No. 2307.

NOVEMBER 16, 1867.

Second Course of LecturesON THE

ANATOMY AND SURGERY OF THEHUMAN FOOT.

Delivered at the Royal College of Surgeons of England inJune, 1867.

BY HENRY HANCOCK, ESQ., F.R.C.S.,SURGEON TO CHARING-CROSS HOSPITAL, AND

PROFESSOR OF SURGERY IN THE ROYAL COLLEGE OF SURGEONS.

LECTURE IV.-PART III.

WHEN, on the other hand, we are doubtful as to the amount lof mischief; when there is the chance of the disease proving soextensive as to necessitate the removal of the entire foot, theproceeding advised by Mr. Teale offers the greatest advantages.He makes a transverse incision across the sole of the foot, com-mencing about three-quarters of an inch in front of one mal-leolus, and ending at a similar point in front of the other. Asecond incision is then made in the median line, beginning overthe tendo Achillis on a level with the ankle-joint, and joiningthe former at right angles in the sole of the foot. The two

lateral flaps thus marked out being next dissected up close tothe bones, the calcaneum and astragalus are thus freely ex-posed. By division of their ligamentous and tendinous con-nexions one or both of these bones maybe easily removed; andshould it be thought desirable to remove also other bones ofthe tarsus, they may be readily reached by extending themedian incision a little forwards. If, from the extent of thedisease, it is found necessary to remove the entire foot, it maybe accomplished by uniting the two extremities of the trans-verse incision by a curved incision across the dorsum of thefoot.

In my own case I made a single semilunar flap in the sole ofthe foot, with the convexity looking forwards, by an incisionfrom one malleolus to the other. I was induced to adopt this,being in doubt as to the extent of the mischief; but for excisionof the os calcis solely, for the reasons stated above, I infinitelyprefer Mr. Holmes’s method.

In his first, second, and third cases Mr. Greenhow made in-cisions from the inner and outer ankles, meeting at the apex ofthe heel; then others along the side of the foot, and dissectedthe flaps back, to expose the bone and its connexions. A wedgeof integument was removed in the first case, but it was foundbetter to avoid this in the others. In the fourth case an in-cision was commenced at the apex of the heel, and carried up-wards to the inner malleolus, and then downwards and for-wards, and the same being repeated on the outer side, two- curved flaps were formed.

Mr. Pemberton, on the other hand, in his first case made ahorseshoe flap, by incisions along the sides of the foot andround the heel. In this course the knife cut deeply on thebones, and divided the attachment of the tendo Achillis. Inhis second case he pursued very nearly the same plan as thatrecommended by Mr. Holmes.

Dr. George Buchanan says the incisions are best made so asto leave the integuments and soft parts suitable for conversioninto a proper covering for amputation, if the disease is foundmore extensive than anticipated; also to avoid the vesselsand nerves of the foot. He therefore adopts the followingplan :-Enter a strong knife at the external malleolus, carry itperpendicularly down to the outer edge of the foot, and con-tinue it two-thirds across the sole, about an inch and a half infront of the heel. At right angles to this make an incisionalong the outer edge of the foot to a point a little in front ofthe calcaneo-cuboidal joint. The two angular flaps are to bedissected up till the external and inferior surfaces of the cal-caneum are nearly exposed. The posterior flap can now beturned back over the projecting heel, and the tendo Achilliscut. By dividing the middle fasciculus of the external lateralligament the bone can be twisted so as to expose the calcaneo-cuboidal articulation, which can be opened by the point of theknife, and the whole bone can be forcibly twisted inwards, theNo. 2307.

point of the knife dividing the interosseous ligaments as theyare put upon the stretch. When the disarticulation is com-pleted, the soft parts on the inner side can be separated with-out any risk of injury to the vessels or nerves.

Lieuhard dissected a foot in which he had excised the oscalcis three years before. The sole of the foot was much flat-tened, and the prominence of the heel had disappeared. Be-neath the skin there was a mass of very dense tissue, in whichthe tendo Achillis, the origin of the short flexors of the toes, theadductor pollicis and abductor minimi digiti, lost themselves.The cuboid was displaced slightly backwards, and was unitedby very strong fibrous bands with the neck of the astragalus.The whole foot was rotated inwards, as in valgus, and the dis-placement existed principally between the scaphoid and astra-galus. The head of the latter was turned almost directlytowards the sole of the foot.

This confirms the account given by Wagner, that the exami-nation during life of persons who have recovered after extir-pation of short bones shows that the defect has been remediedas far as possible by the approximation of the bones which lienearest together. The interval which is left seems to be filledup by a ligamentous material, in which, according to Ried,masses of cartilage or bone are sometimes deposited.

Sir W. Fergusson, in a case in which he amputated at thetibio-tarsal joint seven years after he had extirpated the innerhalf of the os calcis for caries, found the bone partly regene-rated, and the place of the lost substance partly occupied by a

. fibro-cartilaginous material.Giving insertion to the strong tendo Achillis, exposed also

’ to all the shocks and injuries which may assault the foot, we’ cannot be surprised that the os calcis is liable to fracture from’ muscular contraction as well as from other causes.. Mr. Holmes Coote kindly writes me that there is in the_

museum of St. Bartholomew’s Hospital a preparation of frac-ture of the upper part of the os calcis from muscular contrac-

E tion, and that he had at the time of writing a similar caseunder his care, in which the patient, a respectable woman at

Woodford, walked a quarter of a mile after the accident to get3 to the hospital. Here the upper fragment was completely de=

tached.Mr. Henry Smith saved the foot in a case of compound com-

minuted fracture from explosion. The os calcis was brokento pieces. As many fragments as possible were removed atthe time, and the patient recovered, being able to walk.A collier, aged fifty-four, was admitted, under the care of

Mr. Folker, into the North Staffordshire Infirmary on the 21stOctober, 1862, with fracture of the os calcis. The accidentwas caused by a fall of a stone on the heel. The bone wasbroken through, and drawn up by the tendo Achillis. He hadbeen under treatment elsewhere for about a week. It wasfound impossible to reduce the fractured portion, so it was re-moved. The parts healed slowly, but the man was dischargedcured on Dec. 15th. Mr. Folker has since heard that he walksvery well.

I am indebted for the following case to the kindness ofMr. Wheelhouse, of Leeds :--

Eli Sykes, aged nineteen, confined in Leeds borough gaol,had been sentenced to death on December 9th, 1865, for thewilful murder of Hannah Brooke, at Batley, on August 19th.His demeanour after sentence seemed calm and resigned. Hewas confined in a cell on the ground floor for the first day;but as another condemned prisoner seemed not so trustworthy,the latter was put into it, and Sykes removed to one on thefirst gallery. About a quarter before seven on December 23rd,the door of his cell being accidentally unfastened, he got out,ran along the first gallery to the staircase and up to the toplanding, threw himself over the rails, and fell on the stonefloor beneath, a distance of over twenty feet. He appears tohave dropped, rather than jumped from the rails; to havealighted on his feet, and then fallen forwards, striking hisforehead against the ground. When seen by Mr. Price, sur.geon to the gaol, both ankles were much swollen; and at theinside of the left was a wound about the size of a shilling,through which loose portions of bone could be felt, and from

. which there was free arterial haemorrhage. There was alsofree oozing from a wound in the sole of the right foot. Both

. tibia and fibula appeared uninjured. At ten P.M. Mr. Wheel-house saw him in consultation, and removed large fragments

, of the os calcis by means of a crucial incision over the leftankle, which disclosed extensive comminution of the os calcis;

l and there was free arterial bleeding from the bottom of the- wound, for which two ligatures were applied. It was found, that he had also sustained a fracture of the skull over the, frontal sinus. On December 26th his pulse was 140; the

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wound in the ankle looking well. On the 30th he becamedelirious, and so violent as to require restraint. On January3rd secondary haemorrhage commenced from the left ankle; itwas easily arrested at the time, but recurred briskly in theevening, leaving him very weak. He rallied; but on the 6ththe haemorrhage again returned, and, though not profuse, wassufficient to destroy him: he gradually sank, and died fivehours afterwards, being conscious to within an hour of hisdeath.

Autopsy, forty. two hours after death.-Spare frame; ecchy-mosis of forehead and left elbow and shoulder. In the leftfoot was a compound comminuted fracture of the os calcis,which was broken into numerous pieces, the astragalus beingtwisted and drawn down among them. There was consider-able infiltration of the tissues, which were sloughy. Theplantar arteries had been wounded just after the division ofthe posterior tibial. The source of bleeding in the centraland anterior part of the wound could not be made out, as thearteries were lost in the sloughy part of the wound. In the

right foot the os calcis was fractured, though not nearly to thesame extent as the left, the wound in the sole communicatingwith the fracture. There was no extravasation of blood, andhealthy suppuration was going on.Whether from its greater size, its greater number of points

of ossification, or its similarity to the long bones in possessing an

epiphysis, the os calcis would seem to admit of partial excisionbeing performed upon it for disease with much greater prospectof success than any other bone of the tarsus. From the casesrecorded, it is evidently more frequently the seat of diseasethan the rest; and from the nature of the cases recorded, itis an exception to the laws of pathology as enunciated byWagner in his celebrated treatise " On the Reproduction ofBone." Speaking of resection of the os calcis, he observes :" The power of regeneration of short bones is usually placedfar beneath that of the tubular bones; but with respect to theregeneration after resection of the extremities of the longbones, the difference cannot ? priori be assumed to be veryconsiderable. The articular ends of long bones are hardlydistinguishable in anatomical structure from the short bones.Even the periosteum which covers the short bones is wantingin a portion of the others; and the difference can 4 priori befounded only on this consideration: whether in resection ofthe long or tubular bones the shaft is more or less involved inthe operative procedure. That this K priori conclusion is cor-rect is shown by experience. Necrosis most usually attacksthe shaft, seldom the extremities of the bones."

I would here allude to a class of cases which, whilst theythrow some doubt upon the correctness of the latter conclu-sions, are of interest and of no little practical importance, fromthe great resemblance which they bear to disease of the ankle-joint, and the consequent danger of their being mistaken forthat mischief. I allude to the presence of a sequestrum in oneor other of the malleoli or their immediate neighbourhood.Whether from being more exposed to external injury or not,the external malleolus seems to be the seat of this mischiefmuch moie frequently than the internal, and indeed the twoextremities of the fibula are liable to its existence. I have hadcases of necrosis of the head of the fibula wherein the symp-toms so closely resembled disease of the knee-joint as to requirea very careful examination to distinguish between the two;whilst in the external ankle, the thickness and swelling of thesoft parts around the joint, the pain upon movement of thepart, the inability to bring the heel to the ground, or to bearthe weight of the body upon the foot, are all symptoms whichassimilate it to more serious condition of disease of the ankle-

joint itself. The history of the case, the situation of thewound over or close to the malleolus, and the capability ofmoving the joint when the patient is under the influence ofchloroform, will, however, in most instances enable the sur-geon to form a correct opinion of the true nature of the mis-chief ; at all events, they do so with sufficient frequency tojustify the surgeon in making an exploratory examination be-fore having recourse to more serious measures.

Three years ago I operated upon a man, aged thirty-four, at theCharin Hospital, for this disease. He saidthatnine monthsbefore he had had great pain in the outside of the left ankle-joint ; that, being unable to give up his work as a labourer, thepain became more severe, and ultimately an abscess formed,since which time he had been unable to walk. When I firstsaw him he was complaining of great pain, especially when thepart was moved ; there was considerable thickening and swell-ing around the joint, ancl he was unable to bring the heel tothe ground. Directly over the outer malleolus was a smallopening, which, examined by a probe, led to dead bone.

Having placed the man under chloroform, I found I couldmove the joint freely, and I therefore made a crucial incisionthrough the skin over the lower end of the fibula, and applieda trephine over the opening in the bone, taking care only toremove the external shell. This done, I exposed a sequestrum,about the size of a small hazel-nut, which having removed, Ibrought the wound together, and the patient recovered perfectuse of his foot, although he was two months in doing so.In the following very interesting case there was a sequestrum

in the lower end of the tibia, in addition to one in the ex-ternal malleolus :-

R. M-, aged sixteen, was admitted into Charing-crossHospital, under my care, on April 17th, 1866. He stated thatin 1859 a piece of bone was discharged from his sternum. InJanuary, 1866, his left ankle began to swell on its outer side ;an abscess formed, which burst, and a large quantity of matterescaped.On admission, the ankle was much thickened and enlarged ;

moving the joint gave him great pain. There was an openingjust above the outer malleolus, leading down to dead bone, theedges of the wound being surrounded by fungous granulations.On May 12th I cut down upon the malleolus, and with a’small trephine removed the outer shell of bone, including theopening, and, as in the last case, exposed and removed a smallround sequestrum. Upon examining the cavity left by theremoval of the sequestrum with the end of my little finger, Idiscovered a second opening on the inner side of the malleolus,and communicating with the lower end of the tibia, and anexamination with a probe showed the existence of anothersequestrum in this situation. I therefore again applied thetrephine through the first opening, and removed the corre-sponding portions of the inner shell of the malleolus and theouter shell of the tibia, and by this means I was enabled witha pair of long forceps to extract the sequestrum from the tibia,which was about the same shape and size as that removedfrom the fibula, and without any damage to the ankle-joint.Considerable discharge followed the operation; but this was ina great extent removed by the free employment of the iodinepaint, and he was able to move about, and ultimately left thehospital at the end of July.

In some cases, as in the following, for which I am indebtedto the kindness of Mr. Wearn, of Longton, in Staffordshire,the interference with the movements of the joint is much less."A. B- injured his ankle-joint about six years ago, but

has worked off and on as a collier since then up to six weeksback, when he came under surgical treatment for pain andswelling over the lower end of the fibula. This was poulticed,and in a little time matter formed, which was let out. Aboutnine days ago I was called to see the case, as another surgeonhad said there was nothing more could be done but to am-putate above the joint.’ Upon examination with my fingerand probe I am able to make out that the only bone diseasedis the lower part of the fibula. All the other bones appear tobe perfectly sound, together with perfect movement of thejoint in every direction, and without pain. Large externalfungous growths have sprung up, but his general health is.good."

"

As Mr. Wearn paid me the compliment of asking me myopinion upon this case, I suggested that it was in all probabilitya case of necrosis of the external malleolus, which could be bestremoved by the application of a trephine.The late Mr. Hunter, of Margate, also kindly informed me.

that on the 12th of July, 1864, he removed a sequestrum fromthe external malleolus of a man, aged twenty-one. The patientwas discharged from the hospital cured on the 25th of thefollowing October.The following is a still more valuable and interesting case :-

J. S-, aged twenty-six, a shipwright, was admitted intoExeter General Hospital, under the care of Mr. Kemp, suffer-ing from disease of the ankle-joint of three years’ duration.He had been in the hospital two or three times before. Mr.Kemp exposed the outer malleolus, and removed a circularpiece of bone with a trephine, and extracted a large piece ofdead bone from the astragalus without difficulty. The operationwas followed by great pain, which lasted for several hours,but it was combated by opium. No bad symptoms followed.The wound healed in seven weeks, and the patient was enabledto walk well.

Grist removed the entire external malleolus for caries limitedto the external malleolus; at all events he described it as such,but it is questionable whether he did not mistake the nature ofthe case, which in all probability was of the same character as

those under consideration. The mischief appears to have beenentirely restricted to the external malleolus; the motions of

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the ankle-joint were unimpeded, and the ankle-joint itself wasunaffected. However, Grist cut through the peronei muscles,removed the malleolus, and filled up the deep cavity with Icharpie. Violent inflammation succeeded, but the wound is ,

said to have healed in two months, and at the end of threemonths the patient went to work. He could adduct the foot,but neither abduct nor rotate it. He retained the power ofextension and flexion almost to the same extent as before, butthis was effected at the medio-tarsal end, not at the tibio-tarsalarticulation, which was anchylosed. The patient died threemonths afterwards of consumption, and Grist has given thefollowing description of the parts :-The tibia was anchylosedto the astragalus ; the astragalo-scaphoid capsular ligamentwas very loose and extensive ; the fibula closely approximatedto the tibia, and was firmly united to it. There was no rege-neration of bone, but the periosteum was continued directlyinto a ligamentous substance, which formed a sort of blindpouch around the cut end of the fibula, and passed over to thebones of the tarsus.

Mr. Erichsen also, whilst admitting that the os calcis is themost frequently diseased of the tarsal bones, adds that " thisis by caries, not necrosis, the latter occurring but rarely."Dr. George Buchanan, on the other hand, says that true cariesconfined to the os calcis is a rare thing. Circumscribed caries,often round a necrosed bit, admits of removal by gouge, &c.We have already seen that necrosis of the ends of the long

bones is by no means so uncommon as implied by Wagner’sobservations. It has been met with, and not unfrequently, inthe extremities of all long bones ; nor is it so unusual in theos calcis. We have seen it in the interesting case recorded byMr. Csesar Hawkins; we also find it in the following cases :-

Mr. Wheelhouse, of Leeds, removed a sequestrum from theos calcis in February, 1866, leaving a smooth cavity. The casewas progressing favourably when he wrote.

In another case a sequestrum was removed from the left oscalcis. The disease had existed for four years. Cause un-known. A piece of dead bone was removed, which was foundlying in a smooth granulating cavity.Mr. Power, in August, 1866, kindly sent me a patient who I,

had applied to him at the Westminster Hospital for a wound Ion the inner side of the heel. He had been operated upon fornecrosis of the os calcis in 1861.Mr. Liston, in 1844, applied the trephine and removed a

sequestrum, the size of a small nutmeg,from the os calcis ofa girl aged seventeen, who had suffered for three years and ahalf. The patient recovered, and left the hospital three monthsafter the operation. Mr. Liston also removed a sequestrumfrom the inner side of the os calcis by applying the trephinein the case of a girl aged ten years. She recovered completely;as did a woman, aged thirty-two, from whose os calcis Mr.Solly removed a sequestrum in June, 1853.Mr. Samuel Hey, of Leeds, removed a sequestrum from the

os calcis. He was subsequently obliged to amputate the leg,and the patient recovered.

Although, as a general rule, I quite agree with Mr. Holmesin the conviction of the great advantage of complete excisionof the tarsal bones over gouging, still many cases are recordedin which success has attended partial resection of the os calcisfor caries even when effected by the gouge, especially whenthe periosteum has been preserved.W. W-, aged twelve years, was admitted into King’s

Lynn Hospital, under the care of Mr. Kendall, with caries ofthe os calcis, from which he had suffered for some months.Constitutional treatment having failed, he, on the 7th of May,1866, was placed under the influence of chloroform, and onexamination it was found that the greater portion of the oscalcis was diseased. This was gouged out, the periosteum beingleft; and the wound was dressed with a solution of chlorideof lime, thirty grains to the ounce. The cavity filled up with’ Ibone extremely fast, and on the 23rd of June, forty-seven daysafter the operation, he left the hospital quite well, and isnow at work.W. A——, aged twenty-eight, residing at Swaffham, was

admitted into the West Norfolk Hospital, under Mr. Kendall’scare, March 17th, 1866,, with extensive disease of the os calcisand astragalus. There were several sinuses leading down toand opening into the joint, which had existed for more than ayear. As constitutional treatment had failed, Mr. Kendall onthe llth of June gouged away the greater part of the os calcisand the front of the astragalus, leaving the periosteum un-touched as far as possible. The wound was dressed with thesolution of chloride of lime. The patient did very well, andon the 4th of August he was made an out-patient, but wasordered not to rest any weight upon the limb for the present.

The late Mr. W. James, of Exeter, operated upon T. C-,aged eighteen, on the 26th of April, 1860. The operation con-sisted in turning back a flap, and gouging out part of the oscalcis ; then bringing back the flap, which united, and thepatient recovered. Mr. James, sen., kindly wrote me, on the19th February, " I had great pleasure in hearing that in thecase of excision of the os calcis operated upon by my late sonthe patient is now in India, serving in the English navy."

I am indebted for the following case to the kindness of Mr.C. Williams, of Norwich :-A farm-boy, aged eighteen, aboutsix months before admission into the Norwich Hospital, suf-fered deep-seated pain in the outer ankle of his left foot. Afew weeks later an abscess formed in that situation, and shortlyafter several more formed around the heel, so that on admissionthere existed several orifices on either side of the calcaneum,leading to sinuses, through which carious bone could be de-tected, and a rather profuse discharge of unhealthy pus wasissuing therefrom. The ankle-joint seemed free from disease.An incision was made from below one malleolus round the soleof the foot to a similar point on the opposite side, and this wasintersected by an incision along the middle of the heel. Aboutthree-fourths of the os calcis was then exposed and sawn off.No joint was interfered with. The case progressed mostfavourably, and he was dismissed cured six weeks after. Mr.Williams had the opportunity of seeing this case almost a yearlater. The patient had then a capital heel, and could walkwell.

I have collected the particulars of 42 cases of partial ex-cision of the os calcis, although doubtless many more havebeen done. Of these, 25 were performed for caries, 1 fornecrosis, 12 for necrosis with sequestra, 4 for accidents.

Of the 25 for caries, 14 recovered at periods varying fromsix weeks to six months; 2 required a second operation, butrecovered; 1 suffered secondary amputation; 1 died the dayafter the operation, of diarrhoea; of 7 the result is not given.The case of necrosis recovered.Of the 12 cases of necrosis with sequestra, 3 recovered;

1 required a second operation; 1 suffered secondary amputa-tion ; of 7 the result is not given.

Of the 4 cases for accident, 3 recovered-one in seven weeks;1 died in fifteen days.

CLINICAL REMARKSON THE

TREATMENT OF ANTEFLEXION AND ANTE-VERSION OF THE UTERUS BY A NEW

FORM OF PESSARY.

BY GRAILY HEWITT, M.D., F.R.C.P.,PROFESSOR OF MIDWIFERY AND DISEASES OF WOMEN, UNIVERSITY COLLEGE.

THE discomforts and inconveniences produced by variousdeviations of the uterus are, according to my experience, manyin number. Putting aside for the moment marked cases ofprolapsus, where the nature of the affection cannot well escaperecognition, there are very many instances where bending ofthe uterus unduly forwards, or laterally, or posteriorly, givesrise to troublesome dragging sensations, pain in one groin,difficulty in walking comfortably, and various other symptomsof lesser magnitude, the true cause of which is not unfrequentlyoverlooked. Ovaritis, metritis, neuralgia, &c. &c., are often,under such circumstances, supposed, but erroneously, to bethe cause of the suffering of the patient.

Mobility is a quality which the uterus should possess to a,

limited extent only. Passing those limits, painful sensationsarise from undue mobility in whatever direction, and one re-sult is, that the uterus assumes a permanently faulty positionin the pelvis.We have here, however, to do only with the effects, and

not the causes, of uterine flexions and deviations. The objectat this moment is to insist on the importance of recognisingand treating the slighter as well as the more marked instancesof these " positional" affections of the uterus.The diagnosis of anteflexion or anteversion is considerably

more difficult than that of retroflexion. The recognition ofthe first requires a considerable experience in digital examina.tion ; the fundus uteri is readily felt through the posterior

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