, and this has led to
the scoring of the flap, which has been inevitably followed by death of
a portion or the whole of it.”
Domestic surgery, or that of civil life, has in these operations of
excision of the ankle-joint, and of amputation at that part, repaid
her Amazonian sister of military warfare for the improvements she has
introduced into the great art and science of surgery; and a degree of
generous emulation will be excited and maintained between them, which,
it may be hoped, will, during the present war in the East, add much to
its scientific and preservative character.
95. A musket-ball will seldom pass through the foot without injuring
a joint of some kind, or wounding a tendon or nerve; and the injury
to the fascia, which is very strong on the sole of the foot, and
frequently covered by much thickened integument, is always attended
with inconvenience. The extraction of balls, of splinters of bone, of
pieces of cloth, and the discharge of matter become more difficult, and
often cause so much disease as ultimately to render amputation of the
foot necessary. Tetanus is a frequent consequence of these injuries,
and is a disease, in its _acute_ form, certainly irremediable by any
operation or medicine at present known. Amputation has always failed
in my hands, although it was strongly recommended by Baron Larrey. The
operative surgery of the foot should be done as soon after the injury
as it can be conveniently accomplished; for a large, clean, incised
wound is a safe one, compared with a torn surface of much less extent,
and a splintered bone with extraneous substances; as a ball lodged in
the foot is always very dangerous, great attention should be paid in
the examination of even slight wounds. A cannon-shot can seldom strike
the foot without destroying it altogether; it may, however, strike
the heel and destroy a considerable part of the os calcis, without
rendering amputation necessary, if the ankle-joint be untouched; for by
due attention in removing the spicula of bone at first, and by making
free openings for the discharge of matter in every direction in which
it may appear inclined to insinuate itself, the limb may be preserved
in a useful state.
The following case, from the surgeon of the 44th Regiment, in the
Crimea, is an instance of the removal of the foot after the manner
recommended by the late M. Roux, every effort having previously been
made to save it: “Chloroform having been administered, an incision was
commenced immediately in front of and below the internal malleolus;
this was carried downward and forward until it reached the center of
the sole of the foot. From the extremity of this a second incision was
made nearly at right angles, extending backward along the sole and
upward over the attachment of the tendo Achillis to the os calcis.
A third incision was carried from this round and below the external
malleolus to meet the first at its commencement. Disarticulation of the
ankle-joint was made from the outside, the soft parts put well on the
stretch by forcibly depressing the foot, when, by successive sweeps of
the scalpel, care being taken to keep the edge close to the bone, the
os calcis was separated from its connection with the soft parts. The
plantar arteries were divided at the very extremity of the flap. The
operation was completed by sawing off the two malleoli and the thin
scale of the articulating surface of the tibia. The anterior tibial
and the two plantar arteries each required a ligature. Sutures were
inserted, and the flap supported by strips of wet lint. The operation
was performed on the 4th of July. The stump was dressed the second
day after the operation. There had been no hemorrhage; the flap was
partially adherent; on the outer side the skin was red, tense, and
shining; the sutures were very tight; they were removed from this part;
no appearance of sloughing.
“July 26th.--The ligatures came away upon the sixth day; no sloughing
of the flap occurred; a small abscess formed both on the outside and
inside of the leg, just where the malleoli were sawn off. These were
opened; the redness of the skin rapidly disappeared after this. The
line of incision is now entirely healed at the outer part; the inner is
not so far advanced, but is doing well. The flap is becoming a firm,
round cushion; and the pressure, when he walks, will fall upon the skin
taken from the sole of the foot. The advantages which this operation
appears to possess are, that the flap is not so large and baggy as in
the early stage after Syme’s amputation; it is performed with greater
facility and rapidity, and there is less chance of wounding the
posterior tibial artery.”
The accompanying sketch is of the astragalus and calcis of the right
foot, with a ball lodged on the inside, where it joins the smaller
apophysis of the os calcis. The round spot (No. 3) represents the ball,
and the tendons of the anterior tibial and of the common flexor muscles
of the toes must have been divided by it; the proper flexor of the
great toe is at some little distance below, and unhurt; the posterior
tibial nerve and the artery, about to divide into the two plantars,
are still farther distant. In this case the ball might and ought
to have been removed by the gouge, the small chisel, the screw, or
other instrument supplied for this purpose, as soon as possible after
the injury. Nothing was done, however; inflammation and ulceration
extended into the ankle-joint, and the amputation of the foot by the
flap operation at the joint was performed and failed. The leg became
affected; and the case ended in amputation of the thigh, from which the
man recovered, and was sent to England. I know not his name, nor the
regiment he belonged to, nor the surgeon who attended him, nor any more
of the case, as the bone only has been sent to me from Scutari as a
personal attention.
[Illustration:
1. Astragalus.
2. Os calcis.
3. The ball.
4. Ligament descending from the tibia, torn by the ball.
5. Tendons of tibialis anticus and flexor communis cut across by the
ball.
6. The other end of the same tendons.
7. The posterior tibial artery dividing into two branches.
8. The posterior tibial nerve.
9. The tendon of the flexor proprius pollicis.]
If the ball had entered to a greater depth, the proper operation would
have been to remove the bone altogether, which is a difficult and
disagreeable operation, even when done in cases in which this bone has
been dislocated, and is projecting under the skin. It is much more
so when in its proper place; less so when the ends of the tibia and
fibula are also removed for disease of these parts, in which case,
the bone being softened, it yields readily to the scissors, by which
it should be divided, and to which it opposes, when sound, a great
resistance from its solidity. The removal of the astragalus alone has
been successfully performed for disease in children, in two instances,
by Mr. Statham, of University College Hospital, and has been strongly
recommended by Dr. Buchanan, of Glasgow, and others. The operation,
according to Mr. Statham’s method, is to be done as follows: An
incision, four and a half inches long, is to be commenced within the
anterior edge of the fibula, and carried down in a straight line beyond
the anterior end of the metatarsal bone of the little toe; a second
incision, about an inch in length, should then be made from the center
of the wound downward toward the sole of the foot, for the purpose
of giving room. The integuments are then to be raised from the bone,
from the upper edge of the first incision, carrying with them the
extensor tendons toward the inside of the foot, to give more room for
ulterior proceedings, without injuring them. The under joint of a pair
of short, strong scissors, such as are supplied in the capital cases of
instruments, ought then to be pushed under the neck of the astragalus,
at the hollow, where it is attached by a strong interosseous ligament
to the os calcis. The upper blade being then closed upon the bone, it
may be divided, but not without considerable force. The articulating
end of the astragalus with the os naviculare can then be easily removed
by a strong pair of forceps, its ligamentous attachments being first
divided by the knife. In order to extract the remaining portion of
bone, the under blade of the strong scissors must be again pushed
under it from before backward, and made to cut it in two. The outer
part being now separated from the internal end of the fibula, care
being taken not to injure the perpendicular ligament going from that
bone to the os calcis, this piece should be forcibly removed by strong
forceps--an operation which could not be easily borne unless chloroform
were used. The remaining piece or pieces must follow, when an
examination should be made by the finger to ascertain that none remain.
The parts should be brought together, a little lint and cold water
applied, the limb placed on a splint, and interfered with afterward as
little as possible. The wood-cut represents the forceps for extracting
a ball imbedded in the astragalus.
[Illustration]
Many years have elapsed since I stated that muscles might be cut across
without, or with very little, inconvenience resulting from their
division. Mr. Stanley has lately shown that tendons even may be cut
across with little disability following, in a boy who had suffered
an injury to the wrist; inflammation followed, with disease of the
bones; and Mr. Stanley, instead of amputating the hand, made a flap
on the back of it through the tendons. He removed seven of the small
bones--all, indeed, except the trapezium supporting the thumb. The
tendons reunited, and the boy has a remarkably good motion of the hand
and fingers--proving the propriety of an operation which does so much
credit to Mr. Stanley.
The astragalus may be also removed by a similar flap operation dividing
the extensor tendons of the toes, commencing on the outside of the
fibula, and being carried round in front, but not so far as to injure
the tibialis anticus tendon, nor the anterior tibial artery and nerve;
or, when the incision reaches the edge of the outer extensor, the whole
of them are to be separated from the parts beneath, and drawn inward,
when the operation of removing the bone is to be completed, as in
the former instance. But many surgeons believe that when tendons are
forcibly drawn aside, after being separated from their attachments,
they are apt to slough, and that their division would, in most cases,
be less injurious. In neither operation need tendon, artery, vein, or
nerve of any importance be divided.
It may perhaps be stated that less regard is paid generally to gunshot
wounds of the foot in which balls lodge than is desirable; and that
other methods of operating may be devised for removing the astragalus
less difficult in their performance, and more advantageous for the
sufferers. The other bones of the instep and foot should be treated in
a similar manner when balls lodge in them. Their removal may be more
readily effected.
96. Wounds from cannon-shot injuring the fore part of the foot are
better remedied by amputation at the joints of the tarsus with the
metatarsus, than by sawing these bones across; but when the injury
affects only one or two toes, they may be removed separately,
recollecting that it is of greater importance to preserve the great
toe than any other, and that this toe is worth preserving alone,
when any one of the others would be rather troublesome than useful.
Musket-balls seldom commit so much injury as to require amputation as
a primary operation, although they may frequently render it necessary
as a secondary one. The splinters of bone are to be removed, the ball
and extraneous substances are, if possible, to be taken out; and if
the bones, tendons, and blood-vessels are so much injured as to render
the attempt to preserve them useless, amputation is to be performed. If
the preservation of the limb be thought practicable--and it generally
will be so in wounds from musket-balls--the attempt must be made
under the most rigid antiphlogistic treatment, the local application
of leeches and cold water from the first, with free openings for the
subsequent discharge. Musket-balls seldom injure the metatarsal bones
so as to require their removal with their toes, and under the treatment
above mentioned these wounds will in general be healed without further
operation. Wounds from grape-shot occasionally render the removal of
the metatarsal bone of the great toe at the tarsus necessary, although
much should be done to save it. The little and adjacent toes are also
sometimes removed at the tarsus, the middle ones but seldom, as it is
not an easy operation to perform, in consequence of the naturally close
attachment of these bones, and the additional compactness they have
acquired from the pressure of the shoe. Hemorrhage from the arteries
of the foot authorizes amputation in a very slight degree, even when
superadded to other causes; for the incisions necessary to secure the
bleeding vessels will not, in general, add much to the original injury,
unless they be very extensive; while, on the contrary, they render the
wound less complicated and more manageable.
97. Amputation at the tarsus, when it is proposed to save the flap from
the under part of the foot, is performed in the following manner: The
joints of the metatarsus with the tarsus having been well ascertained,
an incision is to be made across the foot, in the direction of the
joints, but from half to three-quarters of an inch nearer the toes,
and the integuments drawn back over the tarsus. From the extremities
of this incision, two others are to be made along the sides of the
great and little toes, for about two inches and a half, according to
the thickness of the foot; the ends of these two incisions are to be
united by a transverse one down to the bone, on the sole of the foot,
the corners being rounded off. The flap thus formed on the under part
is to be dissected back from the metatarsal bones, including as much
of the muscular parts as possible, as far as the under part of the
joints of the tarsus. The metatarsal bones are now to be removed by
cutting into and dislocating each joint from the side, commencing on
the outside, by placing the edge of the knife immediately above, but
close to the projection made by the posterior part of the metatarsal
bone supporting the little toe, which prominence is always readily
perceived. The arteries are to be secured, any long tendons and loose
capsular ligament to be removed with the knife or scissors, and the
under flap, formed from the sole of the foot, is to be raised up so as
to make a neat stump when brought in contact with the upper portion of
integuments that was first turned back; the whole to be retained in
this position by sutures, adhesive plaster, and bandage. When the skin
of the under part of the foot is much torn, which is not uncommon in a
wound made by a fragment of a shell, the flap cannot be formed from it;
in this case it must in a great measure be saved from the upper part;
but the integuments being here so much thinner, the flap is not so good
a defense against external violence, and will be more readily affected
by cold. The metatarsal bones may be sawn across in a straight line, in
preference to removing them at the joint; and although the whole may be
sawn across at once with more ease than any one of them individually,
except the outer ones, yet the stump is never so much protected from
external violence as when the operation is performed at the joints of
the tarsus.
98. Amputation of the foot, leaving the astragalus and calcis, may,
in certain cases of injury anterior to these bones, be performed with
advantage, care being taken to make the under flap so large that the
line of cicatrization may be on the upper and anterior edge of the
stump, rather than transversely across the face of it, in order to
render it firmer, and better able to resist and sustain any pressure
which may be applied to it.
The limb being placed on the table, and held by an assistant, the
surgeon ascertains the situation of the joint formed by the junction
of the astragalus with the scaphoides, which will be indicated by the
prominence on the inside of the tarsus, discoverable by passing the
finger forward from the malleolus internus toward the side of the great
toe. The joint of the os cuboides with the os calcis on the outside
is always to be found about half an inch behind the projection formed
by the posterior part of the metatarsal bone of the little toe. The
under part of the foot being firmly held in the palm of the surgeon’s
hand, he places the point of the thumb on the external joint, and that
of the forefinger over the internal one; these indicate a transverse
oblique line for the first incision, which should commence near the
thumb, and be continued with a semilunar sweep, the convexity toward
the toes, until it terminates at the side of the foot where the
forefinger was placed. The joint between the astragalus and scaphoides
is now to be opened, by directing the knife from within obliquely
outward toward the projection of the metatarsal bone of the little
toe. These bones are then to be dislocated by pressure, and the
ligaments retaining them divided. The joint between the os cuboides
and the os calcis is next to be opened from without inward, and the
bones dislocated. The strong inter-articular ligament being cut, and
the joint largely opened, the knife is to be passed between the under
surfaces of the scaphoides and cuboides, and the soft parts adhering to
them, and a flap cut from behind forward sufficiently large to cover
the wound, which is then to be dressed in the usual manner.
99. Mr. Wakley, jun., has lately performed a successful operation for
the removal of the astragalus and calcis, deserving of imitation in
peculiar cases. It is done as follows:--
“The patient being under chloroform, the diseased foot (the left)
having been drawn forward, so as to be free from the table, an incision
was made from malleolus to malleolus, directly across the heel. A
second incision was next carried along the edge of the sole, from
the middle of the first to a point opposite the astragalo-scaphoid
articulation, and another on the opposite side of the foot, from the
vertical incision to the situation of the calcaneo-cuboid joint. These
latter incisions enabled the operator to make a flap about two inches
in length from the integument of the sole. In the next place a circular
flap of integument was formed between the two malleoli posteriorly,
the lower border of the flap reaching to the insertion of the tendo
Achillis. This flap being turned upward, the tendon was cut through,
and the os calcis, having been disarticulated from the astragalus and
cuboid bones, was removed, together with the integument of the heel
included between the two incisions. The lateral ligaments connecting
the astragalus with the tibia and fibula were next divided, and the
knife was carried into the joint on each side, extreme care being
observed to avoid wounding the anterior tibial artery, which was in
view. The astragalus was then detached from the soft parts in front
of the joint and from its articulation with the scaphoid bone, and the
malleoli were removed with the bone-nippers. The only artery requiring
ligature was the posterior tibial. During the few minutes the
operation lasted, the patient did not manifest the slightest symptoms
of pain or uneasiness. On bringing the edges of the flaps together,
they were found to fit with accuracy, and were secured by twelve
interrupted sutures. The wounds were covered by several folds of lint,
and supported by a light bandage. The patient, who had lost but very
little blood, was then removed to his bed.
[Illustration: The incisions above described are here marked out on a
healthy foot.]
[Illustration: The skeleton of the foot will at the same time show the
amount of bone removed.]
[Illustration: These drawings exhibit the present condition of both
sides of the foot--the amount of deformity is less than might have been
expected.]
“On the 21st of February he was discharged the hospital, exactly two
months after the operation, to go into the country, the foot being
well, with the exception of a small opening. He came again up to town
on the 15th of April, and has become stout. The sinus on the left side
of the foot had closed, but a slight collection of matter had formed
a little above the instep; this was discharged by means of a puncture
with the lancet, and he was directed to return to the country, and dash
cold water over the foot two or three times daily. On the 10th of June
he returned to town to his employment. There was then not the vestige
of a wound, the last opening having completely closed. He was ordered
to wear a high-heeled boot. He is now a healthy-looking man, and walks
very well.”
As the posterior tibial must be divided, the preservation of the
anterior artery is essentially necessary; the success of the operation
depends upon it. This artery, accompanied by its vein and nerve, lies
close upon the astragalus; the artery may be said to be even attached
to it, a point requiring the greatest attention in dissecting out the
bone without injuring this vessel, which is seen under the scalpel.
100. Amputation of a single metatarsal bone, on the outside or inside
of the foot, is to be done by an incision round the root of the toe,
terminating in a line on the outside of the foot, which is continued
down to the joint of the tarsus. The integuments are turned back above
and below from the metatarsal bone, which is to be dissected out,
with the toe attached to it, and the flaps brought together so as to
leave but one line of incision. In military surgery, there is always a
wound; and when the removal of the bone is necessary, it is in general
an extensive one, with loss of substance, so that a covering cannot
be saved in this way, especially on the upper part of the foot, when
struck by a ball or piece of shell. The surgeon, therefore, must be
prepared to look for his covering on the under part, where he will
occasionally not be able to procure it in sufficient quantity, and it
must not be forgotten that the neighboring parts will often be injured.
The object must then be to save the integuments from such parts as
are uninjured, so as to cover in the wound as nearly as possible when
the bone has been removed. In doing this, the first incision should
commence at the upper part and inside of the toe, and be carried round
so as to separate the toe from its attachment to its fellow. If the
injury be entirely on the upper part, the continuation of this incision
must be so regulated as to form the whole of the flap from below, and
its commencement above must be continued round the injured part so
as to meet the lower end near the articulation of the bone with the
tarsus, and _vice versa_. If the ball have gone directly through,
destroying the integuments above and below, the incisions must surround
the injured part in such a manner, on the upper and under side of the
foot, as to allow the flaps to be formed in every other part, except
where the injury was inflicted, from which granulations must arise. By
saving skin everywhere else, the wound will be much diminished in size,
will heal sooner, will be less liable to suffer from external violence
and less obnoxious to the subsequent pain which generally at intervals
attends wounds of this kind.
[Illustration: _Amputation above Knee._
_a_, wooden bucket for stump;
_b_, pin to attach foot;
_c_, the rolling foot;
_d_, straps of attachment to body.]
[Illustration: _Amputation below Knee, No. 1._
_a_, wooden shape to receive knee;
_b_, pin;
_c_, rolling foot;
_d_, _e_, straps of attachment.]
[Illustration: _Amputation below Knee, No. 2._
_a_, wooden bucket to receive the whole of stump;
_b_, fixture to foot;
_c_, rolling foot;
_d_, straps for knee.]
101. M. de Beaufoy has invented a foot for the wooden pin used by the
soldiers in the Invalides, at Paris, who had suffered amputation above
or below the knee; this, Mr. Bigg, of Leicester Square, has tried on
some old soldiers at Chelsea Hospital; one of them reports that he has
not only found his step to be steadier, but that he could walk twice
the distance in the same time that he could with his ordinary pin-leg.
The advantage of the invention is, that whereas a common wooden pin
only gives one point of support, and consequently the body is obliged
to raise itself so as to describe an arc, of which the end of the
wooden pin is the center, the curved foot acts like a _series of
levers_, each successive point of it being a _fulcrum_. The precaution
should be taken to have the aperture at _a_, fig. 2, for the insertion
of the pin, made square, to prevent its turning when in use.