Dr. Little168 recommends that the tendon should be divided from before backwards. There is more risk by this method of wounding the skin, and thus losing the subcutaneous character of the operation.

Professor Pancoast169 divides the inferior portion of the soleus muscle instead of the tendo Achillis.

2. Tibialis posticus.—Next in frequency and importance to that of the tendo Achillis, division of this tendon is much more difficult to perform. It may be performed either above or below the ankle.

(a.) Above the ankle.—The blade of a tenotomy knife should be entered perpendicularly at the posterior margin of the tibia, half an inch or an inch above the internal malleolus, so as to pass between the bone and the tendon of the tibialis posticus, the blade directed towards the latter; the assistant should now evert the foot, the operator pressing the blade against the tendon.170

(b.) Below the ankle, close to the attachment to the scaphoid. This is the better position of the two when the position of the tendon can be made out, which is not always the case, especially in cases of old standing.

Raising the skin just over the astragalo-scaphoid joint, the knife should be entered with its blade downwards, and across the tendon, and should be made to cut on the bone, while an assistant everts the foot till the tendon gives way with a distinct snap.

3. Tibialis anticus may in like manner be divided either just above the ankle, or at its insertion. When it requires division it can generally be made so prominent as to render its division comparatively easy.

4. Peronei.—These do not often require division, cases of talipes valgus being usually paralytic in character. If necessary they can be cut as they cross the fibula.

5. The plantar fascia, may require division; when this is the case, it is so prominent as to render the operation very easy, if conducted on the principles mentioned above.

CHAPTER XIV. OPERATIONS ON NERVES

Nerve-stretching.—Surgical literature in last ten years is full of cases in which nerves have been stretched for all manner of diseases with varying success: an example of the operative procedure may suffice:—

1. Stretching of the great sciatic either for sciatica, sclerosis, or locomotor ataxia.

Operation.—A line drawn from the centre of the space between the tuberosity of the ischium or the great trochanter to a corresponding point between the condyles of the femur will give the direction. A free incision in this line three or four inches in length—the nerve lies just below the the femoral aponeurosis, beneath the edge of gluteal fold, requiring no muscular fibres to be divided. It must be raised from its bed and boldly stretched or elongated into a loop. Symington's experiments have shown that in the average adult 130 lb. are required to break the nerve.

2. The facial has been stretched for spasm. The trunk is easily reached by an incision extending from near the external auditory meatus to the angle of the jaw, which enables the parotid to be pushed forward and the edge of the sterno-mastoid pulled backwards.

Neurotomy and Neurectomy.—Chiefly performed for neuralgia of the fifth nerve.

a. This is a very easy operation if directed at the terminal branches only of the nerve, where they make their exit from the frontal, supraorbital, and mental foramina. The author has done it in very numerous cases, and with great relief, if care be taken to destroy the nerve in the foramen to some extent—a sharp-pointed thermo-cautery does this easily and safely.

b. The more severe and radical operation of cutting out a portion of the trunk of the fifth nerve just after it has left the skull, and destroying Meckel's ganglion, has been done pretty frequently, chiefly by American surgeons—in various ways.

1. Carnochan's Operation.—Exposing the whole front wall of antrum, its cavity is opened into from the front by a large trephine. The lower wall of the infra-orbital canal is cut away by a chisel, the posterior wall of the antrum by a smaller trephine, the nerve thus isolated is traced up to and past Meckel's ganglion, which is removed close to the foramen rotundum by cutting the nerve by curved blunt-pointed scissors.

2. Pancoast's Operation.—Expose the coronoid process by a free incision, divide it at its root and throw it up, then expose and tie internal maxillary artery, after which the upper portion of the external pterygoid is to be detached from the sphenoid, thus exposing the nerve leaving foramen ovale; the second portion is deeper and not so easily got at.

3. The spinal accessory occasionally may be divided before it enters the sterno-mastoid in cases of spasmodic wry neck, with great advantage. This operation is an easy one; the sterno-mastoid edge being once fairly exposed, the nerve is easily seen, and a piece should be cut out at least half an inch in length.

Nerve Suture is occasionally practised with great advantage in cases where nerves have been divided either by accident or in operation. Catgut seems to be the best medium, and cases are on record in which, even after months of separation and subsequent paralysis, improvement has followed an operation for refreshing and joining the divided ends.

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