carried across the sole of the foot, the point of both incisions meeting in front and a little below the malleoli. The soft parts are further divided and detached in such a manner as to allow of the removal of the foot; lastly, the saw is applied to separate the malleoli, and, if necessary, a thin plate of the articular service of the tibia. The tibial and other arteries are secured, and the flap is brought up from the sole of the foot against the ends of the bones, and the wound treated in the usual manner.

This operation is much more difficult than amputation in the leg; but it has such great advantages that, whenever it is practicable, it should be performed. To disarticulate and to separate the skin from the projecting part of the os calcis is a very tedious and protracted dissection, and very frequently the integuments covering the heel are cut; but this is not of much moment, as an opening is rather an advantage than otherwise, as it allows the free escape of pus, should any form. Occasionally sloughing takes place in the posterior flap; but this does not in general cause much annoyance. Care should be taken to preserve the posterior tibial artery, so that it may not be cut across at the upper angle of the flap, and also at its final division in the sole of the foot, so that there may be a sufficient supply of blood for the flap below.

This operation is suitable for gunshot wounds of the tarsus and compound luxation of the ankle-joint, as well as for disease of the joint; and even when the ankle-joint is the principal seat of disease, this operation can be performed, as it is seldom that there is more than a thin layer of the articular surface of the tibia affected. This operation has many advantages; it gives length of limb and stump, and a most perfect covering to the ends of bones, and likewise a good artificial foot can be applied, which will look more scemly than a wooden leg.

It sometimes happens after this amputation, as after others in the long bones, that disease may arise in the osseous surfaces where the saw has been applied; in such a case the cicatrix may be opened up and a part of the bones sawn off.

Pirogoff has recommended that the same semilunar incision should be made in front of the joint and disarticulation affected, and an incision made across the sole of the foot, connecting the

extremities of the anterior flap; afterwards the saw should be applied so as to take away a thin slice of the tibia and fibula, and likewise about half the os calcis, as the case may require, leaving the heel or end of the bone attached to the soft parts. The chief advantage of this method is that the surgeon avoids the tedious and rather difficult dissection round the head of the calcaneum.

One case of amputation at the ankle-joint was performed, eight hours after the accident, in the 75th Regiment; and a very good stump resulted.

With regard to the respective merits of the two methods of amputation at the ankle-joint, viz., that recommended by Mr. Syme, and that by Pirogoff, the profession has not yet come to a decision. Still, there appears to be some advantage in the latter, as being easier of execution, giving a longer stump and firmer support. In Pirogoff's operation, when the ends of the tibia and fibula are sawn straight across, there is always great difficulty, or rather almost an impossibility, in bringing the calcaneum into apposition with the end of the tibia; so that it has been found necessary to remove several slices of the calcaneum with a strong bistoury before the bones could be brought to fit properly. To remedy this difficulty, the following modification was adopted in a case operated upon by me, on the 24th December, 1858, at Fort Pitt. The articular extremities of the tibia and fibula were sawn off obliquely, the thick part of the wedge-shaped pieces being posterior. The os calcis fitted admirably. The wound healed rapidly, and a very good, solid stump resulted. The sawing of the ends of the bones obliquely is an improvement, and is well worthy of being generally adopted, as allowing of easy adaptation of the calcaneum to the ends of the leg bones.

PARTIAL AMPUTATIONS OF THE FOOT.

Chopart's operation consists in the division being made between the astragalus and calcaneum on one side, and the cuboid and scaphoid on the other. The surgeon places the palm of his hand on the front of the dorsum of the foot

and feels for the projection of the scaphoid, which is the only prominent part which can be referred to as a guide; but these joints are so easily opened that there can be no difficulty in accomplishing the operation. A semilunar incision should be made across the dorsum of the foot, the ligaments kept upon the stretch by forcible depression by the left hand, and the joints entered and disarticulated, and a large flap formed from the lower surface of the foot, the incision being extended as far as the ball of the toes. In many cases it is advisable to saw off the exposed articular surfaces of both the astragalus and os calcis, otherwise exfoliation of the extremities of these bones is apt to take place, and there is also a danger of the flap not being sufficiently large to cover the bones.

Hey's Operation.-The surgeon should grasp the foot firmly with his left hand and find out the projection of the metatarsal bone of the little toe, and also of the internal cuneiform; he should then make a semilunar incision from the one point to the other across the dorsum of the foot; the toes should be well pressed down, so as to put the ligaments on the stretch, and then run the knife back again along the dorsum and the articulations entered, and, finally, a long flap formed from the sole of the foot. In disarticulating, it is usual to insert the knife perpendicularly, so as to divide a very strong ligament situated between the internal cuneiform bone and second metatarsal. The internal cuneiform bone projects to such an extent that it is advisable to cut it off with the forceps or saw.

This and Chopart's operations are much to be preferred to the more extensive mutilations at or above the ankle. Occasionally the heel is drawn backwards and upwards, particularly in the case of Chopart's operation, and the weight of the body is thrown on the cicatrix and on the anterior ends of the bones; but if the stump is kept in a good position during the dressing, there is not much cause for anxiety.

In performing these operations, the foot can also be transfixed by a catalin and the flap made first, and then the semilunar incision is made in front and the joints opened; but methods previously described are much more preferable. The great object in all these partial amputations is to save as much of the foot as possible, whether it is through the articulations

or by sawing through any of the bones, so that plenty of flap or covering can be preserved.

Three cases of amputation through the medio-tarsus arrived from India. In one the operation was performed three hours and a half after the injury, caused by a musket ball through the arch of the foot. In the other the operation was performed twelve days after the accident. In both cases the stumps were good. In a third case of Chopart's operation on the foot, the heel was very much carried backwards, so as to bring the line of incision nearly on to the ground when the man attempted to put the stump to the ground to use it in progression. The tendo Achillis was divided, and the heel brought forcibly downwards, so that the weight can be taken upon the extremity of the os calcis, and a boot with an apparatus, so adapted as to prevent a return to the faulty position, has been applied. The astragalus appears to have been removed in this case; but it was sent home from India as a Chopart's operation.

AMPUTATION OF THE TOES.

The remarks made under the head of amputation of the fingers are applicable to the toes, and the same oval method should be adopted; and any surgeon can so form his incisions for any particular case, only always bearing in mind that it is necessary and incumbent upon him to preserve as much of the foot as possible, having at the same time a due regard to the removal of the whole, injured, or diseased parts.

CHAPTER XIX.

EXCISIONS.

SUPERIOR EXTREMITY.

THREE cases of resection of joints have arrived from India, viz., one of the shoulder, and two of the elbow-joint.

Out of a total number of 36 primary resections that occurred in the Crimean war-of which 28 were performed on the superior, and 8 on the lower extremity of the former 6 died and of the latter 4 died, viz., 4 cases of excision of the head of the femur.

Excisions are seldom required in either clavicle or scapula; portions of caries or necrosed bones can be removed by gauge or forceps.

SHOULDER-JOINT.*

When the soft parts are not extensively lacerated by gunshot, this operation can be practised with the best results. When the head of the bone is shattered, the operation can be performed in the following manner :-The patient being seated, or laid on a table with his shoulders raised, a semilunar incision is made with a strong bistoury, commencing opposite the coracoid process, and ending about an inch behind and below the root of the acromion, and thus forming a flap of nearly the whole of the deltoid. It is dissected upwards, and then a firm incision is made through the tendons attached to the tuberosity on the humerus and capsule,

* I beg to refer to "Gunshot wounds with direct penetration and perforation of the larger joints," for further information on this subject.