BILATERAL DIGITAL NEUROTOMY 163 



up with the forceps and cut away as before. Sometimes, 

 when the region is abnormal from disease, or when the in- 

 cision has not been accurately made, the ligament of the 

 ergot may not be observed in the dissection. In such an in- 

 stance superficial search of the parts is made to locate either 

 the nerve or the vein. If the nerve remains hidden the vein . 

 can be used as the land-mark for further search. In every 

 case the nerve will be found adjacent to its posterior aspect, 

 never far beneath its outer level and never anterior to it. 

 In some rare instances anomalies of these relations may 

 exist, but these are so very rare as to require no considera- 

 tion whatever. Suspected changed relations are generally 

 found to be non-existent when the nerve is finallly dis- 

 covered. 



Fifth Step. — Elevation of the Nerve. — Once discovered, 

 the trunk is loosened at one part of one border to give a 

 point of entrance for the nerve elevator, which may then be 

 easily slipped beneath it to the opposite side of the wound. 

 Unless this is respected the elevator, if pointed, might per- 

 forate the vein, and if blunted the parts are unnecessarily 

 disturbed, ' mutilated. When once the elevator is safely 

 passed beneath the trunk, a little tension is brought upon 

 one end so as to draw the trunk outward as the scalpel 

 loosens it from its loose areolar attachments from one angle 

 of the incision to the other. This done the elevator is 

 grasped with both hands, one at each end, and drawn firmly 

 outward until about one inch of the nerve trunk is dragged 

 out from above: 



Sixth Step. — The Neurotomy. — The nerve thus stretched 

 and now hanging loosely out of the wound, is divided first 

 at the proximal angle and then at the distal angle. The ob- 

 ject of thus stretching the nerve trunk before dividing it is to 

 encourage a degeneration as high up as possible. Any 

 divided nerve trunk will degenerate several nodes proxi- 

 mally; if stretched the degeneration will extend much higher 

 and as a consequence no neuromas nor painful scars will 

 supervene the operation. 



Seventh Step. — Suturing the Wound. — The incision is 

 freed from all blood and examined for hairs that might have 

 possibly floated into it, and is then sewed with a single in- 

 terrupted sfitch, mattress stitch, or preferably' the crucial 

 stitch, which is par excellence the best one for the small in- 

 cision of neurotomy. (Fig. 58.) 



Eighth Step. — Applying the Surgical Dressing. — In the 

 recumbent operations the patient might advantageously be 



