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ankle to reach its muscle on the back of the viagra pour homme leg. The turning points are virtually pulleys resting viagra pour homme on the tendons anchored in the great toe, traction upon the tendon raises the ankle in a sling, and under the body weight, the viagra in spanien kaufen back part of the foot, carrying the leg, slides down the tendons toward the front and the arch increases in concavity. The two muscles are known as extensor and flexor of the great toe. But their function is obviously *Read at annual meeting of the Medical Association of Montana, Bozeman, Mont., July 15, 191.5. not to move the toe in relation to the leg — a per- fectly useless performance — but to move the, mov- able, leg in relation to the fixed toe. In fact, in studying the lower extremity as an organ of loco- motion one finds that the still accepted teaching regarding its muscular physiology needs not to be revised merely but to be reversed — that, in general, muscles do not act from proximal parts upon distal, as their names indicate, and as do those of the upper extremity, but from below upward. Or when they do act from a superior upon an inferior part, the superior point must be fixed in adjustment to the working base by muscles acting from below up- ward. All, or nearly all, of which was presented twenty-five years ago by Thomas S. Ellis of Glouces- ter, England, in a valuable little work, "The Human Foot" (William Wood & Co., New York). Rising on the ball of the foot is supposed to be effected by the upward pull of the tendo Achillis muscles on the point of the heel. Were the foot a solid bone from heel to toe, and had the muscles a fixed point above from which to act, they could, independently, perform this function. But trans- verse joints through the tarsus, between the tarsal and the metatarsal bones, and between the metatar- sal bones and the phalanges, divide the foot into segments, viagra pour homme and upward traction on the heel while the toes are against the ground would result simply in depression of the middle of the foot were not the segments kept in their normal arched relation, which is done principally by the muscles whose tendons lead from the great toe as described. They enter also into all adjustments of the leg to the foot, and thus help to provide the point of resist- ance for such muscles as the anterior tibial, which apparently does act from above downward and pos- sibly for the heel cord muscles. But paralysis of the heel cord group does not prevent the subject from rising on the toes, which would indicate that the important function of these powerful muscles is not to raise the heel. A true conception of the mechanism of walking is of fundamental importance in dealing with all me- chanical disabilities of the lower extremity. But confining our attention now to the muscles whose tendons are anchored in the great toe, we find that they take part in raising the heel, maintaining the integrity of the foot and providing a point for muscles to act from the leg upon the foot. It oc- curred to me that the severe disability accompany- ing the loss of the toe is due to cutting loose the muscles, and might be avoided by saving the ten- dons and uniting them over the end of the meta- tarsal bone. November 27, 1914, Dr. viagra pour homme P. H. Mc- Carthy of Butte, Montana, adopted my suggestion in the case of a young woman whose toe he removed for sarcoma of the distal phalanx, and permitted me to take part in the operation. The end of the meta- tarsal bone was denuded, the tendons drawn taut overlapped for an inch or more on the dorsum and were sewm together with chromicized catgut. (It would possibly have been better to have split the thicker tendon and inserted the thinner.) The dressed foot was bandaged viagra pour homme to a board with a pad under the instep, and the patient not permitted to stand on it for six weeks. viagra in spanien kaufen The result is highly gratifying. She has a perfect arch even under the entire body weight with the heel raised, as shown by the accompanying photograph which was taken six months after the viagra in spanien kaufen operation, and walks without perceptible limp. OwSLET Block. September 25, 1915] viagra in spanien kaufen MEDK \l, RECORD. 517 A SINGLE STITCH APPENDECTOMY. PRELIMINARY REPORT. By W. frank fowler. M.D.. ROCHESTER, N. Y. A PAPER by Dickinson,' in which he made an appeal for efficiency engineering in pelvic surgery, stimu- lated my interest in a single .stitch operation. My excuse for adding this method of appendix removal to the countless existing modifications of technique is that it appeals to me as being simple, viagra pour homme easy, and expeditious. The operation is much more easily and quickly done than its description would indicate. Description of the Author's Clamp. — A 7y4-inch curved Fean hysterectomy forceps with longitudinal grooves was bent to approximate a 45-degree angle with a rounded shoulder, leaving a straight arm at the end of about 1 5/10 cm. A similar forceps 61/2 inches long is also useful but not essential. The viagra in spanien kaufen