parts across the sole of the foot. Clear the bones to a level just above the joint, and saw off the malleoli and a thin slice of the tibia.

Occlude the anterior tibial, external plantar, and the internal plantar arteries. Cut off any protruding tendon. Wire the retained portion of the os calcis to the end of the tibia. Provide for drainage, and close the wound as in the case of Syme's operation.

The os calcis may be sawn through from below upward and backward, the dorsal flap raised, and the malleoli sawn off without disarticulating the ankle.

It is of advantage to make the incision across the sole more anteriorly, when a greater portion of the os calcis is preserved in its oblique section.

If the dorsal and plantar incisions are made broadly convex downward to the level of the mediotarsal joint, the os calcis may be sawn through horizontally just below the sustentaculum tali, as recommended by Le Fort. When the section of the os calcis is complete, the joint between the cuboid and os calcis is disarticulated. The stump has a broad base already accustomed to pressure.

Amputations through the Leg.-The circular method of amputating may be practiced, the rules for which have already been considered.

Teale's Operation.-Compress the vessels above the site of the operation. Stand on the right side of the limb. Measure the circumference of the limb at the proposed site of the amputation.

Make an anterior square flap, whose sides are equal to one half this circumference. (The flap will, of course, include more than half of the circumfer

ence of the limb below.) Reflect the flap, which should include all the tissues anterior to the bones and to the interosseous membrane. Avoid nicking the anterior tibial artery, while separating the tissues from the interosseous membrane.

A periosteal flap may be formed for the tibia and raised with the anterior flap.

Connect the sides of the anterior flap at a quarter of its length from its base, by a transverse incision through all the tissues posterior to the bones. Reflect this posterior, rectangular flap, the base of which is one half and the length one eighth the circumference of the limb.

Form an interosseous flap, and retract the tissues by means of a three-tailed retractor. Clear the bones at the junction of the flaps, and begin the section of the tibia at a right angle to its long axis. Complete the section of the fibula while sawing through the tibia. Some prefer the section of the fibula at a little higher level.

Occlude the anterior tibial, the posterior tibial, and the peroneal arteries. Cut off any protruding tendon and pull out and divide the anterior tibial nerve as high up as possible. The angle formed by the crest of the tibia may be rounded off by means of bone-nippers. Double the anterior flap upon itself over the ends of the bones, and stitch together the contiguous edges of the flaps, providing for drainage.

In amputations near the knee, preserve the tubercle of the tibia, and avoid opening into the superior tibio-fibular articulation, which may communicate with the knee-joint.

Disarticulation at the Knee-Joint (Circular Meth

od).-Extend the knee, and compress the vessels above the site of the operation.

Form a circular, cellulo-cutaneous flap, the length of one quarter the circumference of the limb over the joint. The incision will be made about one inch below the level of the tubercle of the tibia. Slit the flap posteriorly, and roll it upward like a cuff.

Flex the knee, and divide the ligamentum patellæ close to the patella, and the capsule of the joint against the condyles of the femur. Sever the lateral ligaments completely, by cutting to the posterior surface of the condyles, and divide the crucial ligaments as they appear in the interior of the joint.

Divide from behind forward, the tissues posteriorly, against the upper extremity of the tibia, about half an inch below the level of the joint. Pass the knife through the joint to divide the posterior ligament, and direct its edge downward along the posterior surface of the head of the tibia, to complete the operation.

Occlude the popliteal artery and vein. Push a director into the synovial pouch above the patella, to its upper and inner limit, and cut down upon the end of the director to make an opening to admit a large drainage-tube.

Bring the edges of the flap together antero-posteriorly; round off the lower angles formed by slitting, and the upper by doubling the flap, and enter the sutures after providing for drainage, above and below.

Bauden's Operation.-Extend the knee and control the vessels above.

Make an oval incision around the limb from one

inch below the tubercle of the tibia anteriorly, to one half inch above the level of the head of the tibia posteriorly. The incision should extend almost transversely across the limb below, so as to form a broad end to the flap.

Reflect the flap up to the ligamentum patellæ. Semiflex the knee, and divide the ligamentum patellæ, the capsule, and the lateral ligaments, to open widely the joint. Sever the crucial ligaments. Pass the knife between the ends of the bones and divide the tissues posteriorly, cutting downward and then backward.

Occlude the popliteal artery and vein. Provide for drainage from the joint-cavity above, and internal to the patella, as in the last operation. Cover the end of the femur with the flap, and stitch the edges of the wound together, providing for drainage.

Amputations through the Thigh (Carden's Operation).-Control the vessels above, and extend the knee-joint; stand on the right-hand side of the limb. Grasp the femur over the condyles between the left index-finger and thumb,

Begin an incision through the skin and cellular tissue at the posterior and lower border of the con dyle, over which the index-finger rests, and extend it downward, in a broad, convex curve, below the patella, and then upward to a corresponding point over the other condyle, over which the thumb has been placed. The end of the flap should extend to the tubercle of the tibia, and should be very broad. Reflect the flap up to the ligamentum patellæ. Flex the knee-joint, and divide the ligamentum patellæ, the capsule of the joint, and the lateral ligaments

The joint can now be examined, as was the case after the first incision of Spence's operation at the shoulder.

Sever the crucial ligaments. Pass the knife through the joint, then extend the joint, and divide the tissues posteriorly, cutting directly backward, thus forming no posterior flap. (The operation is often modified by forming a short posterior flap.)

Grasp the end of the femur by means of lionforceps and saw the bone through the condyles. The bone may be sawn through without disarticulating the posterior tissues, being cut from behind forward. The patella may be dissected out of its capsule.

Occlude the popliteal artery and vein by separate ligatures. Close the wound, providing for drainage.

Gritti's Operation.—A rectangular flap, instead of a convex flap, is fashioned from the front of the limb as in Carden's operation. The femur is divided just above the condyles, and the cartilaginous surface of the patella is sawn off.

The sawn surface of the patella is applied to that of the femur, as in Pirogoff's osteo-plastic operation at the ankle.

Circular Method. -This method of amputation should be practiced, following the rules already discussed. The muscles should be divided fully an inch below the base of the flap, on account of their great contraction.

Lister's Operation.-Control the vessels of the thigh, above the site of the operation. Extend the limb. Measure the circumference of the thigh at the site of the proposed amputation.