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A leading introduction to the Hebrew Bible Introduction to the

Hebrew
J ohn J. Collins’s Introduction to the Hebrew Bible is one of the most reliable and widely adopted critical textbooks
at undergraduate and graduate levels alike, and for good reason. Enriched by decades of classroom teaching, it is
aimed explicitly at motivated students, regardless of their previous exposure to the Bible or faith commitments. The
third edition is presented in a new and engaging format with new maps and images. An index has been added to the
volume for the first time. Collins

Bible
Praise for Introduction to the Hebrew Bible
“At last! This is the introduction to the Hebrew Bible I have been looking for: a balanced and richly informative
introduction that covers essential critical and comparative perspectives and sets up pertinent interpretive issues, leaving
the instructor free to work with the class in any number of directions. Using Collins’s textbook is like team-teaching
with a master teacher. His tone is welcoming but often wry, accessible yet authoritative. This is a textbook written by

Hebrew Bible
someone who not only knows his students but who genuinely likes them—and likes to challenge them. Collins does not

Introduction to the
take refuge in an antiquarian approach to the Hebrew Bible but repeatedly identifies the complex ethical issues raised
by the text and by the responsibilities involved in interpreting the text.”
Carol Newsom, Candler School of Theology
“John Collins’s introduction is a timely and welcome contribution, one based on his own extensive research and on his
many years of teaching the subject. The reader will find not only a careful presentation of the biblical material but also
a judicious assessment of scholarship on it. This book will be a valuable tool for classroom use, and the bibliographies
appended to each chapter will help the student who wishes to pursue a topic in greater detail.” T HI R D e d i t i o n
James C. VanderKam, emeritus, University of Notre Dame
“Drawing on years of teaching in seminary and university, and of addressing Christian and Jewish popular audiences,
Collins has produced a clear, concise, and up-to-date introduction to the Old Testament, including the deuterocanoni-
cal books. Wisely following the canonical order of books (slightly adapted), he describes each book’s contents, critical
issues, and religious meaning. Collins situates each biblical book squarely in its historical setting and deals honestly with
the problems as well as the bounty of the Bible. A special bonus is his masterful coverage of the often-slighted Second
Temple literature. Its seriousness, detail, and sophistication set this textbook apart and make it an excellent resource for
college and seminary courses, and for pastors and educated laity.”
Richard J. Clifford, SJ, emeritus, Boston College School of Theology and Ministry

John J. Collins is Holmes Professor of Old Testament Criticism and Interpretation

at Yale Divinity School and author of many works, including, from Fortress Press,
Encounters with Biblical Theology (2005), Does the Bible Justify Violence? (2004),
and Daniel (Hermeneia, 1994).
THIRD
edition

Religion / Old Testament

John j. collins
 Maps
The Fertile Crescent...............................................................................................................................14
Some Major Archaeological Sites in Anatolia and the Middle East............................................30
The World of the Patriarchs.................................................................................................................87
The Landscape of the Book of Exodus.......................................................................................... 112
Israel Physical........................................................................................................................................ 193
Israel Settlement before the Monarchy............................................................................................ 194
Canaanite Sites in the Late 13th/Early 12th Century b.c.e....................................................... 198
Major Archaeological Sites................................................................................................................ 202
12 Tribes of Israel................................................................................................................................ 210
Tribes of Israel before the Monarchy.............................................................................................. 219
Migration of the Sea Peoples............................................................................................................ 224
Saul’s Kingdom..................................................................................................................................... 238
Minimum Extent of David’s Kingdom........................................................................................... 254
Maximum Extent of David’s Kingdom........................................................................................... 255
Minimum Extent of Solomon’s Kingdom...................................................................................... 263
Ancient Trade Routes.......................................................................................................................... 266
Elijah and Elisha Narratives.............................................................................................................. 284
Israel and Judah under Jeroboam and Uzziah................................................................................ 292
Campaigns of Tiglath-pileser............................................................................................................ 295
Assyrian Empire................................................................................................................................... 297
The End of the Kingdom of Judah................................................................................................. 302
Sennacherib’s Invasion 701 b.c.e....................................................................................................... 348
Neo-Babylonian Empire..................................................................................................................... 356
The Persian Empire at its Zenith..................................................................................................... 411
Alexander the Great’s Invasion.......................................................................................................... 438
Alexander’s Empire at its Zenith....................................................................................................... 439

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 Judah as a Province of the Persian Empire 445–333 b.c.e......................................................... 462
Maccabean-Hasmonean Palestine 166–76 b.c.e........................................................................... 601
The Ptolemaic and Seleucid Empires c. 240 b.c.e........................................................................ 608
The Ancient Near East c. 60 b.c.e................................................................................................... 617

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 Illustrations
The Dead Sea Scrolls caves..................................................................................................................... 7
Isaiah Scroll................................................................................................................................................ 8
Amulet.......................................................................................................................................................23
Slab inscribed with cuneiform..............................................................................................................26
The Rosetta Stone..................................................................................................................................28
Sir Austen Layard removes human-headed bull................................................................................29
Cuneiform tablet with part of the Enumah Elish................................................................................36
Tablet XI of the Epic of Gilgamesh...................................................................................................38
Terracotta relief probably depicting the marriage of Inanna and Dumizi.................................40
Babylonian relief of winged and eagle-footed goddess...................................................................41
Bronze figurine of Baal..........................................................................................................................42
Bronze female figurine (Anat)..............................................................................................................46
Carved head of Akhenaten...................................................................................................................47
Cutaway illustration of an Egyptian pyramid...................................................................................48
Gold mask of Tutankhamun................................................................................................................49
Sculpture of Moses by Michelangelo.................................................................................................54
Noah builds the ark with his sons.......................................................................................................61
Ziggurat of Ur.........................................................................................................................................86
Horned altar from Beersheba...............................................................................................................92
Statue of Ramesses II......................................................................................................................... 108
Relief depicting Asian captives from Temple of Ramesses........................................................ 110
Traditional site of Mount Sinai....................................................................................................... 114
Statuette of Baal................................................................................................................................... 119
Akhenaten, Nefertiti and their children.......................................................................................... 132
Hammurabi receives the law from the god Marduk..................................................................... 135
Bronze calf, Samaria............................................................................................................................ 139

ix

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 Depiction of the tabernacle as described in Exodus.................................................................... 144
Ark of the covenant depicted on a stone relief ............................................................................. 153
Silver amulet found in the Hinnom Valley..................................................................................... 157
King Esarhaddon of Assyria and his mother................................................................................. 165
Tel Dan altar and high place, Israel.................................................................................................. 167
Terracotta figurines of women from Iron Age.............................................................................. 171
King Jehu prostrates himself before Shalmaneser III................................................................... 185
Canaanite cultic place in Stone Age Megiddo............................................................................... 192
Human skull from Jericho.................................................................................................................. 195
Neolithic tower in Jericho.................................................................................................................. 196
Merneptah Stele................................................................................................................................... 199
The goddess Astarte; pottery relief................................................................................................. 217
Egyptian wall relief depicting the Sea Peoples.............................................................................. 225
The Tel Dan inscription..................................................................................................................... 240
Statue of King David, Jerusalem....................................................................................................... 250
Stepped structure in Jerusalem.......................................................................................................... 256
Remains at Megiddo........................................................................................................................... 265
Ruins of six-chambered gate at Hazor............................................................................................ 267
Plans of the gateways at Megiddo, Hazor, and Gezer................................................................. 268
Aerial view of the remains of ancient Megiddo........................................................................... 269
Conjectural reconstruction of Solomon’s temple......................................................................... 271
Plans of Solomon’s temple and temples at Tayinet and Ain Dara, Syria................................. 272
Moabite Stone...................................................................................................................................... 275
Black Obelisk of Shalmaneser III..................................................................................................... 290
Assyrian king Tiglath-pileser............................................................................................................. 293
Assyrian king Sargon II....................................................................................................................... 294
Reconstruction of the citadel at Dur-Sharrukin.......................................................................... 296
Siloam inscription................................................................................................................................ 298

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 Cuneiform tablet from Babylon........................................................................................................ 301
Lamassu from Assyrian palace at Nimrud..................................................................................... 305
Clay models of livers........................................................................................................................... 308
Tiglath-pileser III, bas-relief............................................................................................................. 314
Ivory decoration from Samaria......................................................................................................... 318
Ruins of ancient Samaria................................................................................................................... 323
Bronze relief depicting mother and children................................................................................. 326
Sennacherib “sitting on the throne of judgment”........................................................................ 337
Winged lamassu from Nimrud......................................................................................................... 338
The so-called “Sennacherib Prism”................................................................................................. 345
Relief from Nineveh depicting Assyrian assault........................................................................... 346
Sennacherib on his throne before the city of Lachish.................................................................. 349
Black basalt monument of Esarhaddon.......................................................................................... 350
King Ashurbanipal in lion hunt........................................................................................................ 353
Reconstructed image of ancient Babylon....................................................................................... 362
Auroch glazed brick tile from Babylon............................................................................................ 369
Reconstruction of the Ishtar Gate, Babylon.................................................................................. 374
“Sirrush” from the Ishtar Gate, Babylon........................................................................................ 378
The goddess Astarte; terracotta figurine......................................................................................... 388
The so-called Cyrus Cylinder........................................................................................................... 407
Cave where the Isaiah scroll was discovered................................................................................... 421
Darius I receives a foreign delegation.............................................................................................. 428
Persian warriors; painted relief from Susa...................................................................................... 430
Palace of Darius the Great, Persepolis............................................................................................ 433
Alexander and Bucephalus at the battle of Issus........................................................................... 440
Assyrian relief from Babylon............................................................................................................. 455
Tomb of Cyrus at Pasargadae, Iran.................................................................................................. 461
Shallow drinking vessel, known as a phiale.................................................................................... 469

ILLUSTRATIONS xi

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 Assyrian scribes..................................................................................................................................... 479
Temple Mount, Jerusalem.................................................................................................................. 483
Inside Hezekiah’s Tunnel.................................................................................................................... 488
Lyre players depicted on Lachish relief........................................................................................... 496
Baal from Megiddo, Israel.................................................................................................................. 499
Statue of Amenemhet III................................................................................................................... 523
Coffin fragment of Isis mourning.................................................................................................... 533
Statuette of Job, showing ulcers........................................................................................................ 542
Remains of Persepolis......................................................................................................................... 566
Sculpture “Tobit and the Angel” by Mari Andriessen................................................................. 572
Babylonian clay brick from sixth century b.c.e.............................................................................. 582
Coin of John Hyrcanus...................................................................................................................... 598
Coin of Antiochus IV Epiphanes.................................................................................................... 599
Bronze coin issued under Antigonus II........................................................................................... 603
Aerial view of Masada, Israel............................................................................................................ 610
Plato. Etching by Cunego................................................................................................................... 622
“Creation of Man” by Michelangelo............................................................................................... 629

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 Preface
This book is written out of the experience of teaching introductory courses on the
Old Testament or Hebrew Bible at several different institutions over thirty years. The
students in these courses have included Catholic seminarians (at Mundelein Seminary
and the University of Notre Dame), undergraduates (at DePaul, Notre Dame, and the
University of Chicago), master of divinity students of all denominations (at Chicago
and Yale), and master of arts students who, like the undergraduates, might have a
religious commitment, or might not. They have been predominantly Christian, but have
also included good numbers of Jews and Unitarians (especially at Chicago). Most of
these students came to the courses with some knowledge of the Bible, but some were
unencumbered by any previous knowledge of the subject. This introductory textbook is
written to meet the needs of any or all such students. It presupposes a certain level of
literacy, and some previous acquaintance with the Bible would definitely be helpful. It is
intended, however, as a book for those who are beginning serious study rather than for
experts. It is meant to be ecumenical, in the sense that it does not seek to impose any
particular theological perspective, but to provide information and raise questions that
should be relevant to any student, regardless of faith commitment. The information is
largely drawn from the history, archaeology, and literature of the ancient Near East.
The questions are primarily ethical, and reflect the fact that people of different faith
commitments continue to read these texts as Scripture in the modern world.
The introduction is historical-critical in the sense that it emphasizes that the
biblical text is the product of a particular time and place and is rooted in the culture of
the ancient Near East. Since much of the Old Testament tells an ostensibly historical
story, questions of historical accuracy must be addressed. In part, this is a matter
of correlating the biblical account with evidence derived from archaeology and
other historical sources. But it also leads to a discussion of the genre of the biblical
text. The history-like appearance of biblical narrative should not be confused with
historiography in the modern sense. Our best guide to the genre of biblical narrative
is the corpus of literature from the ancient Near East that has been recovered over the
last two hundred years.
This introduction, however, is not only historical in orientation. The primary
importance of the Old Testament as Scripture lies in its ethical implications. In some
cases, biblical material is ethically inspiring—the story of liberation from slavery in
Egypt, the Ten Commandments, the preaching of the prophets on social justice. In
other cases, however, it is repellent to modern sensibilities. The command to slaughter
the Canaanites is the showcase example, but there are numerous issues relating to slaves,
women, homosexuality, and the death penalty that are, at the very least, controversial in
a modern context. In any of these cases, whether congenial to modern sensibilities or
not, this introduction tries to use the biblical text as a springboard for raising issues of
enduring importance. The text is not a source of answers on these issues, but rather a

xiii

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 source of questions. Most students initially see the text through a filter of traditional
interpretations. It is important to appreciate how these traditional interpretations
arose, but also to ask how far they are grounded in the biblical text and whether other
interpretations are possible.
Since this book is intended for students, I have tried to avoid entanglement in
scholarly controversies. For this reason, there are no footnotes. Instead, each chapter is
followed by suggestions for further reading. These suggestions point the student especially
to commentaries and reference works that they can use as resources. Inevitably, the
bibliographies are highly selective and consist primarily of books that I have found useful.
Many other items could be listed with equal validity, but I hope that these suggestions
will provide students with a reliable place to start. Since they are intended primarily for
American students, they are limited to items that are available in English.
A large part of this book was written in 2000–2001, when I enjoyed a sabbatical
year by courtesy of the Luce Foundation and Yale University. I am grateful to the Luce
Foundation for its financial support and for the stimulation of two conferences with
other Luce fellows. I am especially grateful to Richard Wood, then dean of Yale Divinity
School, for making it possible for me to have a sabbatical in my first year at Yale.
I am also indebted to Samuel Adams, my graduate assistant in the production of this
book, to Tony Finitsis, Patricia Ahearne-Kroll, John Ahn, and Matt Neujahr, who served
as teaching assistants in my introductory course at Yale and gave me valuable feedback, and
to the staff at Fortress, especially K. C. Hanson and Jessica Thoreson, who saw the book
through the production process.
The book is dedicated to the students of Yale Divinity School.

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 Preface to the Second Edition
This revised second edition has updated bibliographies and is presented in a different
format from the original.
I have made only minor changes to the text. I have moved the discussion of the book
of Jonah from chapter 26 (the Hebrew Short Story) to chapter 20 (Postexilic Prophecy).
I have separated out introductory comments on the Deuteronomistic History, Prophecy
and the Writings. I have revised my analysis of the flood in chapter 2. Numerous smaller
changes are scattered throughout the book.
I would like to thank Joel Baden and Ron Hendel for their comments and suggestions.
I am especially grateful to Neil Elliott and the staff at Fortress for shepherding this
revision through the publication process.

xv

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 Preface to the Third Edition
The changes to this new third edition are largely visual, since the content is virtually
unchanged from the second edition. In this edition, the format is now presented in a one-
column design, which allows for more flexibility in the placement and size of the images
in the volume. A number of new images have been introduced, while some of the images
in the second edition have been replaced.
This third edition also features a new map design emphasizing greater readability, and
a number of new maps have been added. A significant new feature of this edition is the
addition of a full index.

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 Abbreviations
AB Anchor Bible
ABD Anchor Bible Dictionary. Edited by D. N. Freedman. 6 vols. Garden City,
NY: Doubleday, 1992
AnBib Analecta biblica
ANET Ancient Near Eastern Texts Relating to the Old Testament. Edited by J. B.
Pritchard. 3rd ed. Princeton: Princeton University Press, 1969
BA Biblical Archaeologist
BAR Biblical Archaeology Review
BETL Bibliotheca ephemeridum theologicarum lovaniensium
Bib Int Biblical Interpretation
BZAW Beihefte zur Zeitschrift für die alttestamentliche Wissenschaft
CBQMS Catholic Biblical Quarterly Monograph Series
CC Continental Commentaries
CEJL Commentaries on Early Jewish Literature
CHANE Culture and History of the Ancient Near East
ConBOT Coniectanea biblica (Old Testament series)
FOTL Forms of the Old Testament Literature
GBS Guides to Biblical Scholarship
HSM Harvard Semitic Monographs
HTR Harvard Theological Review
ICC International Critical Commentary
ITC International Theological Commentary
JBL Journal of Biblical Literature
JPS Jewish Publication Society
JSJSup Journal for the Study of Judaism Supplement Series
JSOT Journal for the Study of the Old Testament
JSOTSup Journal for the Study of the Old Testament Supplement Series

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 LXX Septuagint (Greek version)
MT Masoretic text
NCB New Century Bible
NIB New Interpreter’s Bible
NICOT New International Commentary on the Old Testament
NRSV New Revised Standard Version
OBT Overtures to Biblical Theology
OEANE Oxford Encyclopedia of Archaeology in the Near East. Edited by E. M. Meyers.
5 vols. New York: Oxford University Press, 1997
OTL Old Testament Library
SBL Society of Biblical Literature
SBLDS SBL Dissertation Series
SBLEJL SBL Early Jewish Literature Series
SBLMS SBL Monograph Series
SBLWAW SBL Writings from the Ancient World
VTE Vassal Treaties of Esarhaddon
VTSup Supplements to Vetus Testamentum
WBC Word Biblical Commentary
WMANT Wisssenschaftliche Monographien zum Alten und Neuen Testament

xviii INTRODUCTION TO THE HEBREW BIBLE

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 Introduction

The following pages will introduce the different canons of the Hebrew
Bible and Old Testament, considerations regarding the text of the Bible,
questions about the Bible and history, and methods of biblical scholarship.

WHAT ARE THE HEBREW BIBLE AND OLD TESTAMENT?

The writings that make up the Hebrew Bible or Christian Old Testament are by any
reckoning among the most influential writings in Western history. In part, their influence
may be ascribed to their literary quality, which establishes them as enduring classics—
think, for example, of the depiction of the human predicament in the book of Job. But
not all books of the Bible are literary classics, nor does their importance depend on their
literary merit. The place of the Bible in Western culture derives from the fact that these
books are regarded as sacred Scripture by Jews and Christians and are consequently viewed
as authoritative in a way that other literary classics are not. The idea of sacred Scripture,
however, is by no means a clear one, and it is taken to mean very different things by
different people. Some conservative Christians regard the Bible as the inspired word of
God, verbally inerrant in all its details. At the liberal end of the spectrum, others regard
it only as a witness to the foundational stages of Western religion.
It is often the case that people who hold passionate beliefs about the nature of the
Bible are surprisingly unfamiliar with its content. Before we can begin to discuss what it
might mean to regard the Bible as Scripture, there is much that we need to know about
it of a more mundane nature. This material includes the content of the biblical text, the
history of its composition, the literary genres in which it is written, and the problems
and ambiguities that attend its interpretation. It is the purpose of this book to provide
such introductory knowledge. If the Bible is Scripture, then the idea of Scripture must be
formed in the light of what we actually find in the biblical text.

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 THE DIFFERENT CANONS OF SCRIPTURE
The Hebrew Bible and the Old Testament are not quite the same thing.
The Hebrew Bible is a collection of twenty-four books in three divisions: the Law
(Torah), the Prophets (Nebi’im), and the Writings (Ketubim), sometimes referred to by the
acronym Tanak.
The Torah consists of five books: Genesis, Exodus, Leviticus, Numbers, and
Deuteronomy (traditionally, the books of Moses).
The Prophets are divided into the four books of the Former Prophets (Joshua, Judges,
Samuel, and Kings; 1 and 2 Samuel and 1 and 2 Kings are each counted as one book)
and the four books of the Latter Prophets (Isaiah, Jeremiah, Ezekiel, and the Twelve; the
Twelve Minor Prophets [Hosea, Joel, Amos, Obadiah, Jonah, Micah, Nahum, Habakkuk,
Zephaniah, Haggai, Zechariah, Malachi] are counted as one book).
The Writings consist of eleven books: Psalms, Proverbs, Job, Song of Songs (or
Canticles), Ruth, Lamentations, Qoheleth (or Ecclesiastes), Esther, Daniel, Ezra-
Nehemiah (as one book), and Chronicles (1 and 2 Chronicles as one book).
The Christian Old Testament is so called in contrast to the New Testament, with the
implication that the Old Testament is in some sense superseded by the New. Christianity
has always wrestled with the theological significance of the Old Testament. In the second
century c.e., Marcion taught that Christians should reject the Old Testament completely,
but he was branded a heretic. The Old Testament has remained an integral part of the
Christian canon of Scripture. There are significant differences, however, within the
Christian churches as to the books that make up the Old Testament.
The Protestant Old Testament has the same content as the Hebrew Bible but arranges the
books differently. The first five books are the same but are usually called the Pentateuch
rather than the Torah. Samuel, Kings, Ezra-Nehemiah, and Chronicles are each counted
as two books, and the Minor Prophets as twelve, yielding a total of thirty-nine books.
The Former Prophets are regarded as historical books and grouped with Chronicles and
Ezra-Nehemiah. Daniel is counted as a prophetic book. The (Latter) Prophets are moved
to the end of the collection, so as to point forward to the New Testament.
The Roman Catholic canon contains several books that are not in the Hebrew Bible or
the Protestant Old Testament: Tobit, Judith, Wisdom of Solomon, Ecclesiasticus (or the
Wisdom of Jesus, son of Sirach = Ben Sira), Baruch, Letter of Jeremiah (= Baruch 6),
1 and 2 Maccabees. Furthermore, the books of Daniel and Esther contain passages that
are not found in the Hebrew Bible. In the case of Daniel, these are the Prayer of Azariah
and the Song of the Three Young Men, which are inserted in Daniel 3, and the stories of
Susanna and Bel and the Dragon.
The Greek Orthodox Church has a still larger canon, including 1 Esdras (which
reproduces the substance of the book of Ezra and parts of 2 Chronicles and Nehemiah),
Psalm 151, the Prayer of Manasseh, and 3 Maccabees. A fourth book of Maccabees
is included in Greek Bibles but is regarded as an appendix to the canon, while another
book, 2 Esdras, is included as an appendix in the Latin Vulgate. These books are called
Apocrypha (literally, “hidden away”) in Protestant terminology. Catholics often refer to

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 them as “deuterocanonical” or “secondarily canonical” books, in recognition of the fact
that they are not found in the Hebrew Bible.
Some Eastern Christian churches have still more extensive canons of Scripture. The
books of Jubilees and 1 Enoch attained canonical status in the Ethiopian church.

Why Are There Different Canons of Scripture?

By “canon” we mean here simply the list of books included in the various Bibles. Strictly
speaking, “canon” means “rule” or “measuring stick.” The word was used in the plural by
librarians and scholars in ancient Alexandria in the Hellenistic period (third and second
centuries b.c.e.) with reference to literary classics, such as the Greek tragedies, and in
Christian theology it came to be used in the singular for the Scriptures as “the rule of
faith,” from the fourth century c.e. on. In its theological use, canon is a Christian concept,
and it is anachronistic in the context of ancient Judaism or even of earliest Christianity. In
common parlance, however, “canon” has come to mean simply the corpus of Scriptures,
which, as we have seen, varies among the Christian churches.
The differences between the various canons can be traced back to the differences between
the Scriptures that became the Hebrew Bible and the larger collection that circulated in
Greek. The Hebrew Bible took shape over several hundred years and attained its final form
only in the first century c.e. The Torah was the earliest part to crystallize. It is often associated
with the work of Ezra in the fifth century b.c.e. It may have been substantially complete a
century before that, at the end of the Babylonian exile (586–539 b.c.e.), but there may have
also been some additions or modifications after the time of Ezra. The Hebrew collection of
the Prophets seems to have been formed before the second century b.c.e. We find references
to the Torah and the Prophets as authoritative Scriptures in the second century b.c.e., in
the book of Ben Sira (Ecclesiasticus) and again in the Dead Sea Scrolls (in a document
known as 4QMMT). The book of Daniel, which was composed about 164 b.c.e., did
not find a place among the Prophets in the Hebrew Bible, and this has often been taken
as an indication that the collection of the Prophets was already fixed at the time of its
composition. The preface to the book of Ben Sira also mentions other writings that were
regarded as authoritative. There does not, however, seem to have been any definitive list of
these writings before the first century c.e. Most references to the Jewish Scriptures in the
writings of this period (including references in the New Testament) speak only of “the
Law and the Prophets.” The Psalms are sometimes added as a third category. The Dead Sea
Scrolls include a Psalms Scroll that has additional psalms, and this would seem to indicate
that the canonical collection of psalms had not yet been fixed. The first references to a fixed
number of authoritative Hebrew writings are found toward the end of the first century c.e.
The Jewish historian Josephus gives the number as twenty-two, while the Jewish apocalypse
of 4 Ezra (contained in 2 Esdras 3–14) speaks of twenty-four. It is possible, however, that
both had the same books in mind but that Josephus combined some books (perhaps Judges-
Ruth and Jeremiah-Lamentations) that were counted separately in 4 Ezra.
The fixing of the Hebrew canon is often associated with the so-called Council of
Jamnia, the discussions of an authoritative group of rabbis in the period after the fall of
Jerusalem in 70 c.e. It is misleading, however, to speak of a “Council of Jamnia,” since

Introduction 3

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 CANONS OF THE HEBREW BIBLE/OLD TESTAMENT
The Hebrew Bible Protestant Old Testament

Torah: Pentateuch: Prophets

Genesis Genesis Isaiah
Exodus Exodus Jeremiah
Leviticus Leviticus Lamentations
Numbers Numbers Ezekiel
Deuteronomy Deuteronomy Daniel
Hosea Nahum
Prophets (Former): Historical Books Joel Habakkuk
Joshua Joshua Amos Zephaniah
Judges Judges Obadiah Haggai
Samuel (1 and 2) Ruth Jonah Zechariah
Kings (1 and 2) 1 Samuel Micah Malachi
2 Samuel
Prophets (Latter): 1 Kings Apocrypha
Isaiah 2 Kings 1 Esdras
Jeremiah 1 Chronicles 2 Esdras
Ezekiel 2 Chronicles Tobit
Minor Prophets (“The Ezra Judith
Twelve”): Hosea, Joel, Nehemiah Additions to Esther
Amos, Obadiah, Jonah, Esther Wisdom of Solomon
Micah, Nahum, Habakkuk,
Ecclesiasticus (Wisdom of Sirach)
Zephaniah, Haggai,
Poetry/Wisdom Baruch
Zechariah, Malachi
Job Letter of Jeremiah
Psalms Prayer of Azariah and Song of the
Writings:
Proverbs Three Young Men
Psalms
Ecclesiastes (Qoheleth) Susanna
Proverbs
Song of Solomon (Songs) Bel and the Dragon
Job
Prayer of Manasseh
Song of Songs
1 Maccabees
Ruth
2 Maccabees
Lamentations
Qoheleth (Ecclesiastes)
Esther
Daniel
Ezra-Nehemiah
Chronicles (1 and 2)

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 CANONS OF THE HEBREW BIBLE/OLD TESTAMENT
Roman Catholic Old Testament

Pentateuch Poetry/Wisdom Prophets

Genesis Job Isaiah
Exodus Psalms (Greek and Russian Orthodox Jeremiah
Leviticus Bibles include Psalm 151 and Prayer Lamentations
Numbers of Manasseh) Baruch (includes Letter of Jeremiah)
Deuteronomy Proverbs Ezekiel
Ecclesiastes (Qoheleth) Daniel (with additions)
Historical Books Song of Solomon (Songs) Hosea
Joshua Wisdom of Solomon Joel
Judges Ecclesiasticus (Wisdom of Sirach) Amos
Ruth Obadiah
1 Samuel Jonah
2 Samuel Micah
1 Kings Nahum
2 Kings Habakkuk
1 Chronicles Zephaniah
2 Chronicles Haggai
Ezra (Greek and Russian Orthodox Zechariah
Bibles also include 1 Esdras, and Malachi
Russian Orthodox includes 2
Esdras)
Nehemiah
Tobit
Judith
Esther (with additions)
1 Maccabees
2 Maccabees
(Greek and Russian
Orthodox Bibles include
3 Maccabees)

Introduction 5

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 it suggests a meeting like the great ecumenical councils of the Christian church in later
centuries. Before the fall of Jerusalem, Rabbi Johanan ben Zakkai established an academy
in the coastal city of Jamnia, and this academy assumed a leadership role after the fall.
Its discussions, however, had the character of a school or court rather than of a church
council. We know that the rabbis debated whether some books (Qoheleth and Song of
Songs) “make the hands unclean” (that is, whether they are holy books and should be
included among the Scriptures). There seems, however, to have been further discussions
of this kind at a later time, and there is no evidence that the rabbis proclaimed a formal
list of Scriptures. Nonetheless, it is at this time (70–100 c.e.) that we first find references
to a fixed number of authoritative books. It may be that the list adopted consisted of the
books that were accepted by the Pharisees already before the fall of Jerusalem.
It is important to recognize that the books that were included in the Hebrew Bible
were only a small selection from the religious writings that were current in Judaism around
the turn of the era. A larger selection was preserved in the Greek Scriptures that were
taken over by the early Christians, but had been already developed in Jewish communities
outside the land of Israel, especially in Alexandria in Egypt. According to legend, the
Torah had been translated into Greek at the request of Ptolemy II Philadelphus, king of
Egypt, in the first half of the third century b.c.e., by s­ eventy-two elders. (The story is told
in the Letter of Aristeas, a Greek composition from the second century b.c.e.) The translation
became known as the Septuagint or LXX (Septuagint means “seventy”). The name was
eventually extended to cover the whole collection of Greek Scriptures. These included
translations of some books that were written in Hebrew but were not included in the
Hebrew Bible (e.g., the book of Ben Sira, 1 Maccabees) and also some books that never
existed in Hebrew but were composed in Greek (2 Maccabees, Wisdom of Solomon).
There has been some debate as to whether the Jews of Alexandria had a larger collection
of Scriptures than the Jews in the land of Israel. But there is no evidence that there ever
existed a distinct Alexandrian canon. Rather, the Jews of Alexandria did not set a limit
to the number of the sacred writings, as the rabbis did after the fall of Jerusalem. The
Jewish community in Alexandria was virtually wiped out in the early second century c.e.
Christians who took over the Greek Scriptures of the Jews, then, inherited a larger and
more fluid collection than the Hebrew Bible. Centuries, later, there is still considerable
variation among the lists of Old Testament books cited by the church fathers.
When Jerome translated the Bible into Latin about 400 c.e., he was troubled by the
discrepancies between the Hebrew and Greek Bibles. He advocated the superiority of
the Hebrew (Hebraica veritas, “the Hebrew truth”) and based his translation on it. He also
translated the books that were not found in the Hebrew but accorded them lesser status.
His translation (the Vulgate) was very influential, but nonetheless the Christian church
continued to accept the larger Greek canon down through the Middle Ages. At the time
of the Reformation, Martin Luther advocated a return to the Hebrew canon, although
he also translated the Apocrypha. In reaction to Luther, the Catholic Church defined its
larger canon at the Council of Trent in the mid-sixteenth century.
It should be apparent from this discussion that the list of books that make up the
Hebrew Bible and the Christian Old Testament emerged gradually over time. The list

6 INTRODUCTION TO THE HEBREW BIBLE

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Another random document with
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duodenal opening, there is need for extreme care at the corners and
angles of the suture margins, as here tearing of stitches or
separation by tension, perhaps during the act of vomiting, are most
likely to occur. Fig. 553 indicates the first of the procedures above
mentioned.

Fig. 551

Resection of the pylorus. This figure illustrates the method of fitting the duodenum
to the stomach when the gap in the stomach is too large to fit the duodenum.
(Richardson.)
 Fig. 552

Resection of the pylorus. (The same as Fig. 551). Suture of the stomach to the
duodenum completed. (Richardson.)

In performing complete gastrectomy the cardiac end of the

stomach is brought down and fitted to the upper end of the divided
duodenum, after removal of the stomach, which will usually be
possible under favorable circumstances, but which exposes the
patient to great risks of tearing apart reunited surfaces by undue
tension.
—This consists in making an anastomotic opening between the
stomach and the uppermost part of the jejunum, the duodenum
proper being too bound down in its course to permit of its utilization
for this purpose. Gastro-enterostomy, then, should be referred to as
 Fig. 553 Gastric Anastomosis.gastroj
ejunost
omy. In brief, it consists in
making an opening by which the
stomach shall empty directly into
the upper bowel, and while, for
this purpose, one of the
uppermost loops would
theoretically suffice, it has been
found that the shorter the loop,
i. e., the portion between the
duodenum proper and the upper
part of the bowel used for this
purpose, the better for the
patient.
Gastrojejunostomy is, first of
all, referred to as anterior or
posterior, according to whether a
loop of bowel be brought up in
front of the omentum and around
it, and attached to the anterior
and exposed wall of the
stomach, or whether the lesser
peritoneal cavity be opened by
perforating the omentum behind
the colon and below the
stomach, so that the posterior
wall of the latter is found, drawn
into the wound, and made
Resection of the pylorus according to accessible and utilized for the
Billroth’s second method. (Bergmann.) purpose. The anterior operation
is the easier of performance, but
the posterior is far preferable in most instances. Should it be found
that the posterior wall of the stomach is far more involved in
cancerous infiltration than the anterior, the anterior operation should
be performed.
 Simple as is the procedure in theory there are about it one or two
complications which were not at first foreseen. Perhaps the most
important of these is that bile emptied into the duodenum passes
downward until it has an opportunity to escape through the opening
directly into the stomach, usually in the direction of least resistance.
This may then carry it where it is a most undesirable fluid, and
prevent its passage onward into the intestine, where it is
physiologically needed. This circulation of bile has been spoken of
as the “vicious circle” and it is the formation of a vicious circle which
has complicated not a few of the anastomotic stomach cases, and
which has engaged the attention of not a few clinicians and
operating surgeons.
The second objection is that the contact of stomach contents with
the mucous membrane at a point below where the bowel is normally
prepared for it, and before intestinal contents have been prepared by
bile or materials alkalinized by this fluid, sometimes leads to the
formation of ulcer just opposite the opening, and this has been
referred to as peptic ulcer of the jejunum. This is a possible though
not a frequent complication, but has added weight to the other
considerations regarding the best way of performing anastomosis.
Again, it has been feared that this anastomotic opening would
contract in time, or sometimes completely close. This objection
obtains especially with anastomosis, made with a Murphy button, or
its equivalent, and can rarely be made against the ordinary suture
methods. Again, if the opening in the intestine be made too long the
intestine itself may be narrowed, for too much of the circumference
of the bowel may be taken up in the formation of the anastomosis,
and thus there will be mechanical obstruction with vicious circle.
“Vicious circle” produces symptoms which do not appear until the
lapse of at least three days after the operation. If vomiting should
persist and retain a bilious character it is to be feared that some
complication of this kind has occurred. Under these circumstances
when lavage is practised a large amount of fluid mixed with bile,
perhaps blood, may be returned.
Much depends also on the exact location of the attachment of the
intestinal loop to the stomach. Other difficulties arise from possible
twisting of the loop of small intestine, or its strangulation by being
entangled beneath the bridge of the jejunum, which is always made
in every anastomosis. Again the small intestine may become
incarcerated in an imperfectly closed opening made in the
mesocolon. It will thus be seen that the posterior method has
disadvantages which need to be fully appreciated. On the other hand
it has this great advantage, that it permits of drainage or emptying of
the stomach into the jejunum by gravity, in almost any position which
the patient would ordinarily assume, either sitting or lying. Many
operators have devised methods of preventing formation of the
vicious circle.
Fig. 554 illustrates how valves may form which there is no sure
method of preventing. Fig. 555 represents the suggestion of Braun,
to make a second anastomotic opening between the small intestine
above the stomach opening and below it, hoping that in this way bile,
for instance, may pass directly through this opening, which it will first
meet, into the intestine below, and thus not pass on and into the
stomach. Others have divided the loop of jejunum after making the
second anastomosis, in this way planting the efferent portion of the
bowel in the stomach and then planting the afferent portion of the
bowel into the side of the efferent part. This is the so-called Y-
gastrojejunostomy. Roux does much the same thing, save that his
method is all carried out behind the colon instead of in front of it. The
principal argument in favor of the use of the Murphy button, in this
procedure, is that vicious circle is less frequent after its use than
after most of the suture methods, all of which would simply indicate
that vicious circle is largely a matter of valve formation, and that by
the time the button is loosened and passed on the danger period
seems to have elapsed, and the current in the new direction to be
well established. Nevertheless the button is now discarded by almost
everyone in favor of the suture.
 Fig. 554 Fig. 555

Formation of valves in gastro- Gastro-enterostomy with entero-

enterostomy: 1, intestinal valve; 2, right- anastomosis according to Braun.
sided gastro-intestinal valve. (Bergmann.)
(Bergmann.)

Gastro-enterostomy.—Artificial anastomotic opening between the

cavity of the stomach and some part of the
intestine below is indicated in a number of conditions, which have
been discussed. It is done mainly, however, for two good reasons:
first, to atone for pyloric stenosis, and, secondly, to give the stomach
a more physiological rest in cases of gastric ulcer, permitting food to
pass readily from it into the jejunum, with a minimum of gastric
activity or disturbance. This particular form of anastomosis is but the
application to these viscera of a general principle, which in various
ways, in different parts of the body, has constituted one of the
greatest features in the advance of modern surgery.
The operation is practised in two ways. In the anterior operation
the highest accessible loop of small intestine is brought up in front of
the omentum, or else the omentum is fenestrated in such a way that
the bowel shall be brought through its window, and then attached to
the anterior wall of the stomach, where the latter is much more
accessible. In this operation there is less handling of the stomach
and bowel, and, in general, it is easier of performance. Nevertheless
the bowel loop itself may become adherent to the abdominal wound
and give rise to pain, or even obstruction simulating the vicious
circle. Volvulus of the jejunum has also followed it. Another objection
is that as the patient gains flesh the weight of the transverse colon
and omentum sometimes causes dragging upon the loop, which may
cause serious trouble. The opening thus made is not where gravity
will afford the best drainage of the stomach, and it is now considered
undesirable in almost all cases save those where one is compelled
to its performance, either by necessity for haste, or because the
posterior wall of the stomach is so involved in cancerous infiltration
as to afford no suitable area for fixation and opening. This method is
of use mainly in dealing with malignant disease.
The posterior operation calls for all the resources of a perfected
technique, and takes longer in performance. Nevertheless when
once the anastomosis is safely effected it is more satisfactory.
The posterior operation alone, therefore, will be described at
length in this place, and only that form of it which discards the
anastomotic loop, the writer quite agreeing with the Mayos, who
have had larger experience with this operation than any other
surgeons, and who advise the direct attachment of the jejunum, as
near as possible to the termination of the duodenum, without further
complication by operative procedure. The direction of active
propulsion from the stomach comes from its pyloric end, the larger
end of the stomach being mainly for storage purposes and having
thus a forceful action; consequently the preferable site for the
stomach opening is on a line with the longitudinal part of the lesser
curvature, with its lower end at the bottom of the stomach. The
Mayos have abandoned reversing the jejunum and now apply it
directly to the posterior wall of the stomach from right to left exactly
as it lies under normal conditions, having had better results with this
method than with any other.
In brief the operation is as follows: Incision is made a little to the
right of the median line, the transverse colon is withdrawn by steady
traction to the right and upward, and the mesocolon made to follow it
until the jejunum comes into view. The latter is then grasped at a
distance of three or four inches from its origin. When, now, it is
drawn tight the fold of peritoneum which covers the so-called
ligament of Treitz is demonstrated; this is a small band containing
muscle fibers, having its origin on the transverse mesocolon and
extending down to the beginning of the jejunum, thus acting as a
suspensory ligament. It leads to the base of the vascular arch of the
middle colic artery, and indicates the place where the mesocolon
should be torn through in order to expose the posterior wall of the
stomach. At this point, in the least vascular area which can be
discovered, the mesocolon is first incised and then torn, until a good
liberal opening is made, through which the posterior wall of the
stomach is easily exposed, and, later, drained. It should be forced
through this opening by combined manipulation with one hand
introduced above it and gently urging it through the opening where it
presents. It may be easily identified by its resemblance to its anterior
surface in its thickness, the arrangement of its vessel and the like.
The posterior wall alone is then secured and drawn through the
mesocolic window, in such a way that after the jejunum is attached to
it the anastomotic opening can be made at a point one inch above
the greater curvature and ending at the bottom of the stomach two
and a half inches to the left of the pylorus. This area having been
exposed and prepared, a considerable portion of it is drawn into a
pair of specially constructed clamps (Doyen’s or Moynihan’s), whose
blades are usually protected with rubber. The Mayos prefer to have
the handles lying to the right and to direct the forceps transversely to
the body axis. Moynihan prefers to reverse this direction and make
them point to the right shoulder. The stomach being thus protected,
and prevented from slipping by suitable tightening of the clamps, the
jejunum is similarly secured with forceps lying in a direction parallel
to the first, having within their grasp a portion of the gut extending
between points one and a half and three and a half inches from its
origin. If this be properly effected the left low point of the stomach
lies in the grasp of one pair of clamps and the first part of the
jejunum in that of the other, and these two portions should be easily
brought into close contact with each other. A gauze pad having been
placed behind the damps in order to avoid soiling, should there be
any leakage of intestinal contents, the clamps should now be
carefully and attentively held by an assistant, and their distal ends
may even be bound together in such a way that, after the suturing
process has once begun, nothing shall disturb the perfect contact
between the surfaces thus mutually applied. The first row of sutures,
usually of the ordinary continuous type, is made of silk or thread, the
serous and muscular coats being seized and united over a line some
two inches in length, the suture being carefully secured at either end
of this line. Next, with a scalpel, an incision is made through the
serous and muscular coats, parallel to the line of sutures, at a
distance of about one-quarter of an inch, and over a length a trifle
less than that of the line which they occupy. Here the vessels will
bleed freely and forceps may be momentarily used for their
securement. Through the opening thus made the mucous membrane
will prolapse. Moynihan especially has shown that it is not enough to
merely incise this membrane in the same direction as the other
coats, but that a narrow elliptical portion of it should be excised,
since it tends to prolapse. Therefore with knife or scissors a strip of
the mucosa, perhaps a half-inch in width, should be cut away from
either surface, thus widely opening into and exposing the interior
respectively of the stomach and of the gut. Extreme pains should
now be given to prevent both leakage and soiling, and instruments
used upon the mucosa should be discarded after it has been divided
and sutured. Now with reliable chromicized catgut a row of
continuous sutures is applied by which all three coats of both cavities
are bound snugly together, the needle passing through six distinct
layers as each stitch is made. These sutures should be drawn
sufficiently and secured at frequent intervals so as not only to ensure
perfect application but sufficient pressure to prevent hemorrhage
when the clamps are released. The lower side having been first
closed the same character of sutures is continued until the upper
margin of the buttonhole-like opening is thus completely closed. The
fourth line of sutures, this time of the same material as those used in
the first, is applied in a similar fashion, and with it the serous and
muscular coats are accurately affixed to each other in such a way
that there can be no leakage. Two or three extra sutures at either
end of the line may be inserted for greater security. The clamps are
now withdrawn, the gauze behind the anastomotic opening is
removed, and it should be found that the smaller bowel is neatly and
perfectly fastened to the posterior stomach wall and that no
possibility either of hemorrhage or of leakage remains. This being
accomplished there remains only to tack the margins of the
mesenteric opening to the posterior wall of the stomach, at a
distance sufficient to prevent all possibility of subsequent constriction
or strangulation, after which the parts are carefully cleansed,
restored to the abdomen, the colon and omentum dropped back and
made to cover them, and the abdominal wound closed as usual.
(See Figs. 556, 557 and 558.)
 Fig. 556 Fig. 557

Anterior wall of stomach grasped by Mesocolon lifted and posterior wall of

forceps passed through from behind. stomach drawn through the opening
(Case of saddle-ulcer of lesser curvature made in it. Dotted lines show site of
near pylorus.) (Mayo.) proposed anastomotic openings. (Mayo.)
 Fig. 558

Stomach and jejunum in the grasp of the large clamps, made ready for suturing.
Small forceps still marking low point of stomach. (Mayo.)

Such is the operation with suture, which may occupy from thirty to
forty minutes in performance, it takes a little longer than the methods
either with the button or with the elastic ligature, but seems to be the
method generally used. In this method, as stated at the outset, no
special provision is made as against “vicious circle,” because it has
been found that it is seldom that this unpleasant complication
ensues. If, however, the anastomosis with the jejunum has been
made at a point twelve inches or more beyond its beginning, there is
a likelihood of finding that vicious circle will cause later
complications, and perhaps necessitate the performance of a second
anastomotic opening in the small intestine above and below the
stomach opening.
Of course all the precautions mentioned previously for prevention
of infection, such as washing out the stomach previous to the
operation, and ensuring both its emptiness and that of the upper
bowel, are a part of these procedures and cannot be safely
neglected in any of them.
Many an ingenious device for effecting the same kind of
communication between the stomach and the bowel, or between
various parts of the alimentary canal, has been placed before the
profession, though but a few will be considered more in detail when
dealing with the operations upon the intestines proper. The most
prominent of them, and the one which has found the most lasting
favor in the eyes of the profession, is the Murphy button, or some
similar expedient, by the use of which time is economized and the
operations in some respects simplified. All devices of this character,
however, depend upon a necrotic process for their eventual success,
as the intent is that parts compressed between the halves of the
button shall first adhere and then slough, the button falling through
the opening thus made and passing on. But to rely upon a necrotic
process is much like relying upon a criminal for the performance of a
serious duty. The button, therefore, has gone out of general favor for
purposes of gastro-enterostomy, although for other intestinal work it
is still frequently used.
McGraw, of Detroit, has devised a different and equally ingenious
method of keeping surfaces in contact with each other until adhesion
shall have occurred, and then effecting a further necrotic process by
which opening shall be finally accomplished. This is the so-called
method with the elastic ligature. In many respects it is simplicity
itself, and permits of ready and rapid employment. One needs
especially a round rubber cord, about 2 Mm. in diameter, of the
purest gum obtainable and sufficiently fresh to be reliable. The
surfaces to be united are first approximated by a posterior row of silk
or thread sutures which shall include their outer surfaces. Then a
long straight needle armed with this rubber cord is passed into the
intestine and out again at a distance of from 5 to 10 Cm. An
assistant now holding the intestine, the operator stretches the rubber
suture until it is very thin and then draws it rapidly through the bowel.
This same step is repeated in the opposite direction within the
stomach. A strong silk ligature is next passed across and underneath
the rubber between the latter and the point where the stomach and
the intestine are to come together and a single knot is then made in
the rubber after it has been tightly drawn. Another silk ligature is
passed around beyond the ends of the rubber ligature where they
cross and is here securely tied. The rubber ends thus released are
then cut off. The original silk suture is next continued around in front
until the point of its beginning is reached. In this way the rubber
ligature and the parts which it includes are surrounded with an
elongated ring of silk sutures, and with this the operation is
complete. Here it is the continuous pressure of the elastic suture
which first shuts off the circulation and finally cuts its way through
both coats, and permits the communication between the bowel and
the stomach. This method is as applicable to other portions of the
alimentary canal as to the stomach.
 C H A P T E R X LV I I I .
THE SMALL INTESTINES.

CONGENITAL ANOMALIES OF THE SMALL INTESTINES.

The entire intestinal canal is sometimes too short and sometimes
fails to develop sufficiently in caliber, or sections of it may remain
undeveloped. None of these changes have interest or importance for
the surgeon as such, save those which produce acute or chronic
obstruction or conduce to acute inflammatory affections.
Intestinal diverticula are usually of that type described by Meckel
and everywhere known by his name. Aside from these the others
usually met are irregular sacculations or hernial protrusions which
may be due to previous disease or to some congenital anomaly of
structure. These are sometimes seen in multiple form, and in one
case recently under my observation over one hundred of them were
found scattered along the intestinal canal, but, inasmuch as the
patient died practically of old age without a history of serious
previous disease, it could not be ascertained whether the pouches
were of congenital or acquired origin.
The genuine Meckel diverticulum is a relic of the tubular structure
which leads from the primitive intestine to the vitelline or yolk sac,
and which should persist until about the end of the second month of
embryonic life. After this time it should be completely obliterated and
disappear. When this does not happen there may result a fecal
fistula at the navel, which is then usually referred to as persistent
omphalomesenteric duct, and which implies a continuous passage-
way between the skin and the interior of the bowel.
When the umbilical portion alone persists there results a small cyst
on the posterior side of the navel.
When the intestinal end alone persists a protrusion or sacculation
will remain to mark its site.
The duct may become obliterated and yet fail to disappear, thus
leaving a fibrous cord which represents the original
omphalomesenteric structures and vessels, which will be probably
mistaken for an inflammatory band and may serve as a later cause
of acute obstruction. If such bands lead to the umbilical region their
identity may be easily established.
The presence of Meckel’s diverticulum may cause serious
abdominal mischief. It may become involved in a localized process
exactly as the appendix often does, which may then be referred to as
a diverticulitis, where ulceration and perforation may occur. It may
constitute the whole or a portion of the contents of a hernial sac. I
have twice found it in inguinal hernia, once in umbilical hernia, and
by others it has been reported in all the ordinary hernial locations.
Porter has collected from literature 184 cases in which its presence
caused serious abdominal crises. The condition itself is probably
present in at least 1 per cent. of mankind, and is stated by Halsted to
be the cause of intestinal obstruction in 6 per cent. of cases. In the
184 collected cases above mentioned it caused obstruction in 101.
Out of 21 cases of the above collection it was not only found in the
hernial sac, but in all but 1 was shown to be the actual cause of the
trouble. In 5 of these cases the diverticulum was open at the
umbilicus. In such a case if the opening be large the gut wall might
prolapse and thus form a hernia.
Diverticulitis has been repeatedly mistaken for appendicitis, its
symptomatology not being distinctive. Exact diagnosis is seldom
possible before operation.
On general principles, considering their possible dangers, it would
be well to remove all diverticula which are found in the course of
ordinary abdominal operations, whether they appear to be causing
trouble at the time or not.
While the average length of Meckel’s diverticulum is three inches it
may exist as a mere nipple-like projection, or it may be a free tube
attaining a length of several inches. Its attached end is usually larger
than its distal portion and its diameter usually less than that of the
gut from which it arises. It may be provided with a scanty mesentery
or may hang independently. While ordinarily its distal end is free it
may nevertheless be continued as a solid cord attached, as above
mentioned, to the umbilicus. This cord frequently contracts
secondary adhesions, and it is under these conditions that it most
often constricts the bowel by forming a loop within which the
intestine becomes entangled. Free diverticula of sufficient length are
sometimes found tied in a genuine knot in a manner which is
absolutely inexplicable. There are numerous ways by which such a
diverticulum may produce strangulation of the normal bowel; thus, by
formation of a ring in which its own free end projects, in which is later
entangled a bowel loop, or by surrounding the pedicle of an intestinal
loop as might a noose. Again bowel is sometimes tightly drawn over
such a diverticular band, just as a shawl may be thrown over the
arm, obstruction following in the displaced bowel. When much
contraction is brought to bear the gut may be so acutely bent as to
become occluded. Finally the bowel at the point of origin of the
diverticulum may undergo gross structural changes, the result of
long-continued traction, which may lead to cicatricial narrowing.
More indirectly diverticula seem in some unknown way to predispose
to intussusception at their point of origin, or they have been found
inflated and hanging from the intestine after obstructing it (Fig. 559).
 Fig. 559

Meckel’s diverticulum still attached at the umbilicus and producing obstruction.

(Lejars.)

ACQUIRED MALFORMATIONS OF THE SMALL INTESTINE.

 Of acquired malformations of the small intestine we have mainly to
deal with those which are produced by injury or disease. Among the
former would be the results of violent contusions or of any of the
lacerated, incised, or gunshot wounds to which the bowel is so often
exposed. Should recovery ensue cicatricial contraction is likely to
result. On the other hand, such previous disease conditions as
ulcerations—tuberculous or typhoidal—or the so-called chronic
catarrhal or malignant, may in one way or another occlude and thus
finally obstruct the lumen of the bowel. Distention diverticula may
also result, which correspond to the traction diverticula of the
esophagus already described.

WOUNDS OF THE SMALL INTESTINE.

The small bowel, like the larger or the stomach, may be ruptured
in consequence of abdominal contusions, the condition depending
on the nature of the injury, the degree of fulness of the bowel itself,
and other obvious causes. This character of injury has been already
sufficiently considered in dealing with rupture of the stomach. Their
symptoms are not essentially different, neither are the principles of
ordinary surgical treatment. Of all gunshot wounds those of the
abdomen constitute about 6 per cent., being more frequent than stab
wounds.
Gunshot Wounds.—Gunshot wounds of the intestine would by
themselves fill an interesting chapter in a work
on surgery. In such an epitome as this they can be given but short
consideration. The condition was for centuries hopeless, until the
American surgeons Parkes, Bull, and Senn took up the subject and
taught the profession how to more quickly recognize the injury as
well as to treat it. The special dangers of all punctured wounds of the
bowel, like those of the stomach, are hemorrhage and escape of
fecal contents. The great length of the intestinal tube, and its coiled
arrangement within the abdominal cavity, subject it to the possibility
of multiple punctures, from a dozen to twenty having been inflicted
by the passage of one bullet. The multiplicity of these injuries,
therefore, gives a still more formidable character to their presence.
Much will depend upon the size and velocity of the bullet and the
distance from which it is fired. The perforated gunshot wounds of the
abdomen which occur in civil life are usually inflicted by a smaller
bullet than those occurring in actual warfare, while, at the same time,
the distance is usually short.
Gunshot wounds are followed by an apparently disproportionate
amount of collapse. There is no accurate method of recognizing from
the exterior the amount of harm done by the passage of a bullet into
or through the abdominal cavity. This constitutes one of the greatest
arguments in favor of immediate exploration, an argument which is
strengthened by the fact that almost every penetrating wound of the
abdomen is complicated by injury of some abdominal organ. The
greatest danger attaches to perforation of the transverse colon or of
the small intestine, because these are the most movable parts of the
intestinal canal. The dangerous wounds are those which lie in the
frontal plane. Bullets which pass through the abdomen obliquely are
perhaps less likely to produce fatal result. Astonishing differences
prevail between the severity of those accidents received upon the
field of battle and in civil life. In battle men are shot through the
abdomen and not conspicuously disabled, recovering sometimes
with no other treatment than antiseptic occlusion. It is impossible to
assume that the bowels have not been injured, and yet they recover.
The fact thus stated best indicates the reason for abstention from
intervention on or near the firing-line in battle, and its most prompt
and early performance when the patient is in a well-managed civil
hospital.
Symptoms.—The symptoms of intestinal perforation in these cases
are not so prompt as when the stomach is wounded. Blood may
occur in the vomitus or in the stools, but only ordinarily after the
expiration of a few hours. Should fecal matter be found within the
external wound evidence would be complete, but this is rarely the
case. The probe may show whether the abdominal wall has been
completely perforated or not; beyond this it will give little information.
By far the best probe is the sterile finger, introduced through the
opening enlarged for the purpose. With this more distinct information
may be gained. Some years ago Senn proposed the method of
inflating the colon and small intestine with hydrogen gas, on the
expectation that it will escape through any intestinal perforation into