These drawings exhibit the present condition of both sides of the foot—the amount of deformity is less than might have been expected.
“On the 21st of February he was discharged the hospital, exactly two months after the operation, to go into the country, the foot being well, with the exception of a small opening. He came again up to town on the 15th of April, and has become stout. The sinus on the left side of the foot had closed, but a slight collection of matter had formed a little above the instep; this was discharged by means of a puncture with the lancet, and he was directed to return to the country, and dash cold water over the foot two or three times daily. On the 10th of June he returned to town to his employment. There was then not the vestige of a wound, the last opening having completely closed. He was ordered to wear a high-heeled boot. He is now a healthy-looking man, and walks very well.”
As the posterior tibial must be divided, the preservation of the anterior artery is essentially necessary; the success of the operation depends upon it. This artery, accompanied by its vein and nerve, lies close upon the astragalus; the artery may be said to be even attached to it, a point requiring the greatest attention in dissecting out the bone without injuring this vessel, which is seen under the scalpel.
100. Amputation of a single metatarsal bone, on the outside or inside of the foot, is to be done by an incision round the root of the toe, terminating in a line on the outside of the foot, which is continued down to the joint of the tarsus. The integuments are turned back above and below from the metatarsal bone, which is to be dissected out, with the toe attached to it, and the flaps brought together so as to leave but one line of incision. In military surgery, there is always a wound; and when the removal of the bone is necessary, it is in general an extensive one, with loss of substance, so that a covering cannot be saved in this way, especially on the upper part of the foot, when struck by a ball or piece of shell. The surgeon, therefore, must be prepared to look for his covering on the under part, where he will occasionally not be able to procure it in sufficient quantity, and it must not be forgotten that the neighboring parts will often be injured. The object must then be to save the integuments from such parts as are uninjured, so as to cover in the wound as nearly as possible when the bone has been removed. In doing this, the first incision should commence at the upper part and inside of the toe, and be carried round so as to separate the toe from its attachment to its fellow. If the injury be entirely on the upper part, the continuation of this incision must be so regulated as to form the whole of the flap from below, and its commencement above must be continued round the injured part so as to meet the lower end near the articulation of the bone with the tarsus, and vice versa. If the ball have gone directly through, destroying the integuments above and below, the incisions must surround the injured part in such a manner, on the upper and under side of the foot, as to allow the flaps to be formed in every other part, except where the injury was inflicted, from which granulations must arise. By saving skin everywhere else, the wound will be much diminished in size, will heal sooner, will be less liable to suffer from external violence and less obnoxious to the subsequent pain which generally at intervals attends wounds of this kind.
Amputation above Knee.
a, wooden bucket for stump;
b, pin to attach foot;
c, the rolling foot;
d, straps of attachment to body.
Amputation below Knee, No. 1.
a, wooden shape to receive knee;
b, pin;
c, rolling foot;
d, e, straps of attachment.