730 OPERATIONS ON THE FOOT. 



The next step is the removal of the cartilage altogether. This 

 is done with the single sage knife, held firmly in the hand, either 

 the left or the right, always, however, that corresponding to the 

 side of the heel to be operated upon. Taking a point of rest with 

 the flat of the thumb upon the plantar surface of the foot, the in- 

 strument is pushed between the skin and the cartilage, and the 

 sharp edge turned backward, with a firm rotary motion, down- 

 ward and forward. The detached portion of cartilage is then 

 seized with a pair of bull-dog forcej)s, and brought outward, and 

 the sage knife is brought forward, downward and outward, from 

 under the cartilage. It is a good plan, in order to make more 

 room for working, to raise the skin and coronary band with a 

 blunt tenaculum. The operation should always be commenced 

 at the posterior part, in order to avoid the articular synovial cap- 

 sule, which might be opened if the removal of the cartilage was 

 begun forward. As the operator reaches the anterior part of the 

 cartilage, which is situated almost over this capsule, it is prudent 

 to hold the foot in excessive extension, and thus avoid injury to 

 the capsule. This is an important point to consider in the oper- 

 ation. The sharp instrument being carefully handled, every por- 

 tion of the cartilage is taken ofi", either at once, or better by layers 

 successively, until the whole is removed. It is thus accomplished 

 in three or four pieces. In some instances the anterior portion is 

 cut off by a longitudinal incision, made with a straight bistoury, 

 following the direction of the posterior face of the coronet, the 

 object, in this case, being simply to render the operation easier. 

 The cartilage is thus removed, great care being taken to avoid 

 opening the capsular articular bursse. It is essentially necessary 

 to remove the whole of the diseased tissues, in order to bring the 

 parts into the condition of a simple wound. Still, there need be 

 no alarm if some small portions remain, more fibrous than cartilag- 

 inous, which, deep as they are, may protect the synovial capsules 

 or the ligament ; and moreover, they often slough off by them- 

 selves, with the abundant suppuration which follows. 



To operate with the greater facility, it is well to have two forms 

 of sage knife, one right and one left-handed, and some of extra 

 strength, with which to remove the larger particles of cartilage, 

 the others being small, thin and light, being adapted to the more 

 careful dissection necessary toward the lateral ligament, and 

 about the synovial bm-sse of the joint. 



