638 OPERATIONS ON THE FOOT. 



This first step of tlie operation completed, the operator intro- 

 duces a director into the whole tract of the fistula, and with a 

 sharp sage knife a longitudinal incision is made, following the 

 canula of the directory as a guide, above and below the fistulous 

 opening, and in the direction of the antero-posterior axis of the 

 foot. This done, with the sage knife held in full hand, with one 

 cut the surgeon, by a deep incision, removes the greatest thick- 

 ness of the tissues all around the longitudinal cut he has just 

 made, transforming the fistulous tract into a conical infundibu- 

 lum, whose apex is at the bottom of the wound. If then the apo- 

 neurosis is not yet exposed, the operator removes with the for- 

 cej^s and bistoury whatever tissues still cover it. 



Then follows the excision of the aponeurosis. This is meas- 

 ured by the extent of the necrosis. As a rule, it must reach a 

 little beyond the diseased part, and by that operation the puru- 

 lent synovia finds a free chance to escape. 



If the sesamoid is sound, it must be left alone, but if the 

 diathrodial surface is roughened, ulcerated and on the way to 

 desquammation, it must be scraped off with the narrow and long 

 drawing knife. 



The complications of arthritis cannot be interfered with by the 

 surgeon. It is by general antiphlogistic treatment, and by local 

 and external api^lications that they must be treated. 



The operation ended, the dressing follows, and becomes one 

 of the most important parts of the means of recovery. As light a 

 shoe as possible is placed on the foot, a coat of hoof ointment, 

 Venice turjoentine, or tar, is applied upon the thinned sole ; j^ads 

 of oakum, wet with alcohol, carbolized or not, are then carefully 

 laid on the soft jDarts. 



Some practitioners cover them with cegyptiacum (Mandel) ; 

 others simply with Venice turpentine (Lafosse). 



The pads or balls of oakum must not be too thick or hard, as 

 no pressure is needed. The whole dressing is retained by plates, 

 and several circular straps of tape above the coronary band. Cold 

 water baths are always good afterward. 



In the subsequent dressings one must bear in mind that the 

 work of repair, the granulating, is more rapid in the tissues of the 

 plantar cushion and fleshy sole than upon the bone and tendinous 

 tissue ; and that in this case it is longer than upon bone if this 

 has been scraped. The result of this is a wound which presents 



