514 THE THORAX AND VERTEBRAL COLUMN 



may be attacked by the operation of Costo-Transversectomy, 

 in cases where conservative treatment has failed and where 

 paralytic signs have not improved with rest, or when radiograms 

 suggest the presence of sequestra. As the result of the disease, 

 a certain degree of angular curvature is present, and the incision 

 begins near the most prominent spine. It is carried laterally 

 along the rib below, which is to be resected, and all the soft 

 structures are divided until the rib and the transverse process 

 with which it articulates are exposed. The periosteum is 

 elevated and the rib is divided lateral to its tubercle. The 

 transverse process is divided at its medial end and can be 

 disarticulated, after the ligamentum colli costae and its other 

 connections have been divided. The neck of the rib can then 



Right bronchus 



Left bronchus 

 I 



Oesophagus 



'--- Thoracic duct 

 Descending thoracic a rta *^K-^^l- Vena azygos 



Pleura 



Fifth thoracic vertebra 



FIG. 154. Diagram of a Transverse Section through the Upper Part 

 of the Posterior Mediastinum. 



be cut through close to the head. In the last-named step care 

 must be taken to leave the head of the rib intact, lest the 

 sympathetic trunk, which descends on the heads of the ribs, be 

 injured. The periosteum on the inner surface of the rib is next 

 divided and the pleura, which is now exposed, is retracted. 

 A finger can then be passed medially towards the vertebral 

 bodies, and it should be remembered that the disease is most 

 advanced in the vertebra above the one to which the resected 

 rib corresponds numerically. 



On the right side of the vertebral column the finger meets 

 with no obstruction, but below the level of the third thoracic 

 vertebra on the left side the descending thoracic aorta is 

 encountered (Fig. 154). 



Exposure of the (Esophagus. In the removal of a foreign 

 body from the oesophagus or a bronchus, or in excision of a 



