Lectures on the sympathetic innervation of striated muscle by the late John Irvine Hunter : delivered at University College, London by G. Elliot Smith.

  • Hunter, John Irvine, 1898-1924
Date:
1925
Catalogue details

Licence: Public Domain Mark

Credit: Lectures on the sympathetic innervation of striated muscle by the late John Irvine Hunter : delivered at University College, London by G. Elliot Smith. Source: Wellcome Collection.

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    on its end like a strabismus hook is useful for lifting the sympathetic trunk when defining its branches. Long straight, or slightly curved, artery forceps, 20 cm. long, are also essential, and four should be provided. The struc¬ tures of the abdominal wall and abdominal viscera demand a large, broad, and deep retractor. Hoyle’s retractor for use in operations on the average adult is 8.75 cm. wide and 12.5 cm. deep. It is constructed to act as a light-reflecting surface and has a shelf extending forward from its lower edge so as to depress structures medial to the ganglionated cord. The sympathetic trunk and the rami communicantes should be clearly defined before section. The method of dividing the rami communicantes is usually by avulsion. Each ramus may be seized bv a pair of artery forceps and drawn away from its lateral connexions, though in many instances it is necessary to divide a big ramus with a long pair of blunt-pointed scissors. In young subjects the rami may be easily and effectively broken with the blunt dis- sector. When ramisection of the second, third, and fourth lumbar nerves has been effected, the ganglionated cord is then divided at a level corresponding in position to the fourth lumbar nerve. The operation is then completed. The edges of the 1 umbo-dorsal fascia are first sutured in the region of the trigonum lumbale. The oblique muscles are then sutured to the crest of the ilium and a special point is made of suturing the tendinous portion of the external oblique to its original attachment and to the adjacent fascia lata. When this is done carefully the raw area on the crest of the ilium comes in contact with a raw area of considerable width on the under surface of the external oblique tendon, and this facilitates adhesion. The lumbo-dorsal fascia and the latissimus dorsi muscles are then sutured. The skin is closed without drainage. The whole operation should be performed with very little loss of blood except from small vessels occasionally en¬ countered in freeing the oblique muscles. There is no bleeding in the depth of the wound if the approach is confined to the plane between the peritoneum and the fascia covering the quadratics lumborum and the psoas muscles. Sharp instruments should not be introduced into this wound. The essential dissection can be done with blunt dissectors and long artery forceps. The ilio-hypogastric and ilio-inguinal nerves are both drawn forward with the abdominal wall and the ureter With the parietal peritoneum. The incision has been