. The principles and practice of surgery. in place, butalso because, owing to the relative shortness of the malleolus internus,it is more accessible than the external lateral ligament; moreover,being composed at its origin of one continuous bundle of fibres, whilethe external ligament originates at three distinct points of the mal-leolus, it can be more easily divided. It has an advantage over theexternal ligament, also, in the fact that the malleolus internus beingshorter, a section of the internal ligament, near its origin, enables thesurgeon to carry the knife more easily to the top of the
. The principles and practice of surgery. in place, butalso because, owing to the relative shortness of the malleolus internus,it is more accessible than the external lateral ligament; moreover,being composed at its origin of one continuous bundle of fibres, whilethe external ligament originates at three distinct points of the mal-leolus, it can be more easily divided. It has an advantage over theexternal ligament, also, in the fact that the malleolus internus beingshorter, a section of the internal ligament, near its origin, enables thesurgeon to carry the knife more easily to the top of the astragalus, andthus to complete the disarticulation. The following is the method which I have preferred in this amputa-tion :— First.—The foot being held in a position of extreme extension, thepoint of the bistoury is introduced half an inch below the centreof the lower end of the malleolus internus—in the case of the left foot—and from thence it is carried over the top of the foot, in the line 366 AMPUTATION AT THE Line of Incision in Tibio-tarsal Amputation. of a curve having a slight convexity downwards, to the anterior marginof the lower end of the malleolus externus. The object in commencing this incision half an inch below the mal-Fig. 154. leolus interims is to preserve the symmetry of the transverse incision; and by termi-nating the incision, also, a little furtherforwards, to secure so much additionalwidth to the base of the posterior or plan-tar flap. Upon the inner side I prefer tocarry the incision farther back, that I mayexpose the deltoid ligament more freelyto the knife. The knife, while traversingthe top of the foot, may be pressed withsufficient firmness to divide the tendons and all the tissues down to thebone, including the anterior ligament and the capsule. Second.—The leg being elevated and the foot flexed to a rightangle with the leg, the bistoury may be placed firmly upon the pointwhere the first incision commenced, and from thence
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