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

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.

The incisions above described are here marked out on a healthy foot.

The skeleton of the foot will at the same time show the amount of bone removed.