Chapter V: Part 5

88. Compound fractures of the patella, without injury to the other bones, admit of delay, provided the bone be not much splintered. If the ball should have pierced the center of the patella, and passed out nearly in an opposite direction behind, the limb will not be saved. If the ball have struck the patella on its edge, and gone through it transversely, opening into the joint, it will very rarely be saved; but if it be merely fractured, there is hope under the most rigorous antiphlogistic treatment, and delay is proper. A ball will occasionally penetrate the capsular ligament, and lodge in the knee-joint, with little injury to the bones. If it cannot be extracted without opening extensively into the cavity of the joint, and the extraction of the ball is absolutely necessary, amputation or excision had better be performed at first, for it will be ultimately necessary. The condyles of the femur and the lower part of the bone being spongy, a ball may pass through them or between them, and fall into the knee-joint, or it may make a prominence on the side of the patella, without passing out, or immediately interrupting the motion of the leg, for the soldier may walk some distance afterward. The popliteal artery may also be divided in addition, and either of these cases will render amputation necessary, for the ball must be taken out on the fore part, and the general inflammation of the joint will either destroy the patient in a short time, or, after much distress and hazard, leave him no alternative but amputation. If a ball lodge in the condyles of the femur within the capsular ligament, and cannot be easily extracted, excision or amputation is advisable; for the limb, if preserved, will not be a useful one. If the ball, on the other hand, lodge without the capsular ligament, and cannot readily be extracted, the wound should be healed as soon as possible; and, although it may cause some little inconvenience to the knee-joint, the limb and life of the patient may be saved, as I have seen in many instances, when a continuance of persevering efforts to extract the ball would have exposed both to great danger. Many cases of wounds in the knee-joint, in which the capsular ligament has been wounded, and the articulation opened into without injury to the bones, do well, such as simple incised wounds made with a clean cutting instrument. The success attending all wounds of the knee-joint depends entirely upon absolute rest, upon the antiphlogistic mode of treatment being rigidly enforced, on the healthy state of the atmosphere, and on the locality being free from endemic disease. The limb is to be placed in the straight position, a splint to be put beneath it, in order to prevent any motion, and cold or iced water to be applied, especially in summer, to diminish the increasing heat. General bleeding may be had recourse to in sufficient quantity to keep all general inflammatory action in due bounds; but it is on local blood-letting that the surgeon must principally rely for the prevention of inflammation. Cupping can sometimes be performed with marked effect; but leeches are more serviceable when they can be procured in sufficient numbers; from twenty to forty, or more, may be applied at a time; whenever the sensation of heat is felt, and is accompanied by pain, they should be repeated until these symptoms subside. The necessity for the local abstraction of blood is so great that it should never be lost sight of for a moment; for if suppuration take place throughout the cavity of the joint, it is followed, in most instances, by ulceration of the cartilages and caries of the bones. By local and general bleeding, the application of cold, rigid abstinence, and the straight position, a recovery may sometimes be effected; but wounds of the knee-joint, however simple, should always be considered as of a very dangerous nature, infinitely more so than those of the shoulder, the elbow, or the ankle. When a poultice is applied to a gunshot wound of this kind, I consider it the precursor of amputation. Col. Donnellan, of the 48th Regiment, was wounded, at the battle of Talavera, in the knee-joint, by a musket-ball, which gave him so little uneasiness that he could scarcely be persuaded to proceed to the rear. At a little distance from the fire of the enemy, we talked over the affairs of the moment, when, tossing his leg about on his saddle, he declared he felt no inconvenience from the wound, and would go back, as he saw his corps was very much exposed. After he had stayed with me a couple of hours, I persuaded him to go into the town. This injury, although at first to all appearance so trifling, proceeded so rapidly as to prevent any relief at last being obtained from amputation, and caused his death in a few days.

89. _Excision_ of the knee-joint is an operation formerly attended with so little success that it has been but rarely performed until lately. The result will, in all probability, be more favorable in cases of injury from musket-balls, in which the femur and tibia have both been much injured, without so much mischief being inflicted on the soft parts as would have rendered amputation necessary. In such cases, provided every accommodation, and particularly absolute rest and good air, can be obtained for the sufferer, excision should be attempted, in preference to the amputation recommended in 84 and 85. Some cases of success have lately been published by Mr. Jones, of the island of Jersey; some by Mr. Syme, Mr. Mackenzie, Dr. Gurdon Buck, Mr. Fergusson, and others. Mr. Jones’s method of operating is here transcribed, as sent to me by himself:--

“In my first case, the incisions were in this form ‘H’, two lateral, one along each side of the joint, and a transverse one immediately over the middle of the patella. The flaps were then dissected upward and downward, the patella removed--and I do not see that any advantage can be gained by keeping it, even if not diseased--the crucial and lateral ligaments were then divided, and the joint completely opened. The leg was afterward bent backward on the thigh, and the diseased portion of the femur was cleared, and removed with an ordinary amputating saw. The same method was followed with the tibia: the bones were then placed in juxtaposition, the flaps brought together by means of a few stitches, and the limb placed in a species of fracture-box. Water-dressing was applied. In the second case, I followed very nearly the same plan, with the exception of my first incisions, which were made something in a horseshoe shape. In the third case, I removed a considerable portion of integument, and, I conceive, with marked advantage. In the two former cases, I think the cure was protracted by preserving all the diseased external parts.”

Dr. Gurdon Buck, of the United States of America, in a case of anchylosis, with deformity, after a gunshot wound, removed the knee-joint by a transverse incision from one condyle to the other across the lower margin of the patella. A longitudinal incision intersected this, extending four inches above and below it. The flaps being dissected up, the joint was opened into by an incision across the ligamentum patellæ at the inferior edge of the bone, and also across the lateral ligaments. The adhesions of the articular surfaces were broken up by forced flexion very gradually applied. A slice was then removed with the common amputating saw from the surface of the condyles of the femur, including the pulley-like surface, care being taken to make this section on a plane parallel with the surfaces of support upon which the condyles rest, when the body is erect. The articular surface of the tibia was next removed on a level with the upper extremity of the fibula, after the insertions of the capsular ligament had been dissected up from the posterior half of the circumference of the head of the bone. The broad, fresh-cut bony surfaces, which were very vascular and healthy, admitted of accurate coaptation without stretching the tendons and other parts in the ham. To secure them in close contact, and prevent displacement, a flexible iron wire was passed through both bones on either side, and the two ends twisted and left out between the flaps of skin. The patella, being disorganized and softened, was removed, except the superior margin, which affords insertion to the quadriceps muscle. The flaps of integument having been trimmed, were brought together by sutures and adhesive plaster, and the limb placed in a fracture-box. The constitutional fever was moderate, and disappeared in a fortnight. Suppuration never exceeded half an ounce daily. At the end of five weeks and a half the wires became loose, and were removed. No exfoliation followed. At the end of nine weeks the wound had entirely healed, and the limb could be raised bodily from the bed. There is no mobility between the bones; the difference in the length of the limb, as compared with the other, is one inch and a half, which permits the foot to clear the surface of the ground, which cannot be done when the limb is of the same length as the other.

Mr. Jones, since the publication of his original cases, has in a subsequent one not only preserved the patella, but even the ligamentum patellæ, which he considers to be a great improvement when it can be effected; he operated in the following manner: A longitudinal incision down to the bone, four inches in extent, was made on each side of the knee-joint, midway between the vasti and the flexors of the leg. These two cuts were then connected by a transverse one just over the prominence of the tubercle of the tibia, care being taken not to cut the ligamentum patellæ. The flap was turned upward; the patella and its ligament were freed, drawn over the internal condyle, and kept there by means of a broad, flat, and turned-up spatula. The joint was thus exposed, the synovial capsule was divided as far as could be seen, when the leg was forcibly bent, the crucial ligaments, almost breaking in the act, only required a slight touch of the knife to divide them completely. The articular surfaces of the bones were now completely brought into view, when the diseased portions were removed by suitable saws, the soft parts being kept aside by assistants; the external condyle had been hollowed out by a large abscess, so that it was necessary to saw off (obliquely) another portion of the carious bone, and to gouge out the remainder, until the healthy cancellous structure was reached. The articular surface of the patella had also to be gouged until sound bone was attained. The bones were brought into apposition, and the patella and its ligament replaced, as nearly as possible; at the end of seven weeks the patient, twelve years old, was able to turn the limb from side to side, and ultimately recovered.

This little boy I saw walking firmly on his leg, an admirable instance of conservative surgery. It is, nevertheless, an operation which ought not to be done on the field of battle, unless perfect quiescence and every desired accommodation can be obtained, and no endemic disease prevail.

90. Amputation of the leg is performed in two ways--by the circular incision and by two flaps, the circular incision being only applicable to the calf. In either way the stump should, if possible, be seven inches long, for the more convenient application of an artificial leg, which is now made with a socket to fit the stump, instead of resting against the bent knee, unless the stump be too short for its proper adaptation otherwise.

The operation by the circular incision is performed by necessity in the thick part of the leg, and the bone is usually sawn through about four inches from the patella, so that, when the stump has healed, there may be sufficient length of bone left to support with steadiness the weight of the body on the knee, and that greater facility may be given to the motion of the leg, from the preservation of the insertion of the flexor tendons. The most eligible place for the application of the tourniquet, when used, is about one-third of the length of the thigh from the knee, on the inside, where the artery perforates the tendon of the triceps muscle, and where it can be most conveniently compressed against the bone by a small firm pad, the instrument being on the outside, or opposite the pad; or the compress may be placed between the hamstring tendons, a little distance from the hollow behind the joint, the instrument itself being on the fore part of the thigh. In this method the pad must be thicker, and the compression is more painful, and not more secure. The surgeon should stand on the inside of the leg to be operated upon, that he may more readily saw the fibula at the same time as the tibia, by which the chance of splintering the fibula is diminished; for this bone is held much more steadily under the saw when the tibia is undivided, whatever pains may otherwise be taken by the assistants to secure it. The limb should be a little bent, and the circular incision made with the smaller amputating knife through the skin and integuments to the bone on the fore part, and to the muscles on the outside and back part; and as the attachment of the skin to the bone will not readily allow its retraction, it must be dissected back all round, and separated from the fascia, the division of which in the first incision would avail nothing, from its strong attachments to the parts beneath. The muscles are then to be cut through, nearly on a level with the first incision, down to the bones. The interosseous ligament between the tibia and fibula is to be divided with the catlin; and as several of the muscles cannot retract in consequence of their attachment to the bones, they are to be separated with the knife; in the same manner the inter-muscular septa, or expansions running between them, are to be divided, as they would else prevent their retraction. The retractor with three slips is now to be put on, the center slip running between the bones, by which the soft parts may be pulled back to a sufficient distance, any adhering part being divided by the point of the knife. The bones are to be sawn through with the usual precautions, and the retractor removed, when the three principal arteries should be secured: the anterior tibial, on the fore part of the interosseous ligament, between the tibia and fibula; the peroneal artery behind the fibula; and the posterior tibial near it, more inward and behind the tibia; this artery will frequently, however, contract very much, and will only show itself on the compression being taken off the artery above. It in general causes more trouble to secure it than the others, and I have two or three times seen, even in London hospitals, the needle dipped round it in despair, when merely pulling out the artery with the tenaculum, and dissecting a little round it, would have shown the small retracted bleeding vessels arising from it, and have prevented, in all probability, a secondary hemorrhage. The tourniquet, if used, being removed, the smaller vessels tied, and the stump sponged with cold water and dried, the integuments and muscles should be brought forward as much as possible, and the strips of adhesive plaster applied from side to side--that is, the wound is to be closed vertically or nearly so, that the strips of plaster may not in any way press upon the fore part of the tibia, by which its protrusion will be avoided, an occurrence which almost invariably follows when the line of approximation is horizontal and the strips of plaster press upon the bone. If the spine of the tibia be sharp, it should be removed by the saw, whether the operation be done by the circular incision or by the use of flaps.

91. The flap operation, as performed by Mr. Luke, differs from that of the thigh in some particulars. There is a greater variety in the proportion which the soft parts in the posterior flap bear to those in the anterior, and the distance from the bones at which the limb is transfixed in the first step of the operation is subject to such variety that, when the calf is large, the mid-point for the introduction of the knife lies at some distance from the posterior aspect of the bones; in a small calf, it is close to it. The course of the knife through the limb is oblique instead of transverse, for the purpose of accommodating the line of incision to the plane of the two bones. The anterior flap is formed in the same way as in the thigh amputation, but it has proportionately more integuments and is thinner; yet its base and length are rendered equal to the base and length of the posterior flap, and may be adjusted evenly with it when the stump is dressed. In the circular division of the remaining soft parts, after the formation of the flaps, there is a necessary variation in the proceedings, from the circumstance of there being two bones united by interosseous membrane. It may, however, be accomplished by sweeping the knife around the more distant bone of the two, its point being afterward carried between the bones through the interosseous membrane. While the knife is between the bones, its edge may be so turned that the membrane may be divided longitudinally to any convenient extent for the easy introduction of a retractor, and the soft parts around the bone nearest to the operator may subsequently be divided by a sweep of the knife in a manner similar to that adopted for the division of parts around the more distant bone. The sawing of the bones and dressing of the stump are accomplished as in the thigh amputation; but more care is required to avoid pressure on the acute margin of the tibia, (which, when very sharp, should be removed,) and to prevent the pendulous state of the flaps.

_A._ The mid-point between _B_ and _C_, at which the knife is introduced for carrying it across the limb.

_A_ to _D_. The course of the incision to form the posterior flap, _E_.

_F_ to _g_. The course of the incision to form the anterior flap.]

When the nature of the injury renders amputation necessary at or immediately below the tuberosity of the tibia, the operation may be done with safety. Baron Larrey recommended the removal of the head of the fibula in such cases; I have done it with impunity, and thereby made a better stump than if it had not been done; but as the articulating surface of the head of the fibula does sometimes enter into the composition of the knee-joint, and as this cannot be known beforehand, the removal of this portion of the fibula is not advisable, neither must the tibia be sawn through above the tuberosity lest the capsular ligament be implicated. As an operation by which the knee-joint is saved, it is important; for although the stump is very short, it forms a solid support for the body, enables the patient to walk without the aid of a stick, and admits of the adaptation of an artificial leg. The skin, in these cases, must be saved in every direction by flaps, to form a covering. When in sufficient quantity, the operation may be done by the circular incision, as much muscle as possible being saved to aid in forming a covering on the under and outer sides. The posterior tibial artery will be found to have retracted behind the head of the bone, whence it, or others which may bleed, must be drawn out. The nerves should be cut as short as possible.

EXCISION OF THE ANKLE-JOINT.

92. This operation should be performed in the following manner: Begin the incision behind the external malleolus, an inch and a half above its lower extremity, and carry it downward and then forward across the front of the ankle-joint, then under the internal malleolus and upward, close behind this process, to the extent of an inch and a half; this incision should merely divide the skin, and should not, on any account, wound the subjacent parts. Raise the flap thus made, and, placing the leg on its inside, detach and turn aside the peronei tendons from the groove behind the external malleolus. Cut through the external lateral ligaments of the ankle-joint, keeping the knife close to the end of the fibula; then, with the large bone-scissors or nippers, cut through the fibula from one-half to three-quarters of an inch above its junction with the tibia, and, after dividing the ligamentous fibers connecting the two bones, remove the malleolus externus. Turn the leg on to its outer side, and cut through the internal lateral ligament close to the tibia, to avoid wounding the posterior tibial artery; this will allow the foot to be dislocated outward, and the lower end of the tibia to be brought well out through the wound. An assistant keeping the foot and tendons out of the way, the lower end of the tibia is to be removed by a fine saw to the same extent as the fibula, or as high as the injury or disease requires. The articulating surface, or injured part of the astragalus, is then to be removed, after which the foot is to be returned to its proper position, and the cut surfaces of the tibia and astragalus brought into close approximation, and so kept by suture, strapping, and bandage. The limb is to be placed on an outside leg-splint, having a foot-piece to it; and in order to prevent any matter oozing, an opening should be maintained on the outside of the joint, with a corresponding hole in the dressing and splint for this purpose, until the recovery is completed. The shot-hole will sometimes answer the purpose, when the injury is inflicted by a musket-ball. There are no vessels to tie, unless wounded accidentally.

REMOVAL OF THE OS CALCIS.

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.

“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.

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.

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.

“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.

_a_, wooden bucket for stump;
_b_, pin to attach foot;
_c_, the rolling foot;
_d_, straps of attachment to body.]