It now remains to mention the special treatment appropriate to each variety of talipes.

In talipes equinus, tenotomy of the tendo-Achillis is usually all that is required; but if there is much contraction of the sole, the plantar fascia, or any tense band that can be felt, should first be divided, and when the sole has been straightened out, the tendoAchillis then cut, and the heel brought down either by a Scarpa's shoe or by plaster-of-Paris as before described. A boot with double leg-irons and toe-raising spring must be subsequently worn in paralytic cases, the irons being carried above the knee and the outer iron above the hip to a pelvic band where the flexors or extensors of the leg are also affected (Fig. 235).

In talipes varus, except in slight cases, the tibialis anticus and posticus should first be divided, and the inversion of the foot overcome by some form of varus splint, or plaster-of-Paris. When this has been thoroughly done, the tendo-Achillis should be cut, and the heel brought down as in equinus. Where there is much contraction of the sole, the plantar fascia, or other tense band, should be divided after the tibials but before the tendoAchillis. A similar instrument to that described for equinus should then be worn for six months to a year or more; or as long as any tendency is shown to relapse. In paralytic cases, where the whole leg tends to twist inward from the hip-joint, the outer iron should be carried to the pelvis. In very severe cases the

ligaments on the inner side of the sole and the posterior ligament of the ankle may be divided subcutaneously, as suggested by Mr. R. W. Parker; or, if this is not enough, a wedge-shaped piece of the transverse tarsal joint, or the astragalus, may be removed.

In talipes calcaneus, the extensor tendons, in the congenital form, must be divided if the foot cannot be rectified by plasterof-Paris alone. In the acquired form, a boot and irons, similar to that used in equinus, but with a toe-depressing spring, may be worn. In paralytic cases the tendo-Achillis may in some instances be shortened by removing half an inch or more and splicing the divided ends.

In talipes valgus or flat foot, such exercises as alternately raising the body on tiptoe, or walking on the outer edge of the foot, will, in slight cases of the acquired variety when combined with the use of a valgus pad, and a properly-shaped boot, generally be successful. In severer cases a boot with outside leg iron and rubber band to brace up the sunken arch (Fig. 236), should be worn; while, where there is much rigidity, the foot should be wrenched into position with the patient under an anesthetic and placed in plaster-of-Paris for a month. The wrenching may be repeated, if necessary, and the boot above described subsequently worn. In very severe cases excision of Chopart's joint, and removal of a wedge-shaped piece of the neck of the astragalus, have been performed, and are said to be attended with success. I have never had occasion to do either operation, having always found wrenching sufficient. By some surgeons, division of the peronei tendons is recommended, a procedure which is quite unnecessary, and contrary to the principles which should guide us in the treatment of the deformity.

APPENDIX.

AMPUTATIONS.

AMPUTATIONS.-The objects that should be kept in view in performing an amputation are: 1, to remove the whole of the injured or diseased part that is beyond the reach of recovery, with as little sacrifice of the healthy tissues as possible; 2, to prevent all unnecessary hemorrhage; 3, to secure a sufficient covering for the end of the bone; 4, to avoid adhesion of the cicatrix to the bone; 5, to divide the large blood vessels and nerves transversely, and leave their cut ends in such a part of the stump that they may be little exposed to pressure; and 6, to ensure an efficient drain and aseptic condition of the wound.

Amputations may be performed by the circular or by the flap method.

In the circular method the integuments are first divided by a circular incision round the entire circumference of the limb. They are then retracted, and the muscles divided higher up the limb by a similar circular sweep of the knife. The muscles are next in their turn retracted, and the periosteum is divided still higher up the bone, which is finally sawn through at that spot. This method possesses the advantages that the vessels and nerves are divided transversely, and that the wound is of moderate dimensions; but the cicatrix is opposite the end of the bone, the coverings for the latter are apt to be deficient, and the stump is liable to assume a conical shape. The circular method is now seldom employed, except, perhaps, for amputation of the arm.

In the flap method, double flaps, or a single anterior or posterior flap, are provided for the covering of the bone. The flap or flaps may consist of integuments alone, or of more or less of the muscular and other soft tissues as well. In the former case the flaps are cut and reflected, and the muscles and other soft parts are then divided at the level of the base of the flaps in a circular manner down to the bone, which is sawn through a little higher up. By this method most of the advantages of the circular amputation are secured without its disadvantages. When, on the other hand, the muscles are included in the flaps, the vessels and nerves are liable to be split, or notched, or divided

obliquely instead of transversely, while the mass of muscle in the flap tends to prolong the healing of the wound. These muscular flaps may be cut either from without inward, i. e., from the circumference toward the bone, or from within outward, i. e., by the method of transfixion. In whichever way the flaps are cut, and whether they consist of integuments only, or of integuments and muscle, they may, as regards position, be antero-posterior or lateral, or one may be antero-external, and the other posterointernal, or vice versa. As regards length they may be equal, or one may be long, the other short; and as regards breadth they should be half the circumference of the limb. As a rule they should be cut square, but with rounded angles. The following modifications of the flap operation may be briefly mentioned.

Teale's method consists in making a long and a short rectangular flap. The long flap, which is generally anterior, or antero-external, is quadrilateral in shape, and its length and breadth each equal to half the circumference of the limb; it includes all the soft parts down to the bone. The short flap is posterior, or postero-internal; its length is one-fourth the anterior, and its breadth equal to half the circumference of the limb; it also includes all the soft parts down to the bone, and contains the large vessels and nerves. The advantages claimed for Teale's method are: 1, freedom from tension; 2, a complete covering for the bone free of large vessels and nerves; and 3, a dependent position of the wound. It is applicable to amputations through the leg and lower third of the thigh.

Carden's method, designed for amputating through the condyles of the femur, consists in reflecting a semi-oval flap of integuments half the circumference of the limb in length and breadth from the front of the knee joint, dividing everything else down to the bone by a circular sweep of the knife, and sawing the bone slightly above the plane of the divided muscles.

SPECIAL AMPUTATIONS.-Amputation at the Shoulder Joint.-A large flap, consisting of integuments and deltoid muscle, is usually taken from the outer aspect of the joint, either by transfixion or by cutting from without inward. The flap is turned back, the head of the bone freed from its connections, and the knife passed behind it and made to cut its way out toward the axilla, the axillary artery being seized as it is divided.

Amputation of the arm and forearm is usually performed by double skin flaps and circular division of the muscles. The circular method, however, or amputation by single or double transfixion, or by Teale's method may be employed.

Amputation at the wrist may be performed by two short flaps, by a long palmar flap, or by an external flap taken from the

thumb. On the completion of the disarticulation the styloid processes of the radius and ulna are sawn off.

The thumb may be amputated by transfixion or by an oval incision; the fingers by double flaps or by a long anterior flap. In amputating a finger it should be remembered that the joint is in front of the knuckle. If the whole finger requires removal, the head of the metacarpal bone should be nipped off with bone forceps, unless breadth and strength of hand is the chief desideratum, when it should be left.

Amputation at the hip joint may be done by transfixion or by Furneaux Jordan's method. Although the former can be performed with greater celerity, the latter is by far the better operation, as it is attended with less hemorrhage and provides a much more useful stump. In the transfixion method a long anterior flap is made by transfixing and cutting from within outward, the joint opened, the head of the bone freed from its connections, and the knife carried straight out posteriorly, hemorrhage being controlled by Davy's lever in the rectum, or by Lister's abdominal tourniquet. In Furneaux Jordan's method a circular amputation is first done through the upper third of the thigh, and all bleeding vessels secured. An incision is then carried up the outer side of the thigh to the great trochanter, the soft parts separated from the bone, the joint opened, and the disarticulation completed by freeing the remaining connections, with the knife kept close to the bone.

Amputation of the thigh is usually done by double skin flaps and circular division of the muscles. The flaps may be anteroposterior, or lateral, or one flap may be antero-external and the other postero-internal.

Amputation of the leg may also be done by skin flaps and circular division of the muscles, or by Teale's method. The posterior flap is sometimes cut by transfixion. The sharp edge of the tibia should be cut off obliquely, lest it subsequently protrude through the skin. The division of the fibula should be completed before that of the tibia to prevent splintering. Should the arteries retract, as they are apt to do in this situation, they may be conveniently drawn down by a tenaculum.

Amputation of the foot may be done by one of the following methods:

Syme's amputation consists in removing the foot at the ankle joint, cutting off the ends of the tibia and fibula, and retaining the integuments of the heel as a covering for the bones. An incision down to the bone is made across the under surface of the heel from the tip of the external malleolus to a little behind the internal malleolus; a second incision is next made across the