tion is completed the bones differ but little from the
normal.

After any of these operative procedures, manipulations, massage,
exercises, electrical stimulation of the muscles, and the wearing of
some apparatus must be persevered with for at least twelve months.
Failures are due to not sufficiently over-correcting the deformity in
the first instance, and to neglect of after-treatment; in hospital
practice it is difficult to ensure continuous supervision over long
periods.

Finally, _amputation_ may be called for when other methods have
failed, and the patient is unable to put the foot to the ground
because of suppurating bursae and ulceration of the skin.

#Acquired Talipes Equino-varus.#--In the great majority of cases this
condition results from anterior poliomyelitis. It especially affects
the peronei and the extensors of the toes, and is unilateral. The
patient is unable to dorsiflex and abduct the foot, which hangs with
the toes pointed and the sole turned medially.

At first the joints are flaccid, and the attitude can easily be
corrected by manipulation. In course of time, however, the opposing
muscles--those inserted into the tendo Achillis, the tibialis
posterior, and the long flexors of the toes--become shortened, and
there is secondary contraction of the plantar fascia and of the
ligaments on the medial side of the foot, and the deformity is thus
rendered permanent. The bones also are altered in their shape and
mutual relations, the talus being rotated forwards so that a large
portion of its trochlear surface protrudes from the tibio-fibular
socket. The skin is cold and livid, and readily suffers from pressure
sores. The whole limb is ill-developed, and may be shorter than its
fellow, and the paralysed muscles are wasted and exhibit for a time
the reaction of degeneration.

A similar deformity may result from section of the peroneal (external
popliteal) nerve, from the peroneal form of progressive muscular
atrophy, and from peripheral neuritis.

The _treatment_ of paralytic equino-varus, short of operation, has
been referred to under anterior poliomyelitis (p. 242). If tendon
transplantation is indicated, the tendon of the tibialis anterior is
attached to the cuboid, and a strip of the tendo Achillis to the
dorsal aspect of the tarsus. Jones displaces the tibialis anterior
into the base of the fifth metatarsal.

If the paralysis is widely distributed, and the joints are flail-like,
it is better to