Peroneal neurotomy 191 



able, protruding, slow healing, granulations, which leave an 

 indelible blemish at this conspicuous part of the economy. 

 Sometimes several months will elapse before cicatrization is 

 complete. 



The first step, in closing the wound is to carefully adjust 

 a row of small interrupted cat-gut sutures in the fascia. 

 It is needless to state that these should be sterilized and 

 inserted with precautions to prevent septic contamination of 

 the buried structures. 



The second step consists of the insertion of two or three 

 mattress sutures of braided silk in the skin, about one-half 

 inch from the edges of the wound. These are for the pur- 

 pose of immobilizing the edges; to protect against friction. 

 They are not drawn taut. When tied, the wound should 

 gap a little, about a quarter of an inch. 



The third step is the insertion of a row of small inter- 

 rupted silk sutures along the edges of the skin wound to 

 complete the closure. The loops should be small and a quar- 

 ter of an inch apart. 



The fourth step consists of the application of a plastic 

 dressing over the whole region to still further immobilize 

 the skin, as well as to prevent infection from without. This 

 step is postponed until the subject has regained the standing 

 posture, and all of the bleeding sometimes caused by sutur- 

 ing has ceased. Anti.phlogistine or any other clay dressing, 

 is best adapted for this purpose. It is applied sparingly, 

 with alternate layers of absorbent cotton, until a thick dress- 

 ing is built over the region. In twenty-four hours this dress- 

 ing will harden and then act as an adhesive plaster. Drain- 

 age is not necessary. 



AFTER-CARE. — The subject is kept in the standing 

 position for no less than eight days and at all hazards. Lying 

 down for a single moment will demoralize the whole affair. 

 The sutures will burst and the desired primary union will 

 he defeated. At the end of seven to eight days, the dressing 

 is. carefully soaked off and the stitches removed. The skin 

 should have healed. If, however, there is any doubt as to 

 the integrity of the union, the mattress sutures may be left in 

 place for two or three days and another dressing applied. 



When a union has not been effected, the stitches are re- 

 moved, the patient kept in the standing position for another 

 week and astringent lotions applied frequently and freely. 



The large muscle hernia, which sometimes follows pe'r- 

 oneal neurotomy, should be treated from the beginning by 

 keeping the patient quiet, and by the application of strong 



