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Treatment. As the surgical treatment of talipes cavus is usually of a prolonged character it is not wise to promise much or to prophecy until certain knowledge is obtained, and before proceeding to use surgical measures-every effort should be made to do without them. Attention should be given to see that the patient wears properly fitting boots, which ought to have plenty of room for the toes to stretch forward, and with soles arranged to distribute the pressure as equally as possible along the under surface of the foot. It is important to remember during this treatment that a boot soon becomes too short for the lengthening foot and that frequent renewals are absolutely necessary. To diminish the expense of so many changes sandal shoes without any uppers may be worn with much advantage, but in all cases the arched sock to support the foot and equalise the pressure must be insisted on.
Manipulation of the foot should be carefully carried out, and the amount of force required to extend the foot is considerable. At night the foot ought to be firmly bandaged to sole splints. Where tarsalgia is severe relief is often obtained by the administration of salicylate of potash, or sometimes by the inunction of oil or lanolin. When careful trial of the above-mentioned measures is not successful, but the foot remains contracted, callosities painful and tarsalgia frequent or continuous, complete division of all tight structures in the sole of the foot and immediate extension is the only treatment of any service; and it is the manner of doing this which has been one of my reasons for bringing this subject forward in order that I might start discussion as to the advantages or disadvantages of the open or subcutaneous method of operating.
During the last two years I have frequently practised both methods, reserving the open method for the more severe cases. The ordinary subcutaneous operation requires no description; the only remark I have to make about it is, that I prefer multiple punctures for separate tight bands to the attempt to divide several through one incision, and that I entirely dissent from the subcutaneous division of all structures in the sole of the foot indiscriminately, both because I consider it bad surgery
and because the after-contraction is likely to make the foot as bad as before.
The open mode of operating is as follows:-An incision about one inch and a half long is made over the inner border of the central piece of the plantar fascia, which is usually the tightest band; the fascia is separated from the skin of the sole rather freely. The central part of the fascia is then divided transversely but without cutting any of the muscular fibres of the flexor brevis digitorum beneath. By drawing outwards the muscular fibres of the flexor brevis digitorum the tendons of the long flexors may be reached and divided. Considerable force must be used to extend the foot, and some of the ligaments of the sole may also require division. With the finger in the wound any other tense bands may be felt for and divided. The tendon of the abductor pollicis I usually divide subcutaneously near its insertion. All tight structures having been divided and the foot well stretched the wound is stitched and the foot firmly bandaged to a flat sole splint. As soon as possible the patient is encouraged to walk upon the foot, and when resting, the foot is kept firmly bandaged to the flat splint, which ought not to be left off for two or three months. After the operation frequent stretching and manipulation should be practised. attention to boots or shoes will complete the cure.
What advantages does the open method give over the subcutaneous? It is a rather more severe operation, and unless better results are obtained ought not to be adopted. I was led to the practice of it after noting many failures from the ordinary mode.
The advantages are—
1. The Surgeon is able to divide all that is necessary and nothing more.
2. There is no bleeding into the areolar tissue of the sole.
3. As no muscular fibres are divided, the risk of aftercontraction, from a cicatrix in the muscular tissue is avoided. This I consider to be one of the most important, if not the most important advantage.
4. Deep contracted fibres, which cannot be felt through the
skin, are easily defined and divided, and complete division of the deep flexors is assured.
5. Although the wound takes a little longer to heal, the absence of subcutaneous hæmorrhage renders manipulation less painful.
From my own personal observation, as yet, I cannot say how far clinical experience will bear out the advantages mentioned above. I can only say that in the cases which I have operated on by the open method, I have been better satisfied with the results; but as I have not been accustomed to perform the operation until about three years ago, I do not think the time is long enough to give a positive opinion. It is difficult to draw a fair comparison between the two operations when different patients are compared. In the following case I operated on one foot by the open, and the other by the subcutaneous method.
Miss M., a young lady æt. 21, was placed under my care for severe talipes cavus, which almost incapacitated her from walking from constant tarsalgia. The feet were about equally affected. In October, 1891, I operated on them by different methods. During the first few days the pain usually present on moving the foot after such an operation was hardly felt in the open wound, but at the end of a week there was very little difference between the two. Great improvement resulted in both; but a good deal of pain remained for some weeks after the operation, especially in the subcutaneous case.
Last month, about a year and a half after the operation, I examined the feet. In both the shape was normal, and walking was easy and painless; but in the one treated by the open method there was some cicatricial adhesion of the skin to the fascia beneath, which she said was sometimes painful.
I have selected this case because it is the only one in which I have noticed any such adhesion follow the operation. Altogether I have operated on ten cases by the open method. The number is too small to generalise from, but I am so well satisfied with the results that I should always adopt it in severe or even moderately severe cases.
NOTES ON THE AFTER-TREATMENT OF CASES
OF ABDOMINAL SECTION.
BY CHRISTOPHER MARTIN, M.B. EDIN., F.R C.S. ENG. SURGEON TO THE BIRMINGHAM AND MIDLAND HOSPITAL FOR WOMEN.
(Continued from page 101, vol. xxxiii.)
ON THE USE OF THE DRAINAGE
THE value of drainage in abdominal surgery is admitted by all authorities, although considerable difference of opinion exists as to the class of cases in which it is safe to do without it. There are certain cases in which no wise surgeon would think of inserting a tube; for example, after a simple straightforward ovariotomy, where there have been no adhesions or other complications. There are other cases where the patient's only chance of recovery depends on its intelligent use.
I consider it necessary to drain the peritoneal cavity-
1. Where there is peritonitis or ascitic effusion.
2. Where during the operation the peritoneum has been soiled with fæcal matter, urine, pus, or offensive contents of
3. Where the abdomen has been washed out.
4. Where extensive adhesions have been broken down.
5. Where, from any cause, free oozing of blood is taking place into the peritoneum.
6. Where there is reason to believe the bowel or bladder has been injured.
It is a wise precaution to insert a tube where, even though there be no hæmorrhage at the close of the operation, it is likely to occur afterwards. Thus, the surgeon may feel uneasy as to the security of the ligature on the pedicle; or he may have had to operate on a vascular organ, like the uterus, which is prone to bleed. In all doubtful cases my rule is to drain. I have never seen a case where, after inserting a tube, I have
regretted doing so; and I have seen numerous cases which, had they not been drained, would certainly have died.
The Tube. The form and material of the tube deserve attention. It must be of stout tough glass, strong enough to resist the great pressure to which it is submitted during the violent retching that so often follows the operation. It should be perfectly straight, and maintain the same diameter (nearly half an inch) from top to bottom. It should be open at the lower end, and not rounded like a test tube. The sides should be perforated at frequent intervals, the holes being nearly a line across, and extending almost to the top of the tube. The upper end of the tube should be turned out into a circular lip or flange an inch in diameter. The tube should be of such a length that when the lower end reaches to the bottom of the pouch of Douglas the circular rim sits easily on the skin. Its Functions.—
1. It acts as a sentinel indicating the onset of severe internal hæmorrhage in time for its prompt treatment. It is especially needed in cases where vascular adhesions have been dealt with, where the pedicle has not been ligatured satisfactorily, or where some very vascular organ, such as the uterus, has been operated on.
2. It is a potent hæmostatic, checking free oozing by enabling the blood effused to be at once removed, and by admitting air to the raw surface and keeping it more or less dry. If necessary, astringent solutions may be injected down the tube in order to act directly on the source of bleeding.
3. It prevents peritonitis by the removal of fluid-blood, pus, serum, or tumour contents-which, if allowed to remain, would probably undergo septic changes and excite a fatal peritonitis. Where there is a risk of fæcal extravasation, as when a hole has been torn in the rectum, it is simply invaluable. 4. It is a curative agent in peritonitis with effusion, and in ascites due to tubercular disease or papilloma of the peritoneum. The Use of the Sucker.-Some surgeons do not advise clearing the tube by means of a "sucker." They merely lay a sponge