No. 2284.

JUNE 8, 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.

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LECTURE part I.

MR. PRESIDENT AND GENTLEMEN, - Interesting and im-portant as were the matters treated of in my last course oflectures, they formed but a comparatively small section of

the surgery of the part to which they appertained-indeed, somany subjects of great value still remain to be studied that,even at the risk of appearing tedious, I am induced to devotethe greater portion of this my present course to their considera-tion ; and in this way, as far as my abilities permit, to laybefore the profession a complete epitome of the surgery of thisregion of the body.In accordance with this object I propose to - day to

treat of an operation which, whether considered in rela-tion to the importance of the region in which it is per-formed or the amount of benefit it is destined to afford, hasnot met with that support to which it is fairly entitled.Whilst in England the shoulder, elbow, hip, knee, and otherjoints are freely excised, and, when offering a prospect of suc-cess, a surgeon would almost be considered as deserving ofcensure who would neglect these operations for amputation,excision of the ankle-joint has for the most part been regardedwith disfavour.We may partly attribute this to the confused ideas enter-

tained as to the exact nature of the operation by authors, whowrite upon that which they have never done, and which theydo not understand; and who, consequently, mislead theirreaders by inexactness of detail, and by the heterogeneousmass of discordant cases which they have collected and de-scribed under the head of "Excision of the Ankle-joint,"and which in reality have as little to do with this operation asthey have with Syme’s or Pirogoff’s amputation.A recent American author, for instance, professing to write

upon excision of joints, includes the following operations inhis table and description of excision of the ankle-viz., ex-cision of the astragalus and os calcis; removal of the end ofthe tibia; removal of the ends of the tibia and fibula with theastragalus and navicular; simple excision of the astragalus; ofthe ends of the tibia and fibula, the whole of the astragalus,part of the os calcis, and the three cuneiform bones; of theend of the tibia, the astragalus, scaphoid, and two cuneiformbones; excision of the astragalus and scaphoid; excision of theos calcis, astragalus, and cuboid.Nor are these vague ideas entertained by this author only.

Others who have written text-books for the guidance of stu-dents have published equally vague notions, thus perpetuatingand adding to the obscurity they profess to dispel. AlthoughHippocrates is stated to have removed the lower ends of thetibia and fibula for compound dislocation, whilst Mr. Hey ofLeeds performed the first authenticated operation of the kindas early as the year 1766, it was not until the year 1792 thatthe elder Moreau performed excision of the ankle-joint for dis-ease, being the first occasion upon which this operation hadbeen performed excepting for accident.The case was that of the son of M. Lucot, inspector of

gendarmerie, who met with a sprain, in the year 1791, whichended in extensive caries of the left ankle. After the lapse ofa year there was a fistulous ulcer on each side of the joint, dis-charging sanious and fetid pus ; and the probe being introducedthrough the openings, the articulating surfaces of the tibia andfibula, as well as the body of the astragalus, were felt to bebare. The foot and the lower part of the leg were swollen,and the inatient could not bear his weight on the limb. On the

15th of April, 1792, Moreau excised the ankle-joint, removingthe lower ends of the tibia and fibula, and the whole of thearticulating surface of the astragalus, and a great portion ofits body, till he came down to what was sound. In six monthsthe patient was able to bear his weight upon the foot. Duringthe seventh month he used crutches ; in the eighth he couldwalk with a stick; and by the end of the ninth he walkedwithout any assistance whatever, and in such a way that hecould do as he pleased.Such are the particulars of this celebrated case ; and it is

interesting to read the description given by Moreau’s son ofthe disfavour shown by the French surgeons, not only to thisoperation, but to resection of joints in general. In theyear 1784 Mr. Parks’s observations on cutting out the ar-

ticulating ends of the bones of the elbow and knee-jointswere translated and published in France by Professor Lassas,whose authority, observes Moreau, " one would have thoughtmight have procured for them a favourable reception. Theywere received with astonishment ; and so far were they fromgaining credit, that in 1789 they had acquired so few sup-porters in the Academy of Surgery that some cases of a similarkind, presented to the Academy by the elder Moreau, wererejected, though they were of such a nature, and stated in away that deserved a more favourable reception." Nothingdaunted, Moreau again addressed the Academy of Surgery,supporting his memoir by many facts. His essay, however,met with a most violent opposition. The Academy, as is toooften the case, found it more convenient to deny than to ex-amine these facts; and, instead of taking the trouble to ascer-tain their reality, they answered in a way that forbad all futureinquiry upon matters demanding the greatest attention. It isdue to M. Pellaten to state that of all the then members ofthe Academy he alone appears to have considered the subjectworthy of attention.The second operation on record was performed by Moreau,

junr., in 1796. He preserved the lower end of the fibula, andconsequently had great trouble in getting away the disease,being obliged to use the gouge freely. The recovery was notso satisfactory as could have been desired.The third operation was by Mulder, in 1810. He at the

same time removed five inches of the fibula.In 1813 Champion is reported to have operated upon a

woman, who afterwards frequently walked three leagues to beexamined by Roux and others.

In England there was no example on record of excision ofthe ankle-joint for disease prior to February, 1851, when Iperformed the operation for the first time. Attempts havebeen made to deprive me of the merit of its introduction toBritish surgery, but I doubt not my ability to prove that ifthe term " excision of the ankle-joint" means the excision ofthose parts only which enter into the formation of the joint,the credit is my own ; but that if it means the removal of anyamount of the foot, whether comprehended in the joint or not,that credit is more justly due to Liston, Wakley, Teale, andothers.The author of the work already alluded to says : "It does

not appear, however, that after the above cases (those by theMoreaus) this operation was again attempted for disease until1818, when it was undertaken by Mr. Liston, in Edinburgh.In April. 1830, it was performed in France by M. L. Champion;and in June of the same year, by M. Roux. In Docember,1847, Mr. Thomas Wakley excised the os calcis and astragalus;and in Marc!i, 1850, the end of the fibula, with part of theastragalus. It appears, therefore, that the honour of first per-forming this operation in Great Britain belongs to Mr. Liston,and of reintroducing to Mr. Wakley rather than to Mr. Hancock,for whose excision of Feb. 17th. 1851, it has been claimed."

Moreau, as we have seen, performed his operation on the15th of April, 1792 His proceedings were as follows :-Hemade a longitudinal incision, beginning at the inferior and pos-terior part of the malleolus externus, continuing it upwardsfrom three to four inches. He then made another incision,transverse, which extended from the inferior end of the formerincision to the edge of the tendon of the peroneus brevis. Hemade another longitudinal incision on the inside, which beganat the inferior and posterior part of the malleolus internus, and

extended from three to four inches along the internal borderof the tibia. Then, by a third incision, which began at thelower end of the tibia, he cut the skin transversely till hecame to the tendon of the tibialis anticus. He disengaged thefibula from the tendons, 1igamel,t, and in general from every-thing by which, at its inferior extremity, it is held in its situ-ation ; he passed the handle of a scalpel under it, and witha chissel he cut it across above the ankle. Wishing to cut the

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tibia above the malleolus before he turned it out of the joint,he separated everything that adhered to it; and then, passingthe handle of his scalpel between the posterior surface of thebone and the flesh, he introduced between the spine of thebone and the flesh before the bone the blade of a narrow saw,and cut the bone, sawing from before backward, which was awork of no small trouble. That being done, he turned thefoot outward, and, making the piece of bone which he had cutoff project, he detached it from the tarsus without difficulty.The astragalus being diseased, he removed the whole of itsarticulating surface, and a great part of its body, till he camedown to what was sound. Now, contrast this with Mr.Liston’s case, as described in the Edinburgh llfedical and Sur-gical Journal of Jaruary, 1821. He removed the astragalus,scaphoid, and two cuneiform.

Again, contrast Moreau’s operation with Mr. Wakley’soriginal and celebrated proceeding as detailed in THELANCET of April 12th, 1851, the first of those referred to,and performed on the 27th of December, 1847. I quote Mr.Wakley’s own words :-" The diseased foot (the left) havingbeen drawn forwards so as to be free of the table. I made anincision from malleolus to malleolus directly across the heel.A second incision was next carried along the edge of the sole,from the middle of the foot to a point opposite the astragalo-scaphoid articulation; and another, on the opposite side of thefoot, from the vertical incision to the situation of the calcaneo-cuboidal joint. These latter incisions enabled me to make a

flap about two inches in length from the integument of thesole. In the next place, a circular flap of integument wasformed between the two malleoli posteriorly, the lowerborder of the flap reaching to the insertion of the tendoAchillis. This flap being turned upwards, the tendon was cutthrough, and the os calcis, having been disarticulated fromthe astragalus and the cuboid bones, was removed, togetherwith the integument of the heel included between the two in-cisions. The lateral ligaments connecting the astragalus withthe tibia and fibula were now divided, and the knife wascarried into the joint on each side, extreme care being observedto avoid wounding the anterior tibial artery, which was inview. The astragalus was then detached from the soft partsin front of the joint and from its articulation with the scaphoidbone, and the malleoli were removed with the bone-nippers.The only artery requiring ligature was the posterior tibial."

"

Take, again, Mr. Wakley’s second case, thus reported inTHE LANCET of May, 1850 :-" Mr. Wakley made a crucial;11";";011 tÌir""t:1v nvar thf mitr Tnnllpnlliq and haviDCf (’,>1"’p.-

fully dissected back the small triangular naps, the whole ofthe diseased malleolar process of the fibula was now exposed,as well as the portion of the astragalus. Both these partswere evidently in a carious, partly in a necrosed state, andwere excised principally by means of a gouge."Although undertaken with the same object as that which

actuated the elder Moreau-namely, to excise the ankle-jointsolely, the operation which I performed, whilst attaining thesame result, differed somewhat in certain details, which willbe apparent as we proceed. Instead of making two incisionsat right angles on either side of the joint, I commenced theoperation with an incision behind, and about two inches abovethe external malleolus, carrying it forwards beneath that pro-cess across the front of the joint, and terminating about twoinches above and behind the inner malleolus. This incisionincluded the skin alone, without implicating the tendons ortheir sheaths. The flap thus formed was dissected up, and theperonei tendons were detached from the groove behind thetibula and cut through. as were the external lateral ligamentsclose to the fibula, with a pair of bone-nippers. I next dividedthe fibula about an inch and a half above its inferior extremity,and cutting through the inferior tibio-fibular ligaments de-tached the external malleolus. Now, turning the leg on to itsouter side I cut through the internal lateral ligament, carefullykeeping my knife close to the end of the tibia to avoid theposterior tibial artery. The tendons of the tibialis posticusand flexor communis were then detached from the groovebehind the internal malleolus1 and taking the foot in my twohands, the late Mr. Avery, who assisted me, holding the leg,I next dislocated the foot outwards, thus bringing the end ofthe tibia with the internal malleolus prominently through thewound. These were removed by the common amputating sawapplied half an inch above the horizontal articulating surfaceof the tibia, the soft parts being protected by a spatula, andthe upper articulating surface of the astragalus having alsobeen removed by a metacarpal saw, held horizontally. The footwas then restored to its proper position, the cut surface of theastragalus being adapted to the cut surface of the tibia, and

the wound having been closed by sutures, except on the out-side, which was left open for the free escape of discharge, theleg was placed on its outside on a splint, having an openingcorresponding to the wound, and the patient was returned tohis bed.You will doubtless have observed that the parts here cut

through were the skin, the peronei tendons, the internal andexternal lateral and the inferior tibio-fibular ligaments, andthe lower ends of the tibia and fibula. In subsequent opera-tions I preserved the tendons entire. In no instance have theanterior or posterior tibial arteries been wounded, and in noinstance has it been necessary to apply a single ligature.Let me now demonstrate by the diagrams before you the

amount of skeleton removed, and I doubt not it will then beadmitted that, however honourable to their authors the ope-rations performed by Liston, Teale, and Wakley, assuredlythey were not excisions of the ankle-joint, and that conse-quently they in no way invalidate my claim of having beenthe first to introduce this operation into the arena of Britishsurgery.Although this operation has been performed by the late

Mr. Jones of Jersey, Mr. Canniffe of Canada, the late Dr.M. S. Buchanan of Glasgow, Mr. Barwell, Mr. Canton, Sir W.Fergusson, Mr. Hessey, Mr. Holmes, and Mr. Paget, it is notregarded with that general favour to which its merits entitle it.

DOES BELLADONNA PRODUCE A ROSE-RED RASH?

BY HENRY WM. FULLER, M.D. CANTAB., F.R.C.P.,PHYSICIAN TO ST. GEORGE’S HOSPITAL.

THE question which forms the heading of this article is sug-gested by a paper " On Skin Diseases," published in THELANCET of April 13th, p. 455. After enumerating variousmedicines which give rise, or are supposed to give rise, tocutaneous eruptions, Dr. Tilbury Fox enunciates as a fact that"belladonna produces a rash of rosy hue." Practically, itmatters little whether this statement is or is not correct, as ithas never been suggested that a "belladonna rash" is likely tobe mistaken for the rash of any eruptive disorder. But itwould be interesting, physiologically, to determine whetherbelladonna does exercise a distinct influence on the skin ; andthe statement that it does so acquires a fictitious importancefrom the fact that this alleged influence has been made theground of the treatment of scarlatina by Hahnemann and hisfollowers, and has even led some physicians of eminence to re-commend the administration of belladonna as an antidote to,or preservative against, the scarlatinal poison.

It is difficult to bring an inquiry like the present to a satis-factory conclusion unless the facts on which an opinion issought are clearly defined. It may be well, therefore, to pre-mise that I cannot admit the occasional occurrence of erythemaduring the administration of belladonna as proof that bella-donna produces a cutaneous eruption. The appearance of ery-thema or an evanescent rose-red rash is not an uncommonoccurrence in persons who are not taking belladonna; and insome persons such a rash is apt to arise whenever the stomachis deranged or the blood "heated." " Under such circum-stances it might happen to any practitioner, as it has hap-pened once to myself, to witness the outbreak of a rash of thiskind during the administration of belladonna; but somethingmore than such a coincidence is necessary to establish the rela-tionship of cause and effect. It should be shown that in a fairproportion of cases the alleged effect is found to follow theoperation of the cause-that just as iodism follows the ad-ministration of iodide of potassium, under whatever circum-stances it is exhibited, so the rosy rash attributed to bella-donna should be shown to follow the administration of that

drug. But experience is distinctly opposed to any suchsequence of cause and effect in respect to belladonna.

In a series of experiments which I instituted some yearssince at St. George’s Hospital, the details of which will befound in a paper on the Action of Belladonna,, published invol. xlii. of the " Medico-Chirurgical Transactions, " the extractof belladonna was given for a period of some months, in dosesvarying from a quarter of a grain up to seventy grains daily;the patients were examined four or five times daily, andthe occurrence of any rash or eruption was carefully looked