THE (ESOPHAGUS. 



893 



axis, and from the left inferior phrenic of the abdominal aorta. They have for the 

 most part a longitudinal direction. 



Nerves of the (Esophagus. The nerves are derived from the pneumogastric 

 and from the sympathetic ; they form a plexus in which are groups of ganglion- 

 cells between the two layers of the muscular coats, and also a second plexus in 

 the submucous tissue. 



Surgical Anatomy. The relations of the oesophagus are of considerable practical interest 

 to the surgf.on, as he is frequently required, in oases of stricture of this tube, to dilate the canal 

 by a bougie, when it is of importance that the direction of the 

 esophagus and its relations to surrounding parts should be 

 remembered. In cases of malignant disease of the oesophagus, 

 where its tissues have become softened from infiltration of the 

 morbid deposit, the greatest care is requisite in directing the 

 bougie through the strictured part, as a false passage may 

 easily be made, and the instrument may pass into the medi- 

 astinum, or into one or the other pleural cavity, or even into 

 the pericardium. 



The student should also remember that obstruction of the 

 oesophagus, and consequent symptoms of stricture, are occa- 

 sionally produced by an aneurism of some part of the aorta 

 pressing upon this tube. In such a case the passage of a 

 bougie could only hasten the fatal issue. 



In passing a bougie the left fore finger should be intro- 

 duced into the mouth and the epiglottis felt for, care being 

 taken not to throw the head too far backward. The bougie is 

 then to be passed beyond the finger until it touches the pos- 

 terior wall of the pharynx. The patient is now asked to swal- 

 low, and at the moment of swallowing the bougie is passed 

 gently onward, all violence being carefully avoided. 



It occasionally happens that a foreign body becomes im- 

 parted in the oesophagus which can neither be brought upward 

 nor moved downward. When all ordinary means for its re- 

 moval have failed, excision is the only resource. This, of 

 course, can only be performed when it is not very low down. 

 If the foreign body is allowed to remain, extensive inflamma- 

 tion and ulceration of the oesophagus may ensue. In one case 

 the foreign body ultimately penetrated the inter vertebral sub- 

 stance, and destroyed life by inflammation of the membranes 

 and substance of the cord. 



The operation of oesophagotomy is thus performed : The 

 patient being placed upon his back, with the head and shoul- 

 ders slightly elevated, an incision, about four inches in length, 

 should be made on the left side of the trachea, from the thy- 

 roid cartilage downward, dividing the skin, Platysma. and 

 deej) fascia. The edges of the wound being separated, the 

 pmo-byoid muscle should, if necessary, be divided, and the 

 fibres of the Sterno-hyoid and Sterno-thyroid muscles drawn 

 inward ; the sheath of the carotid vessels, being exposed, 

 must be drawn outward, and retained in that position by 

 retractors: the oesophagus will now be exposed, and should be divided over the foreign body, 

 which can then be removed. Great care is necessary to avoid wounding the thyroid vessels, the 

 thyroid gland, and the laryngeal nerves. 



The oesophagus may be obstructed not only by foreign bodies, but also by changes in 

 its coats, producing stricture, or by pressure on it from without of new growths or aneurism, 

 etc. 



The different forms of stricture are: (1) the spasmodic, usually occurring in nervous 

 women, and intermittent in character, so that tbe dysphagia is not constant ; (2) fibrous, due to 

 cicatrization after injuries, such as swallowing corrosive fluids or boiling water ; and (3) malig- 

 nant, usually epitheliomatous in its nature. This is situated generally either at the upper end 

 of the tube, opposite to the cricoid cartilage, or at its lower end at tbe cardiac orifice, but is 

 also occasionally found at that part of tbe tube where it is crossed by the left bronchus. 



The operation of oesopbagostomy has occasionally been performed in cases where the 

 stricture in the oesophagus is at the upper part, with a view to making a permanent opening 

 below tbe stricture through which to feed the patient, but the operation has been far from a 

 successful one, and the risk of setting up diffuse inflammation in the loose planes of con- 

 nective tissue deep in the neck is so great that it would appear to be better, if any operative 

 interference is undertaken, to perform gastrostomy. The operation is performed in the same 

 manner as oesophagotomy, but the edges of the opening in the oesophagus are stitched to the 

 skin incision. 



FIG. 485. Accessory muscular fi- 

 bres between the oesophagus and 

 pleura, and oesophagus and trachea. 

 (From a preparation in the Museum 

 of the Royal College of Surgeons of 

 England.) 



