ON AMPUTATION 403 



after taking away tlic bones affected, by means of a similar incision commenced 

 further back. 



The separation of the whole metatarsus from the tarsus is an operation 

 seldom called for ; but it is evident, from the account given by the late Mr. Hev, 

 of Leeds,^ who introduced it, that it affords excellent results. When the state 

 of the soft parts permits, the ends of the exposed tarsal bones should be covered 

 with a long flap from the sole, turned up to unite with the dorsal integument, 

 cut very short ; so that the cicatrix, being on the upper part of the foot, may 

 be out of the way both of pressure in walking and of contact with objects in 

 front of it. In performing the operation, it must be remembered that the 

 tarso-metatarsal articulations are not in a regular line, but that the base of the 

 second metatarsal bone is locked between the first and third cuneiform bones, 

 of which the former is the more prominent, and is connected laterally with the 

 second metatarsal by a very strong interosseous ligament. To divide this 

 ligament, Lisfranc adopted the plan of thrusting an amputating knife obliquely 

 downwards and backwards between the first and second metatarsal bones into 

 the substance of the sole, the tissues of which served as a fulcrum, supporting 

 the point of the instrument, when its edge was urged forcibly between the bases 

 of the bones by pushing the handle backwards. This, however, is a needlessly 

 rough proceeding ; for by pressing firmly back between the bases of the bones 

 a strong and short knife, such as ought to be used for the rest of the operation, 

 the ligament may be cut without difficulty ; after which all the articulations 

 are readily separated by scratching through the dorsal and other ligaments 

 with the point of the knife, while the metatarsus is strongly depressed. 



The secret of facility in the operation lies in hitting the line of the articu- 

 lations ; but this is readily enough done by finding first the joints of the first 

 and fifth metatarsal bones, and bearing in mind that the others lie in a line 

 between them, slightly convex forwards, interrupted by the recession of the 

 second bone. The prominence of the base of the fifth metatarsal indicates the 

 situation of its joint, and, if the parts be in a natural condition, the articulation 

 of the first metatarsal with the first cuneiform can also be felt. Should infiam- 

 matory thickening obscure the position of the latter, it might be well to measure 

 the distance of the corresponding joint from the internal malleolus on the sound 

 foot ; or assistance may be derived from the circumstance that the joint lies 

 midway between the malleolus and the metatarso-phalangeal articulation. 



These points having been precisely ascertained, the surgeon grasps the fore 

 part of the sole with his left hand, placing the tip of the forefinger at one of the 

 joints, and the thumb at the other, to mark their j^osition. and cuts tirmly across 



' Hcy's Observalioits, p. 555. 



