1 40 (Esophagus 



front of the oesophagus, and the thoracic aorta is to its left, but as the 

 large artery passes through the back of the diaphragm it is behind the 

 gullet, and slightly to its right side. 



/;/ tJie abdomen the oesophagus runs a short and unimportant 

 course, being covered in front and behind by peritoneum ; in front 

 also is the left lobe of the liver. 



structure. The muscular coat consists of external longitudinal 

 and internal circular fibres, which, being continuous with the fibres 

 of the inferior constrictor above, are striated. Lower down, the muscle 

 is a mixture of striated and pale fibres, and in the lower half of the 

 oesophagus the fibres are entirely non-striated. 



From the lower end of the oesophagus the longitudinal fibres pass 

 on as the longitudinal fibres of the stomach, the circular fibres of the 

 oesophagus becoming the oblique upon the cardiac end of the stomach. 



The mucous membrane is extremely movable over the submucous 

 coat, and it is usually thrown into temporary longitudinal folds or rugiu. 

 The epithelium is thick and stratified. 



Supply. CEsophageal arteries come from the inferior thyroid, the 

 thoracic aorta, the intercostals, and, possibly, from the internal mam- 

 mary, also from the phrenic and gastric arteries. The veins take a 

 somewhat similar course. 



The lymphatics enter the cervical and posterior mediastinal glands. 

 When cancer of the oesophagus, or even of the stomach, is suspected, 

 the glands at the root of the neck should be examined. 



The nerves come from the two vagi and from the sympathetic 

 ganglia in the thorax. 



Stricture of the oesophagus may be caused by the contraction ol a 

 scar left after swallowing corrosive liquids, and by malignant disease. 

 In either case the probang must be used with the greatest care, for the 

 walls of the dilatation which always exists upon the buccal side of 

 the obstruction are necessarily thin, and, being easily traversed, 

 the instrument may then wander into the posterior mediastinum, the 

 pericardium, or the pleura, and so determine a fatal inflammation. 

 Malignant ulceration of the gullet may open into the pleura and 

 determine the occurrence of pneumothorax and empyema. 



Sometimes cesophageal obstruction is due to the pressure of an 

 aortic aneurysm, in which case rough instrumentation might cause an 

 immediate and fatal haemorrhage. 



In malignant stricture gastrostomy (p. 223) has not proved a highly 

 satisfactory procedure. Probably it will eventually be considered 

 better surgery to pass a tube through the contraction before closure 

 is complete, and to allow it to remain there, so that the patient may be 

 fed with fluid nutriment, as recommended by Symonds. 



CEsophagotomy may be needed for the extraction of a foreign 

 body. The patient's shoulders are raised, his head is thrown back, 

 and his face is turned to the right side. A three- or four- inch incision 



