BILATERAL AND UNILATERAL PLANTAR NEUROTOMY 151 



dissecting forcep. If these manipulations are not fruitful 

 the depth of the wound must not be increased until all of the 

 blood-soaked areolar tissue in the foreground is picked up 

 and dissected away. Most always this procedure will un- 

 mask the desired structure, which is then separated nomi- 

 nally along one edge preparatory to its elevation. 



Fourth Step. — Elevation and Resection. — The elevator is 

 forced under the trunk from before backwards or vice versa 

 according to which edge was loosened in the preceding step, 

 and then taken with both hands or between the second 

 fingers of one hand and pulled quite forcibly outward from 

 the superior commissure of the wound. This pulling process 

 brings out one and a half and often two inches of the trunk, 

 causes it to degenerate a considerable distance upwards and 

 thus prevents the formation of sensitive scars and neuromas. 

 When thus stretched the bistoury is passed beneath it as 

 near to the superior commissure as possible, dividing it with 

 an outward stroke. The divided trunk is then picked up 

 with the dissecting forceps, loosened along the whole length 



Fig. 93 — The Author's Nerve Elevator. 



of the wound with the scalpel and then divided at the inferior 

 commissure. 



Fifth Step. — Suturing. — The needles previously threaded 

 and retained in an appropriately clean container are then 

 picked up with the forceps, and needle holder. One edge of 

 the wound is held with the dissecting forceps as the needle 

 is inserted through the skin at the proper location with the 

 needle holder held in the other hand. When the needle is 

 pulled through this edge of the wound the other one is simi- 

 larly elevated with the dissecting forceps as the needle, which 

 lias again been picked up with the needle holder, is passed 

 through it. This manipulation of the suture, a recommen- 

 dation belonging to the domain of general surgery, is re- 

 peated here because of the great importance of healing these 

 conspicuous surgical wounds without the contamination that 

 is certain to follow digital contact; During the course of 

 such an operation the fingers are generally soiled in one way 

 or another, and are at this stage unfit to handle the needle 

 and thread that were so carefully sterilized. The single in- 

 terrupted suture is generally sufficient except for long 

 wounds where two might be required to assure perfect coap- 



