A Manual of the Operations of Surgery

It has been so completely superseded by the infinitely preferable amputation at the ankle-joint of Mr. Syme, as rarely, if ever, to be practised in this country. Indeed, amputation at the ankle-joint may be said to have taken the place of all these amputations through the tarsus; for though cases are occasionally met with in which the limitation of the disease or injury may render Chopart's possible, and though at first sight it appears to have an advantage in removing less of the body, still the following objections are nearly fatal to its chance of being selected:—1. In cases of injury, through leaving a long stump, and, at first sight, a useful one, experience shows that the tendo Achillis sooner or later (being unopposed by the extensors of the toes) draws up the heel so as to make the end of the stump point, and the cicatrix press on the ground, rendering it unable to bear any weight. 2. In cases of removal for disease of the tarsus, the bones left behind, though apparently sound at the time, are almost sure to become eventually diseased.

As it has an historical interest, and as this operation (defective as it is) had been the means of saving many legs prior to the invention of amputation at the ankle-joint, a brief description may be appended:—

Chopart's own manner of operation was briefly somewhat as follows:—

The tourniquet having been applied, the surgeon is to make a transverse incision through the skin which covers the instep, two inches from the ankle-joint. He is to divide the skin, and the extensor tendons, and the muscles in that situation, so as to expose the convexity of the tarsus. He is next to make on each side a small longitudinal incision, which is to begin below and a little in front of the malleolus, and is to end at one of the extremities of the first incision. After having formed in this way a flap of integuments, he is to let it be drawn upwards by the assistant who holds the leg. There is no occasion to dissect and reflect the flap, for the cellular substance connecting the skin with the subjacent aponeurosis is so loose, that it can easily be drawn up above the place where the joint of the calcaneum with the cuboides and that between the astragalus and scaphoides ought to be opened. The surgeon will penetrate the last the most easily, particularly by taking for his guide the eminence which indicates the attachment of the tibialis anticus muscle to the inside of the os naviculare. The joint of the os cuboides and os calcis lies pretty nearly in the same transverse line, but rather obliquely forwards. The ligaments having been cut, the foot falls back. The bistoury is then to be put down, and the straight knife used, with which a flap of the soft parts is to be formed under the tarsus and metatarsus, long enough to admit of being applied to the naked bones, so as entirely to cover them. It is to be maintained in position with three or four straps of adhesive plaster, etc.38

Chopart's amputation, after an interval of comparative neglect, was introduced into this country by Mr. Syme in 1829. His method of performance is simpler and easier than Chopart's. He thus describes it:—"The blade of the knife employed should be about six inches long, and half an inch broad, sharp at the point and blunt on the back. The tourniquet ought to be applied immediately above the ankle, having compresses placed over the posterior and anterior tibial arteries. The surgeon should measure with his eye the middle distance between the malleolus externus and the head of the metatarsal bone of the little toe, which is the situation of the articulation between the os cuboides and os calcis. Placing his forefinger here, he ought to place his thumb on the other side of the foot directly opposite, which will show him where the os naviculare and astragalus are connected. An incision (Plate II. figs. 4 and 5) somewhat curved, with its convexity forward, is then to be made from one of these points to the other, when, instead of proceeding to disarticulate, the operator should transfix the sole of the foot from side to side at the extremities of the first incision, and carry the knife forwards so as to detach a sufficient flap, which must extend the whole length of the metatarsus to the balls of the toes. The disarticulation may finally be completed with great ease, as the shape of the articular surfaces concerned is very simple, and nearly transverse."39 Regarding the method of disarticulating at the astragalo-calcaneal joint, and removing all the foot except the astragalus, no detail need be given. Malgaigne advises an internal flap, thus sacrificing the valuable pad of the heel. Roux, Verneuil, and others endeavour to save the pad. This operation, however, has now fallen almost completely into disuse.

Subastragaloid Amputation has been highly recommended. In it the flap is made as in Syme's, then anterior bones removed as in Chopart's, and os calcis grasped by lion forceps and twisted off, its attachment and the insertion of tendo Achillis being cautiously avoided. If flaps are scanty, head of astragulus may be cut off with a small saw.—Hancock and Ashurst.

Tripier's Amputation40 is a modification of above, the skin incisions being made as in Chopart's amputation, and then the calcaneum is sawn through on a level with the sustentaculum tali on a plane at right angles to the axis of the leg.

Amputation at the Ankle-joint, or Syme's Amputation.—This operation is one of much interest and great practical importance. In our cold variable climate caries of the bones of the tarsus, and strumous disease of the ankle-joint, are very common and very intractable maladies, and for both of these, when far advanced, Syme's amputation is the only justifiable procedure. When properly done, according to the exact plan of its proposer, it removes the whole of the diseased parts and not an inch more, is an operation of very slight danger to life, and results almost invariably in a thoroughly useful comfortable stump. Much of its success depends on the manner in which it is performed, and as many surgical manuals are not sufficiently full, some positively in error regarding this point, and as very many modifications have been devised diminishing in value and applicability very much in proportion as they diverge from the original description, I think it advisable to describe the operation minutely, and point out in detail the parts of it which seem absolutely essential to success.

Operation.—The foot being held at a right angle to the leg, the point of a straight bistoury, with a pretty strong blade, should be entered just below the centre of the external malleolus (Plate IV. figs. 12, 13), (1.) and then carried right across the integuments of the sole, in a straight line (or in the case of a prominent heel, slightly backwards), (2.) to a point at the same level on the opposite side. (3.) This incision should reach boldly through all the tissues down to the bone. Holding the heel in the fingers of his left hand, the operator then inserts his left thumb-nail into the incision, and pushes the flap downwards, as with the knife kept close to the bone, and cutting on it, he frees the flap from its attachments. The thumb-nail guards the knife from in any way scoring the flap. (4.) This process is continued till the tuberosity of the os calcis is fairly turned, and the tendo Achillis nearly reached. Shifting his left hand he then extends the foot, and joins the extremities of the first incision by a transverse one right across the instep. (5.) Thus he opens the joint between the astragalus and tibia, (6.) divides the lateral ligaments, disarticulates, and still keeping close to the bone, removes the foot by the division of the tendo Achillis.

The lower ends of the tibia and fibula are then to be isolated from the soft parts, and a thin slice, including both malleoli, to be removed. If the disease of the joint has affected the lower end of the bone, slice after slice may be removed, till a healthy surface of cancellated texture is obtained. The vessels are then secured.

Dressing of the Stump.—From its peculiar shape and position, the escape of any blood into the stump is much to be deprecated, for as it cannot easily get out, on the one hand it gives pain, and may cause sloughing from its pressure, and on the other it is sure eventually to cause suppuration, and delay union. To avoid such results care must be taken to secure every vessel that can be seen; if there is any general oozing it is best merely to pass the sutures through the edges of the flaps, but not bring them together, thus leaving the stump open for some hours; then apply cold, and when the surfaces are fairly glazed over, remove any clots and bring the flaps together.41

Another plan introduced by Mr. Syme was to make a longitudinal slit in the flap, through which all the ligatures are to be drawn; these give a dependent drain to any pus that may be formed, and by their presence greatly expedite the healing of the wound. Again, in cases where from the amount of disease existing before the operation, and the gelatinous thickening of the flap and neighbouring parts, much suppuration may be looked for, probably it will be found best to keep the flaps quite apart for some days, by stuffing the wound with lint, and aiming only at secondary union by granulations.

A drainage tube passed through the breadth of the flap, and brought out at the angles, and retained for a few days, will do admirably.

Notes.—(1.) If commenced further forward, as in Pirogoff's modification, it will be found difficult to turn the corner of the heel; if further back, the nutrition of the flap is endangered.

(2.) This is very important. In several well-known text-books, even in the last edition of Gross's Surgery, the incision is figured passing obliquely forwards. This is a fatal error, for besides making a flap far too long, it forces the operator to cut fairly into the hollow of the sole, quite off the prominence of the os calcis, and he finds that it is utterly impossible to free his flap without using great force, and inevitably scoring it in all directions. Sloughing is almost inevitably the result.

(3.) The incision is to stop at least half-an-inch below the internal malleolus. Most surgical manuals, even when they profess to describe Mr. Syme's own method of operating, say that the incision should extend from malleolus to malleolus. If this is done, the flap becomes unsymmetrical, too long, and also the posterior tibial artery, on which much of the vascular supply of the flap depends, is cut. When the incision is properly made, the vessel is not cut till after its division into the plantar arteries.

(4.) Scoring the flap. Some may ask, Why do you object to a little scoring, the tissues are thick enough, and besides, don't you advise a slit in the flap yourself? Yes. One look at an injected preparation will show that the vessels supplying this thick flap come to it from its inner surface, and are inevitably cut across in any scoring of it, and also, that scoring cuts across the vessels, and must divide dozens of them; the slit we make is parallel with their course, and may not divide one.

(5.) Across the instep. Some authors recommend a semilunar anterior flap; this is quite unnecessary, increases bagging and delays union. It can be required only in cases where the heel flap has been destroyed or lessened by disease, or by operators in whose hands the heel flaps occasionally slough.

(6.) It is not impossible that a careless operator may (by cutting a little too low) miss the joint and get into the hollow of the neck of the astragalus, where he may cut away for a long time without making much progress.

Advantages.—1. It is wonderfully free of danger to life. It is very hard to obtain exact statistical information, but my experience is that the mortality is certainly not more than about 10 per cent., a very remarkable result when compared with that of amputations through the leg, the operation which used to be required for those cases which now require only amputation at the ankle-joint.

In the Statistical Report by the Surgeon-General of the United States, 9705 cases of amputation resulted in death, the proportions being as follows:—

2. It is the most perfect stump that can be made, in fact the only one in the lower extremity which can bear pressure enough to support the weight of the body; all the others require the weight to be distributed over the general surface of the limb by means of apparatus. A good ankle-joint stump can bear the whole weight of the body, as when the patient hops on it without any artificial aid, or without even the interposition of a stocking between the stump and a stone floor. More than this, I have seen a patient who had both his feet amputated at the ankle-joint run without shoes or stockings on the stone passages, without even the aid of a stick, and with very great swiftness.

The reason of this may be found in the nature of the flap itself, originally intended to bear the weight of the body, there being no cicatrix at the part on which pressure is borne. I have noticed that perfection in walking on an ankle-joint stump has a certain relation to the freedom of movement which the pad has over the face of the bone. This ought to be pretty considerable. It is explained by the new attachments formed by the tendons, and is under the control of the patient, being elicited when he is told to move his toes.

It has been objected to this operation that the flap is apt to slough. When improperly performed, as when the flap is scored transversely in its separation, and especially when the flap is cut too long (as has been already noticed), this may occur; but that there is nothing whatever in the position or condition of the flap itself that at all necessitates its sloughing, is thoroughly proved by the following remarkable case, given by Mr. Syme in his volume of Observations in Clinical Surgery. I quote it entire:—

"P.C., aged thirty-three, was admitted into the hospital on the 25th July 1860, in the following state:—He had been treated in the Manchester Infirmary for popliteal aneurism by pressure, so decidedly applied that it had caused an ulcer, of which the cicatrix remained; but without producing the effect desired. The femoral artery was then tied with success, in so far as the aneurism was concerned, but with the unpleasant sequel, some months afterwards, of mortification in the foot, which was thrown off, with the exception of the astragalus and os calcis with their integuments, a large raw surface being presented in front where the bone was bare. Although the patient was extremely weak, and the parts concerned might be supposed more than usually disposed to slough, I did not hesitate to perform the operation, with the speedy result of a most excellent stump and complete restoration to health."—Pp. 49, 50.

The modifications of Mr. Syme's original operation have been very various. It will be unnecessary even to name them all. One or two may require notice. Retaining Mr. Syme's incisions in their integrity, some operators prefer not to disarticulate the foot, but remove it by sawing through the tibia and fibula at once, while still in connection with the foot. That most excellent surgeon and first-rate operator, Dr. Johnston of Montrose, used to prefer this method.

In cases where the pad of the heel has been destroyed by disease or accident, so as to be partially or entirely unavailable for the flap, the late Dr. Richard Mackenzie42 practised the following operation by internal flap:—With the foot and ankle projecting from the table with their internal aspect upwards, he entered the point of the knife (Plate I. fig. 14) in the mesial line of the posterior aspect of the ankle, on a level with the articulation, carried it down obliquely across the tendo Achillis towards the external border of the plantar aspect of the heel, along which it is continued in a semilunar direction. The incision is then curved across the sole of the foot, and terminates on the inner side of the tendon of the tibialis anticus, about an inch in front of the inner malleolus. The second incision (Plate III. fig. 4) is carried across the outer aspect of the ankle in a semilunar direction, between the extremities of the first incisions, the convexity of the incision downwards, and passing half an inch below the external malleolus.

Precisely the same principle might supply the flap from the outer side in cases where the internal flap as well as the heel was deficient, but probably the nutrition of the external flap would be more doubtful. Neither the one nor the other is nearly so good as the true heel flap, and they are both only very poor substitutes for it when it cannot be had.

The modification devised by Dr. Handyside does not seem to have any advantages over the original operation, and has not been adopted.

The modification invented by Professor Pirogoff involves a much more important principle than any of the preceding. Instead of dissecting the flap from the posterior projecting portion of the os calcis, and removing the tarsus entire, he sawed off the posterior portion of the os calcis obliquely, leaving it in contact with the pad of skin, which is retained. Immediately after making the cut which defines the posterior flap and divides the tissues down to the bone, he opens the joint in front, disarticulates, and then putting on a narrow saw immediately behind the astragalus and over the sustentaculum tali, he saws the os calcis obliquely downwards and forwards till he reaches the first incision; then removes the ends of the tibia and fibula and brings up the slice of os calcis into contact with them.

Advantages.—It is easy of performance, saving the dissection from the heel, which some find so hard. It leaves a longer limb. It is said to bear pressure better, and there is certainly not so much chance of bagging of pus, and the mortality is exceedingly small, Hancock's collected cases giving only 8.6 per cent.; in cases of injury it is quite a warrantable operation.

Disadvantages.—It is contrary to sound principle in cases of disease, for it wilfully leaves a portion of the tarsus, in which disease is almost certain to return. It leaves too long a limb, for it is found that the shortening in Mr Syme's method is just sufficient to admit of a properly constructed spring being placed in the boot to make up for the loss of the elastic arch of the foot. It brings the firm pad of the heel too much forward, thus tending to lean the weight of the body on the softer tissues behind the heel. It takes much longer to unite and consolidate.

The author has now, in a large number of cases of Syme's amputation for disease, found advantage in leaving the periosteum in the heel flap, i.e. he cuts fairly into the os calcis when dividing the skin of heel, and then using a periosteum scraper instead of the knife, it is quite easy to remove the whole of the periosteum from the bone; this results in a large and more rounded pad of great strength and thickness.

In cases where from disease or injury it is impossible to obtain either a heel flap or a substitute lateral one, the question is, Where should amputation be performed?

It was for a long time the opinion of nearly all the best surgeons, and still is the opinion of many, that amputation of the leg should be performed at what was known as the "seat of election," just below the knee, even in cases where abundance of soft parts could be obtained for an amputation much lower down. The rule in surgery, to save as much of the body as possible in every amputation, was in the leg believed to be set aside by objections which militated strongly against all the other operations in the leg except the one performed just below the knee. Very briefly, these were somewhat as follows:—1. Just above the ankle you have large bones with nothing to cover them except skin and tendons. 2. Higher up in the calf you have plenty of muscle, but it is all on one side, and that the wrong one; it is very heavy, very difficult to dress and keep in position, and then when you have succeeded with it, the muscle wastes away and the stump is flabby. 3. And chiefly, as in all the amputations of the leg, the cicatrices are so much in the way, and the bones are so ill covered, that the patient can never rest his leg on the stump itself, but has either to rest his weight on his patella impinging on the top of a bottle-shaped leg, or just to stick out his stump behind him and kneel on the top of his wooden leg; therefore it is no use to have a stump longer than a few inches; in fact, the longer the stump is the more it is in the way. And more than this, many of the stumps made near the ankle, or through the calf, are not only useless, but positively painful. The skin becomes attached to the bones, the cicatrix never properly firms at all, the patient can hardly bear the pressure of a stocking, far less can he make use of the limb. For these reasons, secondary amputations below the knee are of very common occurrence.

Now, this idea has been much modified, and a few isolated cases in the past, and series of cases considerably more numerous in the present day, show that under certain conditions, and as a result of certain precautions in their performance, such operations are both warrantable and successful.

In the past, as we find in an erudite note in South's Chelius, Dionis, White, and Bromfield had each of them many successful cases of amputation just above the ankle, successful in so far that artificial limbs could be used which preserved the motion of the knee, and gave the patient much more command of the limb than is possible with the short stump below the knee.

A still more important point to be remembered is, that amputation just above the ankle is a much less fatal amputation than that just below the knee (Lister in Holmes's Surgery, 3d ed. vol. iii. p. 716; Gross, 6th ed. vol. ii. p. 1113; Ben. Bell, 6th edit. vol. vii. p. 312).

There is little doubt, however, that the principle so much in vogue in the present day, of one long anterior or posterior flap, instead of two equal flaps, or of circular amputations, has done very much to make amputations at the ankle or through the calf justifiable and useful in bearing the weight of the body.

Amputation just above the Ankle.—Cases admitting of this operation must always be rare, for disease of the tarsus or ankle-joint hardly ever goes so far as to contra-indicate the performance of Mr. Syme's greatly preferable operation; and an accident which would require this operation from injury to the ankle would in most cases require an amputation a good deal higher up from the splintering of the tibia so apt to occur.

In a suitable case the plan of the operation should be as follows:—A long anterior flap slightly rounded at the end should be cut (Plate I. figs. 15, 16)—from the outside, not by transfixion,—and the anterior muscles dissected up along with it. It should be long enough to fall down over the face of the bones at the point of section, and easily cover the point of the posterior flap, which is to be made by cutting through all the tissues with one bold transverse stroke of the knife. This operation, which is the plan of Mr. Teale of Leeds very slightly modified, is equally applicable at any point of the leg, with this difference only, that the length of the anterior flap must always be carefully proportioned to the mass of the muscular flap behind it has to cover in.

This operation provides a skin covering, without any danger of the cicatrix being pressed on or becoming adherent.

The author has within the last few years operated nine times in this manner, in cases of accident in which the heel flaps had been completely destroyed; and seen a tenth case in which Mr. Syme did so. All ten cases recovered completely and rapidly, and walked on useful limbs, with the free movement of the knee-joint.

Where from injury in a muscular patient a long anterior flap cannot be had, recourse should be had at once to the operation at the seat of election, rather than run the risk of pressure on the cicatrix by using a double flap operation, or trust that broken reed, the long posterior flap from the great muscles of the calf.

In June 1865, Mr. Henry Lee described a method of operating which he hoped would unite the benefits of Mr. Teale's method to the ease of performance of the old flap from the calf. I append a short account of his method. From its position, however, it has the great disadvantage of retaining the discharges, and by its weight straining the stitches and weighing down the cicatrix:—