without separation of the astragalus from the bones of the leg. Pick states that the usual classification for these dislocations is forward, backward, inward, and outward, but that the displacement is, as a rule, oblique, the foot passing backward and outward or backward and inward. The causes are twists.

Symptoms. In subastragaloid dislocation the astragalus projects on the dorsum; the foot is everted in outward dislocation and inverted in inward dislocation; the relation of the malleoli to the astragalus is unaltered; the ankle-joint is not absolutely rigid; the foot "is shortened in front and is elongated behind" (Pick).

Treatment.-To treat subastragaloid dislocation make extension in the direction opposite to that of the displacement. In dislocation of the tarsus backward fix a bandage around the foot, on a level with the heads of the metatarsal bones, which bandage the surgeon ties around his shoulders. The surgeon puts one knee in front of the angle and thus fixes the leg, raises himself up to make extension upon the tarsus, and moulds the bone into position. Tenotomy may be necessary. After reduction apply a silicate dressing for three weeks. The ankle-joint, fortunately, is not involved, and stiffness of this articulation need not be apprehended. If reduction is impossible, take the same course as in luxations of the astragalus.

Dislocations of the other tarsal bones are very rare. Single bones may be dislocated, or the luxation may occur at the mediotarsal articulation.

Symptoms and Treatment-Projection is an obvious symptom in dislocation of the other tarsal bones. The treatment is to reduce by extension and moulding, the part being put up in silicate-of-sodium dressing for two weeks. Dislocations of the metatarsal bones are rare.

Symptoms and Treatment-Shortening of the toes and projection of the dislocated bone are symptoms of dislocation of the metatarsal bones. To treat these dislocations reduce by extension under ether and put up in a silicate dressing for two weeks. If reduction fails, the functions of the foot will not be much impaired.

Dislocations of the phalanges are very rare. The first phalanx of the big toe is the one most liable to dislocation.

Symptoms and Treatment.-Dislocations of the phalanges are obvious. The treatment is by reduction as in dislocations of the thumb. Immobilize for two weeks.

5. OPERATIONS UPON BONES.

Osteotomy.-By the term osteotomy the modern surgeon means literally the sectioning of a bone for the purpose of straightening a limb ankylosed in a bad position, correcting a bony deformity, or amending a vicious union of a fracture. In a linear osteotomy the bone is transversely divided in one spot; in a cuneiform osteotomy a wedge-shaped portion of bone is removed. The operation of osteotomy may be performed with a saw (Fig. 123) or with an osteotome. The saw creates dust, draws much air into the wound, and lacerates the tissues to a considerable degree. Most surgeons prefer the chisel or the osteotome. The osteotome slopes down to a point from each side (Fig. 124); the chisel is straight on one side and on the other is bevelled to a point.

Osteotomy for Genu Valgum, or Knock-knee (Macewen's Operation, Fig. 126).—In this operation the instruments re

FIG. 123.-Adams's large saw.

FIG. 124.-Osteotome.

FIG. 125.-Rawhide mallet.

quired are the scalpel, hemostatic forceps, osteotomes of several sizes, a mallet (Fig. 125), and a sand-bag wrapped in an aseptic towel.

Operation. The patient lies upon his back, being rolled a little toward the diseased side. The leg of the diseased side is partly flexed upon the thigh and the thigh upon the pelvis, and the extremity is laid upon its outer surface, the sand-bag being pushed between the extremity and the bed, opposite to the site of section. The flexion of the knee relaxes the popliteal vessels and saves them from injury. The surgeon, if operating on the right leg, stands outside of that ex

tremity; if operating on the left leg, he stands opposite the left hip (Barker): Enter the knife at the inner side of the knee, just in front of the adductor tubercle of the inner condyle and on a level with the upper border of "the patellar articular surface of the femur" (Barker); cut down to the bone, and make an incision upward one inch in length, in the direction of the axis of the

femur.

At the lower angle

of this wound insert an osteotome and turn it to a right

FIG. 126.-Osteotomy of the right femur in a case of knock-knee: A B, epiphyseal line; c, section of Macewen; DE, section of Ogston.

FIG. 127.-Macewen's operation for genu valgum: the chisel is held in the line for striking with a mallet; the arrow shows the direction in which the chisel is levered up and down so as to make a wide gap in the bone (after Barker).

angle with the shaft, half an inch above the epiphysis (Fig. 126); strike the osteotome several times with a mallet; move the handle several times toward and from the body, so as to widen the cut in the bone (Fig. 127); strike the osteotome again several times, move it again, and continue this process until the bone is cut one-third through. If the osteotome becomes tightly fixed, withdraw it and introduce a smaller

When the bone is cut two-thirds through withdraw the osteotome, hold a piece of wet antiseptic gauze over the opening, and fracture the femur by strong adduction. Do not suture nor drain the wound, but dress it antiseptically, wrap the entire extremity in cotton, and apply a plaster-ofParis dressing up to the groin. This dressing may be removed in two weeks, and the patient may subsequently be treated with sand-bags, as for an ordinary fracture of the thigh, but without extension. This operation is scarcely ever fatal.

Ogston's Operation (Fig. 126).—In this operation the internal condyle is sawed off obliquely with an Adams saw-a proceeding which permits the straigthening of the knee. The objection to this operation is that it opens the knee

joint, and that this cavity fills up more or less with a mixture of blood and bone-dust. Macewen's operation is decidedly the safer.

Osteotomy for a Bent Tibia.-In this operation the instruments required are the same as those indicated in the above operation. The tibia is divided transversely or obliquely (linear osteotomy), or a wedge-shaped piece is removed (cuneiform osteotomy). The oblique incision is the best. If the convexity of the tibial curve is inward, cut the bone from above downward and from in front backward; if the curve is forward, section the bone from above downward and from within outward. The fibula need rarely be interfered with. After the osteotomy the limb is treated just as it would be for an ordinary fracture.

Osteotomy for Faulty Ankylosis of the Hip-joint.This operation is performed in order to allow straightening of a limb that has undergone bony ankylosis in a faulty or an inconvenient position. In some cases an attempt is made to obtain a movable joint, but in most cases the surgeon must be satisfied with an ankylosis in extension. Osteotomy may be performed through the neck of the femur or through the shaft of the femur below the trochanters.

Osteotomy through the neck of the femur is performed (1) with a saw (Adams's operation) or (2) with an osteotome. 1. Adams's Operation (Fig. 128). In this operation the instruments required are a scalpel, hemostatic forceps, a long, blunt-pointed tenotome, and an Adams saw.

Operation. The patient lies upon his sound hip; the surgeon stands upon the side to be operated upon, and back of the patient. The knife is entered a finger's breadth above the great trochanter, is pushed in until it strikes the neck of the bone, is then carried across the front of and at a right angle with the neck, and is withdrawn, enlarging the wound in the soft parts, as it emerges, to the extent of an inch. The saw is now introduced and the neck is entirely divided. After the osteotomy dress the wound antiseptically and place the extremity straight. To straighten the limb it may be found necessary to cut contracted tendons and fascial bands. Apply the weight-extension apparatus and the sand-bags. Begin passive movements

FIG. 128-Osteotomy through the neck of the femur: A, Adams's operation; B, Gant's operation.

from the start if a movable joint is desired; few patients can

tolerate the pain necessary to bring this about. If it is determined to aim for a stiff joint, treat the case as an intracapsular fracture would be treated.

2. With an Osteotome.-The instruments required in this operation are the same as those used for genu valgum. No sand-bag is required. The position of the patient is the same as that in Adams's operation. An incision one inch long is made, starting just above the great trochanter, ascending in the axis of the femoral neck, and reaching to the bone. An osteotome is introduced, is turned to a right angle with the bone, and is struck with a mallet until the bone is completely divided. (It is not to be divided partially and then broken.) The after-treatment is the same as that for Adams's operation. The operation with the osteotome is to be preferred to that by the saw.

Osteotomy of the Shaft of the Femur below the Trochanters (Gant's Operation).-In this operation (Fig. 128) the saw may be used, but the osteotome is to be preferred. The instruments employed are the same as those used for Adams's operation, plus an osteotome.

Operation. The position in Gant's is like that in Adams's operation. A longitudinal incision one inch long is made upon the outer aspect of the femur and on a level with the lesser trochanter. The osteotome is inserted and the bone is completely divided below the lesser trochanter. The after-treatment is the same as that for Adams's operation. Gant's operation is the best method for correcting faulty position in bony ankylosis, and Adams's operation can only be employed in those cases where the femur still has a neck which practically is unchanged.

Osteotomy for Faulty Ankylosis of the Knee-joint.This operation is performed for bony ankylosis of a knee in a position of flexion. The instruments employed are the same as those used for genu valgum.

Operation-The patient lies upon his back with his thighs flat upon the bed, the legs hanging over the end of the bed. The surgeon stands on the patient's right side. Just above the patellar articular surface upon the femur a transverse incision is made, one inch in length and reaching to the bone. The osteotome is introduced and the bone is cut nearly through. The leg is then forcibly extended. Do not extend too violently, or the popliteal vessels may be injured. In cases where the structures of the popliteal space are tense, do not at once bring the leg into extension, but do so gradually by means of weights. The wound is dressed