Elements of Surgery

by Robert Liston

Accidental injury, as already stated, is the most frequent cause for amputation at this part, and this will always influence the method of incision. There is nothing peculiar in the after-treatment of the stump. But it ought always to be remembered, that the operation is one of great severity; that a large part of the body has been suddenly removed; that, consequently, there is risk of the mere shock being dangerous, and of an untoward constitutional condition supervening—and, therefore, the after-attendance should be zealous and careful.

The phalanges of the toes are removed in the same way as those of the fingers. This latter operation may be required on account of bad onychia, large exostosis or injury. This and the other must also be removed on account of diseased bone, such as here represented with affection of the interposed joint. The osseous shell formed by the enlargement of the original tissue encasing a segmentum is well represented. In the amputation at the proximal joint, it is to be recollected that the extremity of the metatarsal bone lies more removed from the web of integument betwixt the toes than the metacarpal bone does from that of the fingers. The incision upwards, therefore, requires to be deeper; but in other respects the operations are precisely the same.

In amputating at the proximal articulation of the great toe, there is often a difficulty in obtaining a sufficient covering for the wound, on account of the presence of the sesamoid bones, and the general bulging of the heads of the bones. The knife is entered on the dorsum of the metatarsal bone, about half an inch above the joint, and then inclined to each side, marking out lateral flaps of considerable length; these are then reflected,—in making the outer, the instrument being dextrously passed round the sesamoid bone,—and the disarticulation completed.

In removing the great toe, along with the metatarsal bone, the bistoury is entered over the articulation of the metatarsal bone with the tarsus, and carried straight downwards, along the centre of the dorsum of the bone, till near its extremity; it is then inclined to each side, in the manner described for amputation of the metacarpal bones. The integuments are dissected off on each side of the longitudinal incision, and the knife run up along the inside of the bone, till stopped by the tarsus. The surgeon now presses the toe outwards, so as to assist the disarticulation; and after this has been completed, the bistoury is carried downwards, close to the outside of the bone, and not brought out till past the lower articulation. The external flap thus formed is then laid accurately down, so as to cover the wound, and retained. The preferable mode of making the flap, so as to expose the metatarsal bone for division or disarticulation, is well illustrated in the Practical Surgery, p. 375. The entire bone must be removed in such cases as that here sketched. In cases in which the shaft is comparatively sound, and the disease is principally seated in the articulation with its distant extremity, the shaft may be divided with the cutting forceps at a point sufficiently removed from the disease. The operations on the other metatarsal bones are the same as those on the metacarpal. They may be removed, either entirely or in part, along with the corresponding phalanges, by operative procedure similar to that practised on the hand.

Sometimes disease of the foot is not so extensive as to require or justify removal of the whole organ; the metatarsal bones are not involved throughout their whole extent. The same remark applies to injury by accident. In such circumstances, amputation is performed at the articulation of the metatarsal bones with the tarsus. The operator first ascertains the exact site of these joints, and then transfixes the foot at that point, passing the knife close along the plantar aspect of the bones; carrying the instrument downwards, a sufficient flap is formed to cover the stump, or a semicircular flap may be made and reflected by cutting from without inwards. The integuments on the dorsum are then divided in the line of articulation, the joints divided successively, and the parts removed. The flap is raised, adjusted, and retained. In dividing the articulations, it is to be recollected, that the base of the second metatarsal bone, reckoning from that of the great toe, is lodged considerably higher than the others; and, therefore, the knife must be inclined upwards at that point, or else the use of the saw is requisite. The stump thus formed proves exceedingly useful: the subsequent lameness is not great; the heel and tarsus compose a very efficient support for the weight of the body, and the flexion is unimpaired; by attention, too, the deformity may be in a great measure concealed. In short, the surgeon who amputates above the ankle, for disease or injury not extending to the articulation of the metatarsus with the tarsus, is guilty of a serious error.

The disease may reach higher than is compatible with the preceding operation, and yet it may be possible to save the heel. In such cases amputation is performed in the articulations of the os calcis with the os cuboides, and of the astragalus with the os naviculare. The plan of the incisions is the same as that for the operation at the bases of the metatarsal bones.

No amputation is more frequently performed than that of the leg. Operation near the ankle is inadmissible; sufficiency of soft parts, for the protection of the stump, cannot be procured lower than the calf. Incision is completely limited to two points, either immediately below the tuberosity of the tibia, or in the bellies of the gastrocnemii. The former is the situation to be preferred in hospital practice, and amongst the lower orders generally; the latter is suitable to the better classes of society, that is, to those who can afford to purchase an expensive artificial support. The amputation below the tibial tuberosity being the most frequently required, will, with propriety, be described first. Suppose the right leg is to suffer:—The operator places himself on its inner side, according to the general rule formerly inculcated, and grasps the lower part of the limb with his left hand, an assistant supporting the foot at a proper height, and controlling motion. The knife is entered over the fibula, on its outer aspect, and carried upwards along that bone for an inch and a half, or two inches; it is then brought across the limb in a semilunar direction, the convexity of this incision pointing towards the foot, and after reaching the inner and lower part of the tibia transfixion is performed, the instrument being pushed along the posterior surface of the bones, and made to emerge at the upper part of the fibular incision. By then carrying the knife downwards, a posterior and larger flap is formed sufficient to cover the stump. All this is effected by uninterrupted sweeps of the knife, that is, without ever removing the point or edge from the track of incision. The integuments on the fore part are then dissected upwards a little, by a few touches of the knife, so as to form a small semilunar flap; at this part of the operation there is no necessity for laying down the knife and using a bistoury. The muscles in the interosseous space are then completely divided, and the knife swept round the bones to detach the soft parts still uncut. The saw is applied, either in a horizontal or perpendicular direction; I prefer the latter for reasons already assigned. The vessels are secured, and there are generally but three—the popliteal, and two sural. I now generally aim at cutting the vessel before it divides, and seldom fail in doing so. There is then possibly the popliteal only requiring ligature, and there is less chance of secondary hemorrhage. This has occurred, so as to prove fatal at a considerable period after the operation, in consequence of the posterior tibia being cut close to its origin, and no clot having formed in it. Before adjusting the flap, it is well to assist nature in rounding off the end of the tibia, and thereby prevent danger to the integument; with this view the sharp anterior ridge of the bone is cut away and rounded off by means of the pliers. This must be done sparingly if at all, and with great caution. The nipped surface is liable to exfoliation, or the medullary web is apt to be injured, and this is inevitably followed by more or less death of bone. To some the fibular incision may appear unnecessary; but I have long practised it from conviction of its advantage. It is an excellent mark for transfixion, and assists greatly in preventing entanglement of the knife betwixt the two bones; besides the soft parts in this situation must be divided at one or other step of the operation, and hence the procedure cannot be objected to on the ground of causing unnecessary wound. In operating on the left limb, there is not the same danger in transfixion, and consequently so long a preliminary incision on the inside is not requisite; in other respects the steps of the operation are the same as for removal of the right. In muscular subjects two semilunar flaps had better be made, one from the anterior aspect of the limb, the other from the posterior, the muscles being cut short in the ham, and the incision made to reach the popliteal artery.