Commentaries on the Surgery of the War in Portugal, Spain, France, and the Netherlands / from the battle of Roliça, in 1808, to that of Waterloo, in 1815; with additions relating to those in the Crimea in 1854-55, showing the improvements made during and since that period in the great art and science of surgery on all the subjects to which they relate.

by G. J. Guthrie

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.