MEDIAN NEURECTOMY 159 



cut, regular incision. This brings into view the superficial fascia, which 

 should be likewise incised. The muscle is the next structure to be dealt 

 with, and after carrying the incision through this we see the deep layer 

 of dense fascia. Extreme care should now be taken, since at this spot 

 the nerve and vessels are immediately beneath the fascia, for this is the 

 position where they curve round the edge of the radius in front of the 

 Flexor Metacarpi Internus Muscle. As a precaution the deep fascia should 

 simply be pricked by taking the knife in the hand with only about a 

 quarter of an inch of the point of the blade exposed. 



Through this small opening a grooved director should be introduced, 

 and the opening may then be safely enlarged. The nerve is now exposed, 

 together with the Posterior Radial Artery and its accompanying vein, 

 but the relation of these structures to one another at this spot is very 

 inconstant. The vein may be found in front of the artery, and vice versa ; 

 and the same remark applies to the nerve. It is not uncommon to find 

 two or three of the structures named encapsuled in a layer of fibrous tissue, 

 whilst occasionally the nerve may be found blended, as it were, in the wall 

 of the vein. But whatever relationship the parts bear one to the other, 

 all are here quite superficial. They are easily seen by the operator, who 

 is thus enabled to expose the nerve satisfactorily by dissection. No 

 leverage is necessary at this seat, and it has a further advantage, inasmuch 

 as, should it be subsequently necessary to repeat the operation, the higher 

 seat mentioned is still at the operator's disposal. 



Having exposed the nerve and freed it from the surrounding struc- 

 tures, it should be brought through the cutaneous opening with the 

 tenaculum. The upper extremity of the exposed part should first be 

 severed with the scissors, and the distal severed end seized with a pair of 

 artery forceps. About one inch and a half of the nerve should be in 

 this manner excised. 



The nerve may be recognised by its longitudinal striation, by the fact 

 that it appears flatter than the artery, and lastly, of course, by the absence 

 of pulsation. If there is any doubt after the nerve has been exposed on 



