Читать книгу Commentaries on the Surgery of the Npoleonic War in Portugal, Spain, France, - G. J. Guthrie - Страница 12

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93. If this bone should be much shattered, and the injury nearly confined to it alone, it may be removed in the following manner: Make a semilunar incision down to the bone from the posterior angle of the inner malleolus, across the sole of the foot to the external malleolus, the convexity of the flap being forward. This flap being turned back, the tendo Achillis is brought into view, and is to be separated from its attachment or cut across above it. The point of junction between the calcis and astragalus having been ascertained, the ligamentous fibers are to be cut through and the joint between them opened, when the knife is to be carried from behind forward, in order to divide the interosseous ligament between them. Some ligamentous fibers passing between the calcis and cuboid bones are then to be cut through, when the os calcis may be dissected out without difficulty. The posterior tibial artery and nerve will be divided.

This bone was first removed for disease of its substance by Mr. Hancock, and the operation has been done several times since by Mr. Greenhow and others with success.

94. When the bones of the leg are not injured, although those of the tarsus are so far destroyed as to render amputation necessary, the operation introduced by Mr. Syme for removing the foot at the ankle-joint will be well adapted for this injury, provided the soft parts have not been so much destroyed as to prevent the formation of the covering flap or flaps. His directions are:—

“Pressure should be made on the tibial arteries by the finger of an assistant or a tourniquet applied above the ankle. The only instruments required are a knife, the blade of which should not exceed four inches in length, and a saw. The foot being held at a right angle to the leg, the point of the knife is introduced immediately below the malleolar projection of the fibula, rather nearer its posterior than anterior edge, and then carried straight across the bone to the inner side of the ankle, where it terminates at the point exactly opposite its commencement. The extremities of the incision thus formed are then joined by another passing in front of the joint.

“The operator next proceeds to detach the flap from the foot bone, and for this purpose, having placed the fingers of his left hand over the prominence of the os calcis, and inserted the point of his thumb between the edges of the plantar incision, guides the knife between the bone and nail of the thumb, taking great care to cut parallel with the bone and to avoid scoring or laceration of the integuments. He then opens the joint in front, carries his knife outward and downward on each side of the astragalus so as to divide the lateral ligaments, and thus completes the disarticulation. Lastly, the knife is carried round the extremities of the tibia and fibula so as to afford room for applying the saw, by means of which the articular projections are removed, together with the thin connecting slice of bone covered by cartilage. The vessels being then tied, and the edges of the wound stitched together, a piece of wet lint is applied lightly over the stump, without any bandage, so as to avoid the risk of undue pressure in the event of the cavity becoming distended with blood, which would be apt to occasion sloughing of the flap. When recovery is completed, the stump has a bulbous form, from the thick cushion of dense textures that cover the heel, and readily admits of being fitted with a boot.

“The advantages which I originally anticipated from this operation were—first, the formation of a more useful support for the body than could be obtained from any form of amputation of the leg; and, secondly, the diminution of risk to the patient’s life, from the smaller amount of mutilation, the cutting of arterial branches instead of trunks, the leaving entire the medullary hollow and membrane, and the exposure of cancellated bone, which is not liable to exfoliate like the dense osseous substance of the shaft. From my own experience, amounting to upwards of fifty cases, and that of many other practitioners who have adopted amputation at the ankle, I now feel warranted to state that these favorable expectations have been fully realized, and that, in addition to its other advantages, this operation may be regarded as almost entirely free from danger to life.”

This operation has not answered, in some of the hospitals in London, the expectations entertained of it from its success in Edinburgh, the flap formed from the under part, or heel, having frequently sloughed. This, Mr. Syme declares, is the fault of the operators, and not of the operation, sufficient attention not having been paid to make the flap of a proper length, and no more, and to preserve the posterior tibial artery intact, until it has divided into its plantar branches. He insists, with reason, that the operation should be done exactly as he has described it in the following explanation:—

“A transverse incision should be carried across the sole of the foot, from the tip of the external malleolus, or a little posterior to it, (rather nearer the posterior than the anterior margin of the bone,) to the opposite point on the inner side, which will be rather below the tip of the internal malleolus, but can be readily determined by placing the thumb and finger at opposite sides of the heel. If the incision be carried farther forward, a considerable inconvenience is experienced from the greater length of the flap; and I believe a great deal of the difficulty that has been attributed to the operation has arisen from this source—the operator getting into the hollow of the os calcis, cuts and haggles, in striving to clear the prominence of the bone, with the desperate energy of an unfortunate mariner embayed on a lee shore in a gale of wind. Another incision is then to be carried across the instep, joining the ends of the former. The next point to be attended to is, that in separating the flap of skin from the os calcis you must cut parallel to the bone. This is of the greatest importance, since when the flap is detached from the bone, its only supply of nourishment must be the branches which run through it parallel to the surface; and if, instead of keeping parallel to the surface, you cut on the flap as a butcher does when he skins a sheep—you will, by scoring it in this way, necessarily cut across these branches. I have reason to believe—nay, to know—that the sloughing which has occurred in some cases has been due to these defects in the performance of the operation; the flap having been cut too long, difficulty has been experienced in separating it from the calcaneum, and this has led to the scoring of the flap, which has been inevitably followed by death of a portion or the whole of it.”

Domestic surgery, or that of civil life, has in these operations of excision of the ankle-joint, and of amputation at that part, repaid her Amazonian sister of military warfare for the improvements she has introduced into the great art and science of surgery; and a degree of generous emulation will be excited and maintained between them, which, it may be hoped, will, during the present war in the East, add much to its scientific and preservative character.

95. A musket-ball will seldom pass through the foot without injuring a joint of some kind, or wounding a tendon or nerve; and the injury to the fascia, which is very strong on the sole of the foot, and frequently covered by much thickened integument, is always attended with inconvenience. The extraction of balls, of splinters of bone, of pieces of cloth, and the discharge of matter become more difficult, and often cause so much disease as ultimately to render amputation of the foot necessary. Tetanus is a frequent consequence of these injuries, and is a disease, in its acute form, certainly irremediable by any operation or medicine at present known. Amputation has always failed in my hands, although it was strongly recommended by Baron Larrey. The operative surgery of the foot should be done as soon after the injury as it can be conveniently accomplished; for a large, clean, incised wound is a safe one, compared with a torn surface of much less extent, and a splintered bone with extraneous substances; as a ball lodged in the foot is always very dangerous, great attention should be paid in the examination of even slight wounds. A cannon-shot can seldom strike the foot without destroying it altogether; it may, however, strike the heel and destroy a considerable part of the os calcis, without rendering amputation necessary, if the ankle-joint be untouched; for by due attention in removing the spicula of bone at first, and by making free openings for the discharge of matter in every direction in which it may appear inclined to insinuate itself, the limb may be preserved in a useful state.

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.