THE ANTERIOE ABDOMINAL WALL. 1407 



(ESOPHAGUS. 



The average length of the oesophagus in the adult is 10 in. (25 cm.); the 

 distance from the incisor teeth to its commencement is 6 in. ; to the point or 

 level where it is crossed by the left bronchus, 9 in. ; to the oesophageal opening 

 of the diaphragm, 14 to 15 in. ; to the cardiac orifice of the stomach, 16 in. These 

 measurements, which are of great importance in diagnosing the seat of oesophageal 

 obstructions, should be marked off from below upwards upon all oesophageal 

 bougies and probangs. Posteriorly, the oesophagus extends from the level of the 

 sixth cervical spine to that of the tenth thoracic, a little to the left of which 

 is the. situation at which the stethoscope is placed in order to hear the sound pro- 

 duced by the passage of fluid into the stomach. 



Clinically it is important to bear in mind the relation of the oesophagus to the trachea and 

 left bronchus, to the left recurrent nerve, to the bronchial and posterior mediastinal glands, 

 to the descending thoracic aorta, and to the right posterior mediastinal pleura. Ulcers of 

 the oesophagus are liable to open into either the trachea, the left bronchus, or the right pleura. 



The veins of the inferior end of the oesophagus open partly into the systemic veins and partly 

 into the portal system ; like those at the inferior end of the rectum they are liable to become 

 varicose in conditions which give rise to chronic interference with the portal circulation. 



The lymph vessels of the upper part of the oesophagus 'open into the inferior deep cervical 

 glands, the remainder into the posterior mediastinal glands. 



The oesophagus is very distensible in the transverse but not in the antero -posterior direction, 

 hence the most useful forceps for removing foreign bodies from the oesophagus are those which open 

 laterally. 





THE ABDOMEN. 

 THE ANTERIOR ABDOMINAL WALL. 



The configuration of the abdomen varies with the age, sex, obesity, and muscular 

 development of the individual. In the child it is wider above than below, while 

 the reverse is the case in the adult female. It is most prominent in the region of 

 the umbilicus, which is situated, normally, below the mid-point between the infra- 

 sternal notch and the symphysis pubis, usually a little below the level of the highest 

 part of the iliac crest, and opposite the middle of the body of the fourth lumbar 

 vertebra. In the obese, and especially when the abdominal muscles have lost their 

 tone, the umbilical region becomes prominent and more or less pendulous, so that 

 the umbilicus may come to lie considerably below the normal level. In the child 

 it is relatively lower than in the adult, in consequence of the undeveloped state of 

 the pelvis. 



In spare subjects the inferior end of the body of the sternum, the xiphoid 

 process, and the costal margin, can readily be traced. The slight depression or 

 notch formed by the seventh costal cartilages and the inferior border of the body 

 of the. sternum is termed the infrasternal notch. Below the notch, and bounded 

 on each side by the seventh, eighth, and ninth costal cartilages, is the infracostal 

 angle, which varies considerably according to the shape of the chest ; it is relatively 

 wider in the child than in the adult. The inferior border of the curve of the 

 tenth costal cartilage is easily recognisable, and was selected by Cunningham as 

 the level of the plane of separation (infracostal plane) between the upper and 

 middle abdominal zones. 



The anterior abdominal wall is limited below by the fold of the groin and the 

 crest of the pubes. In a spare muscular subject the recti, the furrows correspond- 

 ing to the inscriptiones tendineae (O.T. linese transversse) and the supra-umbilical 

 portion of the linea alba, can be readily made out. When the outline of the 

 rectus is not visible the lateral border may be indicated by a line drawn from the 

 tip of the ninth costal cartilage to the mid-point of a line joining the umbilicus 

 and the anterior superior iliac spine, and from thence to the pubic tubercle. In 

 the angle between the lateral border of the rectus and the ninth costal cartilage, 

 on the right side, is a slight triangular depression which overlies the fundus of 

 the gall-bladder. Between the inferior part of the lateral border of the rectus and 

 the prominence above the anterior part of the iliac crest, caused by the lower 



