404 ON AMPUTATION 



the dorsum of the foot in a Une sHghtly convex forwards, a httle anterior to the 

 articulations, taking care that the incision commences and ends fairly in the 

 sole. He then opens the joints of the first and fifth metatarsal bones, so as to 

 ensure finding the line of the articulations afterwards, and next shapes a long 

 plantar flap by an incision extending from the extremities of that already made 

 along the sides of the foot and roots of the toes, dissects up the flap from the 

 bones, and completes the disarticulation in the manner above described. 



When the anterior part of the sole is unsound, a shorter plantar flap and 

 a proportionately longer dorsal one may be made, as recommended by Sir Astley 

 Cooper.^ 



Sometimes the proceeding may be greatly simplified by sawing through 

 the metatarsal bones a little anterior to their' bases, and so avoiding disarticu- 

 lation altogether. This method would probably have another advantage, from 

 making the stump of the foot longer and therefore a more effectual lever for 

 opposing the muscles which act upon the calcaneum through the tendo Achillis ; 

 for experience has shown that when the foot is much shortened, the heel is apt 

 to be drawn up, so as to cause the end of the stump to point more and more 

 towards the ground, producing lameness or entire inability to walk. This has 

 been noticed especially after Chopart's amputation through the tarsus, which 

 is consequently an undesirable operation, even in cases of injury : while in caries 

 it is further objectionable, because the part of the tarsus left behind, though 

 apparently sound at the time, may become affected with the same disease at 

 a later period. 



If it be wished, however, Chopart's operation may be performed on the 

 same principle as Hey's, by making a very short dorsal flap, and a plantar one 

 reaching to the balls of the toes, to cover the exposed anterior surfaces of the 

 astragalus and os calcis. The articulation between them and the navicular and 

 cuboid bones will be found in a line running across the foot, through a point 

 midway between the external malleolus and the base of the fifth metatarsal 

 bone. 



In the amputation at the ankle devised by Mr. Syme, the bones of the leg 

 are divided just above the bases of the malleoli, a covering for the osseous surfaces 

 being provided from the integument of the heel ; the result being a stump 

 admirably fitted for bearing the weight of the body. At the same time, the parts 

 likely to originate carious disease are completely got rid of ; so that this operation 

 is calculated to supersede entirely that of Chopart, besides taking the place of 

 amputation of the leg in the majority of the cases formerly supposed to demand it. 



The operation should be performed as follows. Provision being made against 



^ Surgical Lectures, edited by Tyrrell, vol. ii, p. 432. 



