Amputation of the phalanges of the toes. A small and very narrow-bladed scalpel should be procured for these operations, which may be executed precisely in the same manner as the corresponding amputations on the hand. (See page 66, fig. 14.) The phalanges may be removed by a single palmar flap, or by double flaps.

The toes may also be removed at their metatarsal joints by the same shaped incisions, and in the same manner, as was recommended for the corresponding articulations of the hand (page 67). In amputating the great toe at its metatarsal joint, the operator should observe the prominence of the head of its metatarsal bone, and in the incision of the soft parts should provide accordingly for its sufficient covering.

Amputation of the toes en masse at their metatarsal joints. -The operator facing the sole of the foot, and being armed with a strong narrow knife, five inches in length in the blade, should grasp the extremities of all the toes with his left hand, his thumb being against their plantar surface; having extended the toes, he should make a curved incision from left to right, with its convexity directed forwards, across the sole of the foot, commencing on the right foot over the metatarsal joint of the little toe, and extending to the corresponding joint of the great toe on the opposite side of the foot. This cut should reach as far as the angles between the toes, and should fall on the transverse marks in the skin which separate the toes from the sole of the foot. The position of the left hand should now be changed, and the extremities of the toes be grasped, and strongly flexed; the thumb of the operator being now on their dorsal surface. Another curved incision should be made on the dorsum of the foot, joining the extremities of the first, and falling across the forks of all the toes (fig. 22a). The flap thus traced out may be reflected for a short distance, until the metatarsal articulations are exposed; these

being opened, and the capsular ligaments completely divided, the blade of the knife should be passed behind the heads of all the phalanges, and by a slight sawing movement should be made to cut its way close along the plantar aspect of their shafts, until it appears in the sole at the extremity of the first incision.

Lisfranc's amputation."-This consists in the removal of part of the foot, at the articulation between the tarsus and metatarsus. The operator should glance at the line of articulations he is about to open (fig. 22); he will perceive that with the exception of that belonging to the second metatarsal bone, they are arranged in a pretty regular curve across the dorsum of the foot; while the proximal end of the bone in question dips down towards the tarsus, and is wedged in between the first and third cuneiform bones: again, this and the first metatarsal bone are connected by strong plantar ligaments to the internal cuneiform bone; and lastly, the tendon of the peroneus longus is attached to the base of the metatarsal bone of the great toe; these connections, which must all be divided in this operation, form the principal difficulty in its

execution.

The operator, having the same knife that was used in the last operation, should stand facing the right foot, the sole of which he should grasp in the palm of his left hand, the extremities of his thumb and forefinger being placed just behind the tarsal ends of the metatarsal bones of the little and great toes respectively. The former of these being prominent, its situation may be easily ascertained on the outer side of the foot, while the latter is found about an inch in advance of the prominence of the scaphoid on the inner side. These two points, marked by the finger and thumb, should be connected across the dorsum of the foot,

* Often called Hey's operation.

half an inch in advance of the articulations about to be opened, by a slightly curved incision, having its convexity turned towards the toes (fig. 22, page 91). The extremities of this first cut must now be joined by an incision running along the sides of the metatarsal bones of the great and little toes, and crossing the sole in a curved manner, just at the ball of the toes, as represented in the ad

joining woodcut (fig. 23). This flap, traced on the sole, should be longer on its inner than on its outer side, and it should be cut deeply, down to the bones. The foot being now firmly grasped in the left hand, and the dorsal ligaments put on the stretch, they may be divided over the line of the tarso-metatarsal articulations, and the latter be opened. The knife should now be inserted between the shafts of the

first and second metatarsal bones, its point being directed towards the tubercle of the os calcis, and its edge looking upwards; it should be grasped in the fist, and should be made to move in a direction which we trust may be expressed by the accompanying woodcut (fig. 24); at the same time the left hand of the operator should bear downwards upon the end of the foot. The object of this pro

ceeding is to divide the ligaments at the base of the second metatarsal bone, and set its articular extremity free; the division of these ligaments is easily ascertained by the resistance to the left hand suddenly ceasing, and by the wide separation of the tarsus from the metatarsus. All the ligamentous connections of the bones being divided, the blade of the knife should be passed behind them into the sole, and being carried with a sawing movement close along the

under surface of the metatarsus (fig. 25), be made to cut its way out into the sole, at the extremity of the flap that has been previously traced.

Chopart's operation is the partial amputation of the foot at the articulation between the calcis and astragalus on the one side, and the cuboid and scaphoid bones on the other

Fig. 25.

(fig. 22); the principal covering for the stump being taken from the sole. We shall describe the operation as it is performed on the right foot.

The operator, grasping the sole of the foot in the palm of his left hand, should feel for the prominence of the scaphoid bone on the inner side, and having placed the end of his forefinger upon this, should next ascertain the position of the