THE THORACIC CONTENTS 511 



passed, in a medial and backward direction,, through the anterior 

 part of the left pleural sac. 



When the effusion is purulent, exposure and drainage of the 

 pericardium is rendered necessary. A curved flap is turned 

 upwards and to the left, exposing the left half of the lower part 

 of the sternum and the costal cartilages of the fifth and sixth 

 ribs. The sixth costal cartilage is carefully removed piecemeal 

 and the internal mammary vessels (p. 503) are exposed lying 

 on the trans versus thoracis (triangularis sterni). When they 

 have been ligated, the transversus thoracis is divided and the 

 pericardium is exposed with a thin covering of mediastinal fat. 

 If necessary, the fifth costal cartilage and the intercostals may 

 be removed. The fat is wiped away, and the left pleural 

 reflection is identified and displaced laterally with the ringers. 

 The pericardium can then be opened and drained. 



In suture of the heart for stab-wounds good access is essential 

 and is obtained by a modification of the approach described 

 above. The incision is larger and an extensive flap of the 

 chest-wall may be turned up, by dividing the third, fourth, fifth, 

 and sixth ribs after their costal cartilages have been cut through 

 near the sternum. 



The (Esophagus begins opposite the sixth cervical vertebra 

 and descends through the neck, lying behind the trachea and 

 in front of the vertebral column (p. 139). In the upper part 

 of the thorax it projects slightly beyond the left side of the 

 trachea and, opposite the fifth thoracic vertebra, it is crossed 

 anteriorly by the left bronchus. Below that point, the 

 oesophagus lies behind the pericardium and in front of the 

 vertebral column, but it curves forwards away from the latter 

 as it leaves the thorax. The oesophagus passes through the 

 diaphragm opposite the tenth thoracic vertebra, and its 

 abdominal part, which is only half an inch in length, ends at 

 the cardiac orifice of the stomach. 



The oesophagus is slightly constricted at its commencement, 

 which lies six inches from the incisor teeth, and again at the 

 point where it is crossed by the left bronchus, which lies four inches 

 lower down. It possesses a third constriction as it passes through 

 the opening in the diaphragm, which is sixteen inches distant 

 from the incisor teeth. (Esophageal bougies should be graduated 

 from the distal extremity so that the surgeon may locate the 

 position of an cesophageal obstruction. In healthy subjects 

 some obstruction may be encountered at the lower end of the 



