37G OPEKATIONS OX THE DIGESTIVE APPARATUS. 



di-awn out Avitli tlie left hand, tile right holding the curved scis- 

 sors, which being jDassed from above downward, and separating 

 the remaining portion of cellular tissue, holds the organ resting 

 upon its blades, in readiness for the third step (Fig. 366). 



3d Step, or Incision of the cjesophagus. — The operator then, 

 supporting the scissors with the oesophagus resting upon them, 

 in the left hand, with a straight bistoury with the edge tuimed 

 upward, in the right, makes a large puncture in the oesophageal 

 walls, passing through their entire thickness, and afterwards en- 

 larging it with the aid of a director. At this point of the operation, 

 and at each deglutition, there is usually an escape of mucosities 

 mingled with food. "WTien the impact forms a decided projection, 

 the incision should be made directly over the prominence. 



Professor Nocard has modified the operation in cases where 

 the obstruction can be di^'ided in small pieces, by making only a 

 correspondingly small incision. He uses both a straight and a 

 curved tenotome, and performs the first and second steps as in 

 the preceding methods, the third one being made as follows: 

 "The oesophagus being exposed, isolated and placed over the 

 scissors, the operator introduces the straight tenotome through 

 the oesoi:)hageal membranes, the blade running parallel with the 

 muscular fibers, into the thickness of the impact (apple, potatoe, 

 pieces of beet, etc..) avoiding injury to the opposite surface of the 

 canal; then sHding the curved tenotome against the straight one, 

 and pushing it through the entire mass until it touches the op- 

 posite wall of the oesophagus, he withdraws the straight instru- 

 ment, and divides the impact by movements of the curved instru- 

 ment, analogous to those made in the division of the tendons in 

 the operation of plantar tenotomy. The blunt end of the curved 

 tenotome protects the oesojDhagus from any enlargement of the 

 original wound." 



Cagny, after exposing the oesophagus, as already described, 

 crushes the obstruction by rejDeated gentle blows of a small 

 mallet, as before described. He prefers this mode to that of in- 

 cision if the impact, though hard and flat, possesses but little force 

 of adhesion. ^\Tien the objects of the cesophagotomy have been 

 reahzed, there is no necessity for fm'ther interference, the appli- 

 cation of sutures being generally considered rather injurious than 

 otherwise, and though the resulting wound is of a somewhat com- 

 pHcated nature, its perfect cicatrization in a comparatively short 



