Ligations and amputations / by A. Broca.

  • Auguste Broca
Date:
1917
Catalogue details

Licence: In copyright

Credit: Ligations and amputations / by A. Broca. Source: Wellcome Collection.

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    coracobrachialis, into which it passes ; knowing that it springs from the outer head of the median, that nerve is easily found. R. Brachial in the Middle of the Arm.—Make a skin incision two inches long, preferably two or three millimetres in front of the line of the vessel, certainly not behind it, so as to reach the fleshy body of the biceps and not pass behind the muscle border. For this first step and the following the elbow is extended. There is nothing to fear in the subcutaneous tissue; the basilic vein is certainly behind the incision. Open the deep fascia, from end to end of the incision, over the biceps muscle, the border of which must always be seen before pro¬ ceeding further. (When the incision is made behind the line of the vessel, and the border of the biceps is not seen in the wound, the internal intermuscular septum is reached, and the operator runs the risk of dividing this behind the artery ; the ulnar nerve may then be taken for the median, and the inferior profunda artery for the brachial.) Free the border of the biceps by a stroke of the director from end to end of the wound, and have it raised, vertically, on the broad end of a retractor, flexing the elbow to relax the muscle. In its place, under a thin layer of fascia, lies the vasculonervous bundle ; open the fascia from end to end, either on a director or with the point of a scalpel ; nine times out of ten the median nerve will now appear. With a longitudinal stroke of the director, held flat to the arm, pass under the posterior surface of the nerve and have it raised, vertically, by the assistant, on the same retractor as the biceps. In place of the nerve the artery, with its two accompanying veins, is now seen ; clear the vessel, and pass the aneurysm needle indifferently from one side or the other. Remember that in about one case out of ten the nerve is behind the artery. C. The Brachial at the Bend of the Elbow.—The elbow is held extended, the forearm supinated. A nearly transverse incision is sometimes advised, but this is, in my opinion, very ugly, and does not give any better access than an incision parallel to the vessel, that is to say, made somewhat obliquely downwards and outwards along the internal border of the biceps tendon, over the point where the line of the brachial in the arm joins the line of the radial in the forearm. The incision should be two and a half inches long, and is supposed to be made half above and half below the fold of the elbow ; but since the artery deepens as it. descends, just as does the biceps tendon, the work is made easier if two-thirds of the incision is placed above, and one-third below, the bend of the elbow: a modest trick that will never count against a candidate in air examination (see Figs. 10 and 11). Always begin by an effort to define the course of the median basilic vein (Fig. 0), which may be made to fill and stand out by pressure
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