low four strips of a six-tailed retractor to be passed through the spaces. Retract the flaps and the tissues in the interosseus spaces and saw through the metatarsal bones.

Cut off the protruding part of any tendon and stitch the plantar to the dorsal flap, providing for drainage.

2. Disarticulation.-Disarticulation of separate metatarsal bones should be performed by a pyriform incision, as for disarticulation of the proximal phalanx, supplemented by a dorsal incision over the bone up to the level of the tarso-metatarsal joint. Avoid wounding the plantar arch.

In disarticulating the first tarso-metatarsal joint, avoid wounding the communicating branch between the dorsalis pedis and the external plantar artery.

Lisfranc's Operation. -Extend the ankle and grasp the sides of the foot, with the left index-finger and thumb resting over the bases of the fifth (tuber. osity) and first metatarsal bones. The base of the first metatarsal bone is situated one and a half inch below the tubercle of the scaphoid.

Cut a dorsal cellulo-cutaneous flap slightly convex downward, whose base shall extend to the middle of the sides of the foot at the level of the tarso-metatarsal articulations. Reflect this dorsal flap.

Grasp the toes in the left hand and flex the ankle, to render the sole of the foot accessible. Join to the ends of the dorsal incision an incision extending down the sides of the foot and across the sole through the center of the balls of the toes. This incision divides all the soft parts, and in crossing the sole is on a level with the heads of the metatarsal bones. The incision

will be slightly convex downward and reach a lower level internally than externally.

Extend the ankle and bear down on the metatarsal bones. Divide the dorsal tendons at the level of the base of the dorsal flap. Begin the disarticulation by carrying the knife around the tuberosity of the fifth metatarsal bone to its inner side, where its articular surface is situated. Disarticulate in a line downward and inward until the knife is arrested by the second metatarsal bone. Disarticulate from the inner side the first tarso-metatarsal joint.

Pierce with the knife, having its edge directed forward, the tissue between the bases of the first and second metatarsal bones, and, by making the handle of the knife describe an arc toward the ankle, divide the attachments of the second metatarsal bone to the first metatarsal and internal cuneiform bones. The same manœuvre is practiced on the other side of the second metatarsal bone. Divide the dorsal ligament between the middle cuneiform and the base of the second metatarsal bone by making transverse parallel cuts at short intervals until the line of the articulation is found.

All resistance is now overcome and the articular surfaces exposed. Sever the inferior attachments to the bones together with the insertion of the peroneus longus into the base of the first metatarsal bone.

Pass a narrow-bladed knife behind and then be neath the disarticulated bases of the metatarsal bones and cut downward, following closely the bones until the plantar flap is completed.

The lateral arching of the metatarsal bones is destroyed by this disarticulation, hence the knife can

follow the bones while piercing the foot from side to side. Occlude the dorsalis pedis, the internal plantar, and external plantar arteries. Stitch the plantar to the dorsal flap, providing for drainage.

Amputation and Disarticulation through the Tarsus.-1. Amputation. Molière and Hancock recommend sawing through the tarsus without considering the line of the articulations.

Form a plantar flap of large size and an inversely large dorsal flap, following Lisfranc's operation as a model. Make the section of the bones as if operating upon a single bone.

2. Chopart's Operation (Disarticulation at the Medio-tarsal Joint). Grasp the sides of the extended foot just posterior to the tubercle of the scaphoid and over a point one inch posterior to the tuberosity of the fifth metatarsal bone between the left thumb and index-finger. Make a short dorsal cellulo-cutaneous flap with its base extending to the middle of the lateral surfaces of the foot at the points over which the left thumb and index-finger are applied. The flap should be slightly convex downward.

Flex the ankle, grasping the toes to present the sole of the foot to the operator. Join the ends of the dorsal incision by an incision extending down the sides of the foot and across the sole just posterior to the balls of the toes. This incision should divide all the tissues down to the bones, and should extend across the sole about one-half inch from the heads of the metatarsal bones.

Reflect the dorsal flap. Forcibly extend the foot and divide the dorsal tendons over the line of the articulations. Disarticulate the bones in a line ex

tending across the tarsus from half an inch below the peroneal tubercle to a point just above the tubercle of the scaphoid.

Pass a narrow-bladed knife between the disarticulated surfaces and turn its edge toward the toes. Cut the plantar flap, keeping close to the bones.

The plantar flap is often fashioned more symmetrically by including only a portion of the tissues internally, making the internal and external edges of equal thickness.

Occlude the dorsalis pedis, internal plantar, and the external plantar arteries.

Disarticulation at the Ankle-Joint (Syme's Operation).-Grasp the foot with the left hand and flex the ankle until the foot is at a right angle with the leg.

Begin an incision at the tip of the external malleolus and extend it downward and across the sole of the foot to a corresponding point on the inner side of the limb. The incision will terminate at a point a little below the posterior border of the inner malleolus, and should divide all the tissues to the bone.

Connect the ends of this incision by an incision across the instep in a line which bisects the angle made by the foot and leg. This incision should only divide the skin and subcutaneous fascia.

Raise the heel-flap, keeping the edge of the knife always directed toward the os calcis and using the left thumb in the wound to push back the flap. Avoid wounding the posterior tibial artery. Separate the attachment of the tendo Achillis and reflect the flap over the tuberosity of the os calcis.

Forcibly extend the ankle, and having raised the

skin and cellular tissue, cut the tendons anteriorly in the line of the joint. The bones may now be cleared at a level just above the ankle-joint and the two malleoli with a thin slice of the tibia sawn off at a right angle to the axis of the leg.

The joint may be disarticulated by dividing the ligaments anteriorly and around the malleoli, and only the malleoli sawn off obliquely upward. If the joint is to be disarticulated, it may be done before the heel-flap is raised, and then the flap separated from above downward.

Occlude the anterior tibial, external plantar, and internal plantar arteries. Cut off any protruding tendon. Make a longitudinal slit one half inch long through the posterior thin part of the flap, just external to the tendo Achillis. Cover the ends of the bone with the heel-flap, providing for drainage on each side and posteriorly.

Pirogoff's Operation.-Flex the ankle so that the foot is brought to a right angle with the leg.

Make an incision from the tip of one malleolus across the sole of the foot to the tip of the other malleolus dividing the tissues to the bone. Join the ends of this incision by an incision across the instep, at an angle of 45° to the axis of the leg, dividing the integument and cellular tissue.

Reflect the short dorsal flap, and forcibly extend the ankle. Divide the dorsal tendons and disarticulate the joint.

Separate from above downward the tissues from the os calcis, until the sustentaculum tali is uncovered. Saw the os calcis obliquely, from just behind the astragalus to the edge of the incision through the soft