Part 12

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.

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.

LECTURE VI.

PRIMARY AMPUTATION, ETC.

102. An upper extremity should not be amputated for almost any accident which can happen to it from musket-shot; and there is scarcely an injury of the soft parts likely to occur which would authorize amputation as a primary operation.

103. If the head or articulating extremity of the bone entering into the composition of the shoulder-joint be merely or slightly injured by musket-shot, the arm ought to be saved with some defect of motion in the joint. The wound should be enlarged in the first instance, to allow of a sufficient examination with the point of the finger, and any loose pieces of bone should be removed. Inflammation is to be restrained within due bounds until suppuration has been established, when, if a clear depending opening should not exist for the discharge of the matter poured out, it should be made, and any loose portions of bone removed. The principal points to attend to are, the prevention of sinuses around the joint, by the formation of dependent openings, position, perfect quietude, due support, the methodical application of bandages, and occasional mild stimulating injections into the wound. A simple incised wound penetrating the joint, and even injuring the bone, does not call for any immediate operation. An attempt should be made to effect a cure by the first intention, which can only be managed by means of proper position and support.

104. If the head of the bone be much splintered, or if a ball have gone through it, that portion should be sawn off; for a part thus injured has often been a source of great inconvenience and suffering for many years afterward--during, in fact, the remainder of the life of the sufferer; which misery would have been avoided by the excision of the head of the bone in the first instance--an operation which ought in fact to be done even at a later period, if it had not been performed at the time when the injury was received. Secondary operations of this kind are never so successful as primary ones, and great discrimination should be exercised in attempting to save the head of the bone, or, in other words, to avoid the operation for its removal.

105. When the splinters extend far into the shaft of the humerus, it may be proper to amputate the whole extremity, especially if the great artery be also wounded; but the shaft is seldom broken in such accidents to any great extent, and amputation should be confined almost to injuries from cannon-shot or shells, or heavy machinery, destructive of the soft parts as well as of the bone.

106. When the injury done to the upper arm is so extensive that it cannot be saved, although the head of the humerus be not injured, the amputation should take place immediately below the tuberosities, and not at the joint, which latter operation always renders the shoulder flatter, and the appearance of the person more unseemly, than when the head of the bone is left in its place.

107. It will frequently happen that the arm may be irrecoverably shattered, and the thorax partake in a less degree of the injury, there being apparent only some slight contusion or grazing of the skin; if low down, the elasticity of the false ribs may have prevented the integuments being much injured in appearance, although the blow has been violent; yet the force of the large shot may have ruptured the liver or spleen. If higher up, it may perhaps fracture the ribs, in addition to a more severe contusion of the integuments. When these accidents occur, the symptoms arising from the wound or contusion of the trunk of the body are to be first considered. If they do not indicate a speedy dissolution of the patient, or the prospect of such an event in two or three days, the operation ought to be performed, and a chance of recovery given to the sufferer, which he would not have, the arm being retained, and the injury of the chest remaining the same. The danger to be apprehended in the more favorable cases is from inflammation, and this will be rather diminished than increased by the operation; the danger of deferring which is manifest and certain, while the injury committed in the thorax or abdomen is not ascertained, and its effects may be obviated. If the termination should be unfavorable, it can only be a matter of regret for the sake of the individual, and not for the non-performance of a duty. If the cavity of the chest be laid open, or several ribs beaten in, or a stuffing of the lungs take place from a large ruptured blood-vessel--all of which circumstances are obvious, and cannot be mistaken--the operation would, in all probability, be useless. A hemorrhage of short duration, or the expectoration of blood in moderate quantities, although a dangerous symptom, is not to be considered as depriving the patient of a reasonable chance for life, for it frequently follows blows from more common causes, from which many people recover. If the operation be delayed to ascertain what injury may have been done to the chest, from the symptoms that will follow, the danger resulting from both will be increased; and even when it has been ascertained that there is but little mischief existing in the thorax, the operation can no longer be performed with the same propriety, in consequence of the inflammation which has supervened; and the patient will probably die, when he would have recovered under a more decided mode of treatment.

108. A round shot or flat piece of shell may strike the arm, after rebounding from the ground, or when nearly exhausted in force, without breaking the skin, or only slightly doing it, yet all the parts within may be so much injured as not to be able to recover themselves: the bone may be considerably broken or splintered, the muscles and nerves greatly contused. The injury may not, perhaps, be quite so extensive. The bone may be merely fractured, and yet the soft parts will often be so much destroyed as not to be able to carry on their usual actions. A ruptured blood-vessel may, with an apparently slight external wound of this nature, pour out its blood between the muscles, and inject the arm to nearly double its size, all of which are causes rendering an operation necessary, and requiring decision, for inflammation will, and mortification may, ensue in a short time, when the most favorable moment for operation will have been lost.

109. _Amputation at the shoulder-joint_ is an operation of little surgical importance. The fear formerly entertained of loss of blood has passed away, and every surgeon now knows that if he should happen to cut the axillary artery unintentionally, it can be held between the forefinger and thumb, without difficulty or danger, until a ligature can be placed upon it. No accomplished surgeon of the present day should give himself the least concern about compressing the subclavian artery. It is, on the contrary, better, when the arm is raised from the side preparatory to entering or using the knife, that the surgeon should then feel the pulsation of the artery in the axilla, that he may the more easily avoid, and subsequently command it. The axillary artery does not throw out much blood at each pulsation, and a little pressure with the end of the forefinger will always prevent bleeding, until the surgeon is prepared to take hold of the vessel with the tenaculum or forceps. The operator should, in fact, divest himself of all fear of hemorrhage. When gentlemen are afraid, however, and cannot help it, (for Henry IV. of France, _ce roy si vaillant_, always felt an inconvenient intestinal motion when a fight began,) compression may be made upon the subclavian artery by the thumb of an assistant, the round handle of a key, or the padded end of the handle of a tourniquet; the latter forms the best pad, and is usually at hand.

110. The great point to be attended to in performing the operation is to save skin to cover the stump. The directions, therefore, which are usually given for doing it after any particular method can only be occasionally useful; for the surgeon may not always be able to select the parts to be divided or retained. In cases of malignant disease of the bone and periosteum of the middle of the arm, my experience directs the removal of the whole of the bone at the joint, and not the amputation below the head; although the appearance of the integuments, and of the bone itself, would seem to encourage the attempt to preserve the roundness of the shoulder. In such cases, the removal of the extremity at the joint may be done by any one of the many ways which have been recommended for its performance. In none should the acromion or coracoid process be exposed, unless previously injured. Neither is it necessary to lose time, or to give pain, by depriving the glenoid cavity of its cartilage; but it should always be borne in mind that if the nerves be not shortened after the removal of the arm, they may be included in or adhere to the cicatrix, and cause, during a long life, much distressing pain to the sufferer.

111. Amputation at the shoulder-joint, performed immediately after the receipt of an injury, is now a very simple operation, for which simplicity English surgery is also indebted to the Peninsular war. As a _secondary_ operation, or done at a later period, when the parts are all impacted together, it is less so. In both stages it is absolutely necessary to remember--1st. That, except in cases of disease, and not of injury, the shaft of the bone must be broken; and that _all_ the directions usually given for rotation of the arm inward and outward during the operation are _unnecessary cruelties_ not to be attempted, and rarely to be effected if attempted, with a broken bone. 2d. That the arm should always be raised from the side and supported by the hand of an assistant, who can feel, if he please, at any time of the operation, the pulsation of the axillary artery; and all operative methods are hereby condemned in which this precautionary measure is not the first step.

112. _Operation by two flaps, external and internal._--The outer--beginning nearly an inch below the acromion process, the hair in the axilla having been previously removed--is to be carried down with a gentle curve so deeply as to divide the deltoid muscle, and to show the long head of the triceps at its under and outer edge. The second incision is to be carried in a similar direction on the inside, through the deltoid muscle, but need not divide the insertion of the pectoralis major, which should be exposed. These flaps being held back, the joint will be seen and readily opened into at its upper part, by cutting upon the head of the bone, in doing which the long tendon of the biceps will be divided, allowing the head of the humerus to drop from the glenoid cavity sufficiently to admit the forefinger of the left hand, on which the supra-spinatus, infra-spinatus, and teres minor may be cut through externally, as they go to be inserted into the great tuberosity, and the thick tendon of the sub-scapularis muscle internally, where it is attached to the smaller tuberosity. The head of the bone is then readily drawn out from the glenoid cavity, when the inner flap, including the axillary artery, vein, and nerves, may be taken hold of between the two forefingers and thumb of an assistant, while the surgeon, with one sweep of the knife, divides all the remaining parts below. The axillary and the posterior circumflex arteries will have to be secured; the anterior circumflex, when arising from the posterior, is frequently cut off with it; the nerves are to be shortened; the flaps brought together by sutures; and an especial pad placed upon the pectoralis major, to prevent unnecessary retraction, if possible.