NEUROTOMY OF THE MEDIAN NERVE. 



175 



of the sterno-aponeuroticus muscle. Check any hemorrhage 

 from the skin, subcutis, or muscle. The tenacula are in- 

 serted cautiously in the lips of the wound, and these being 

 drawn apart the white anti-brachial fascia is brought into 

 view and a search is made with the index finger to determine 

 the exact location of the nerve, the fascia is divided with 

 the scalpel and an oval piece excised with the scissors im- 

 mediately over the nerve. If much fatty tissue is found be- 

 neath the fascia it may be dissected away carefully with the 

 scalpel or cut away with the scissors. There now comes in- 

 to view a delicate reddish colored fascia-like membrane, the 

 nerve sheath, behind which a dark cord, the brachial vein, 

 V, is visible, the latter being intimately connected with the 

 nerve sheath. The vein lies mostly behind and beneath the 

 nerve and may project out from beneath the border of the 

 same. The operator needs be careful not to prick this vein with 

 the tenacula, as the hemorrhage therefro?n is exceedi^igly annoy- 

 ing' during the operation. Avoid the use of tenacula after pene- 

 trating the fascia and retract the tvound lips cautiously with 

 aneurisr7i Jieedlcs instead. Still further forward and deeper 

 may be felt the pulsating brachial artery. Incise the nerve 

 sheath carefully and divide it upward and downward with 

 the scalpel or scissors, whereupon the yellowish and dis- 

 tinctly fibrous nerve comes into plain view. Pass an 

 aneurism needle beneath the nerve pushing it so far through 

 that the distal end is readily grasped and drawing it up and 

 down with the two hands, separate the nerve from the 

 adjacent tissues throughout the length of the wound. 

 Be careful to not cut the nerve too high ajid erroneously 

 include the motor nerve of the flexor of the metacarpus and 

 the flexors of the foot, which is generally giveyi off posteri- 

 ■orly just below the htcmero radial articulation. Lift the nerve 

 up and cut it through at the superior angle of the wound 

 by a sudden clip with the scissors or with the probe pointed 

 bistoury. Lay the peripheral end of the nerve bare to the 

 lower angle of the wound, and excise at least 3 cm. of it. 



