778 DISEASES OF THE WITHEBS. 



ing knives, biill-dog forceps, and an amputating saw; and with 

 these the appliances usually needed in the way of hemostatics, 

 and the necessary dressings, artery forceps, oakum, sponges, 

 draiaer-tubes, dog seton needles, etc. The various steps of the 

 operation are thus described by Peuch and Toussaint : 



"Everything being ready, the operator enlarges the fistulous 

 tract, simple or ramified as it may be, so as to expose the ne- 

 crosis. In making this special attention must be taken to give 

 the incision a direction favorable to the escape of the pus. This 

 first step of the operation is accompanied with abundant hemor- 

 rhage, which must first of all be arrested either by ligating the 

 divided blood vessels, or by plugging the wound with oakum 

 moistened with a solution of perchloride of iron. The hemor- 

 rhage stopped, and the necrosis exposed, the second step, and the 

 important one of the operation, is proceeded with. To effect this 

 the necrosed surface is limited by a double incision, made with a 

 sharp instrument, straight bistoury, or sage-knife. This iacision 

 involves the entire thickness of the cervical ligament and the fibro- 

 cartUage covering the apex of the spinous process and passing 

 under this cartUage. In making this incision the operator must 

 be careful not to injure any of the other processes if they are not 

 diseased. This done, with the sage-knife the deepest layers of 

 the cartilage are excised, and then, vnth the drawing knife, the 

 bony tissue underneath is resected so as not to leave the smallest 

 particle of necrosed tissue. Here, as in some cases of foot opera- 

 tion, not only must all the diseased tissue be removed, but some 

 of the healthy structures. The resection of the apex of the ne- . 

 crosed processes can be made with the saw instead of the draw- 

 ing knife. But this instrument is preferable, as it is easier to 

 manipulate and it always leaves a smooth wound." 



The subsequent treatment is of the routine kind. The parts 

 are, of course, thoroughly cleansed; the hemorrhage is controlled 

 by pressure, a drain tube is secured at the lower angle of the 

 wound, and the edges are brought together by quiUed sutures. 

 Repeated injections of phenicated water are passed through the 

 drainage tubes, and the patient is watched in order to prevent him 

 from injuring himself by rubbing. If the season and the circum- 

 stances permit, continued irrigation is established. 



Toward the fourth or fifth day the sutures are removed and 

 the dressing changed. The granulating process is carefully 



