[11] In England, of course, this is always called Syme's amputation. It constitutes the type _par excellence_ of the end-bearing stump. Upon a good Syme stump a patient may be able to walk ten miles without an artificial foot, wearing simply an "elephant boot." Amputations above the Syme level are not end bearing, however long the stump may be. The other amputations in this region seen in English war surgery are the various types of osteoplastic amputations in which a part of the os calcis is retained (Pirogoff's amputation, etc.). These have the following defects:-- (1) There is often sepsis between the tibia and the os calcis, necessitating re-amputation. Osteoplastic amputations are unsuitable for septic surgery. (2) Ankylosis between the os calcis and the tibia is often imperfect so that the bulbous end of the stump is unstable. (3) The stump is too long to allow of the fixation of a good artificial ankle joint beneath it. A Syme's amputation leaves two to two and a half inches clearance between it and the ground. I have not yet seen a sub-astragaloid amputation in war surgery, and only once a disarticulation through the ankle joint, the latter could not bear pressure and it was necessary to convert it into a Syme's amputation. In fact, in this region there is Syme's amputation and a number of other far inferior amputations which should never be considered when a Syme's amputation is possible. (Ed.) Certain limb makers consider these operations are bad for the same two reasons that we have already refuted in connection with amputation through the condyles of the femur, viz.-- (1) The stump being enlarged at its lower end will not fit into a wooden bucket. (2) The stump is too long to allow an artificial foot to be fixed below it. From this it simply follows: 1. That complete enclosure of the stump in a wooden bucket is impossible; 2. That pressure must be placed directly and exclusively upon the end of the stump. The latter condition is only possible if the state of the soft parts allows the cutting of a thick plantar flap to cover the cut surface of the bone and if care be taken to resect the posterior tibial nerve in the flap. We therefore draw special attention to the excellent elliptical supra-malleolar amputation with posterior flap (Guyon's method) in which it is sufficient to retain a bare finger's breadth of skin from the plantar surface in front of the point of the heel. It bears direct pressure well, perfectly if a layer of the os calcis is cut with the scissors from the area adjacent to the tendo-Achillis and applied under the cut end of the tibia. For all these amputations the anterior flap is bad. The thin dorsal skin of the foot is incapable of withstanding the direct pressure which is indispensable for this method of fitting.