WOUNDS. 



ftlfo necefiary, in order to hinder the dreflings from being 

 pulled off, and the wound torn open again, by the reftlefs 

 movements or aftual violence of the patient. 



In cafes in which the whole diameter of the trachea is cut 

 through, the French furgeons have propofed the introduc- 

 tion of a flexible catheter from one of the noitrils into the 

 larynx and trachea, in order to infure a paflage for refpira- 

 tion, which, they fay, without this means is liable to be 

 completely intercepted when the outer wound is clofed, in 

 confequence of the two portions of the windpipe being 

 drawn away from each and not correfponding. ( Richerand, 

 Nofogr. Chir. t. iv. p. 170. edit. 4.) This, however, would 

 not be the pra£lice to which we (hould give a preference ; 

 firtt, becaufe the introduftion of a flexible catheter is a 

 thing which cannot always be accompliftied with facility ; 

 fecondly, becaufe its ufe in this way is conftantly produftive 

 of confiderable irritation ; and, thirdly, becaufe we deem 

 the employment of a future the bed means of hindering one 

 part of the trachea from becoming feparated far from the 

 other, and thus of infuring a paflage for refpiration. 



With refpeft, however, to the introduftion of a flexible 

 catheter from one of the noftrils into the oefophagus, for the 

 purpofe of giving food and medicines to the patient, with- 

 out any motion or difl:urbance of the wounded parts, we 

 confider the method entitled to the highefl; praife in all cafes 

 of ferious wounds, either of the larynx, the trachea, or the 

 cefophagus. When a perfon fwallows, the mufcles con- 

 cerned in the elevation and depreflion of the larynx aft in a 

 fudden convulfive kind of manner, and caufe a mofl; inju- 

 rious difturbance of the wound. But when nourifliment 

 and medicines are injefted into the ftomach through a 

 flexible tube, introduced from one of the noftrils down the 

 oefophagus, this hurtful aftion of the mufcles is entirely 

 prevented ; the inftrument may be kept there without any 

 annoyance or irritation, and the requifite quantity of ali- 

 ment, and whatever internal remedies may be indicated, can 

 be given with the utmoft convenience. We confider this 

 ufe of flexible catheters as conftituting a very material im- 

 provement in the treatment of fevere wounds of the throat. 

 The military furgeon, in particular, fiiould never be without 

 thefe inftruments ; and whoever has read the relations of M. 

 Larrey, in hia Menioires de Chirurgie Militaire, will fee, 

 that fometimes in bad wounds of the throat, the patient's 

 chance of recovery depends almoft entirely upon the aid to 

 be derived from the ficilful employment of an elaftic gum 

 tube. 



Wounds of the cefophagus may either amount to a total 

 or partial divifion of that tube ; they may be either with 

 or without a total divifion of the trachea ; and with or 

 without injury of other important parts in the vicinity. 

 Hence fuch wounds are fometimes abfolutely fatal ; and, in 

 general, when they admit of cure, nature has a greater 

 (hare than art in bringing it about. Some benefit, how- 

 ever, is to be derived from good furgery, and infinite harm 

 may refult from bad. 



A total divifion of the oefophagus mufl; prove imme- 

 diately fatal. The inevitable fimultaneous injury of other 

 important parts would render fuch a cafe at once mortal. 

 The celebrated Pruflian furgeon, Schmucker, has treated 

 fmall wounds of the pharynx and upper part of the oefo- 

 phagus with fuccefs. Wounds dividing half or even two- 

 thirds of the tube are alfo ftated to have been cured. 

 (Mem. de I'Acad. de Chir. torn. iii. p. 151. edit. izmo. ) 

 The poflibility or impoflibility of a cure muft obvioufly de- 

 pend upon what other parts of confequence are injured. 



Jncifed wounds, which divide the front of the oefophap;us, 

 iT.ull derive iidditi0n.1l danger from the fimultaneous divifion 



of the whole circle of the trachea ; and, iiuleed, fo much 

 would the internal jugular vein, par vagum, and carotid 

 artery, be expofed to the edge of the knife in a cut of this 

 kind, that it is difficult to conceive how they can ever 

 efcape. Mr. John Bell, as we have feen, believed that they 

 never could ; and were it not for the many examples pub - 

 lirtied, fome of them by fuch a man as Default, and for an 

 inftance which was lately in St. Bartholomew's hofpital, we 

 (hould have joined Mr. J. Bell in thinking, that all re- 

 ports of this kind were miftakes, arifing from the wound 

 extending through the root of the tongue into the mouth, 

 and not aftually injuries of the cefophagus itfelf. 



A punftured wound, penetrating the fide of the oefopha- 

 gus, may not be comphcated with injury of the trachea, 

 and therefore may not be attended with fo much peril as an 

 incifion. But although ftabs injuring the oefophagus are 

 not regularly and certainly mortal, they are always to be 

 regarded as dangerous cafes. 



Should the cafe be one of thofe fortunate incifed wounds 

 which leave the great veflels uncut, though the injury of 

 the oefophagus be complicated with a complete divifion of 

 the trachea, the furgeon can leffen the fpace between the 

 edges of the wound in the oefophagus by bringing the 

 divided portions of the trachea together. This effeft muft 

 refult from the manner in which the pofterior part of 

 the windpipe ia connefted with the cefophagus. But for 

 this purpofe, a future is only to be ufed in fuch a ftate of 

 the wounded trachea as amounts to a total divifion of the 

 tube ; for in all other cafes, a proper pofition of the head, 

 and the ufe of adhefive plafter to the external wound, ftiould 

 be the means with which the furgeon ought to be content, 

 with a view of bringing the margins of the wound of the 

 trachea near to each other. 



In cafes of wounds of the oefophagus, it was recom- 

 mended, as long fince as the time of Ravaton, to injeft 

 nourifliment and medicines into the ftomach, through a 

 fmooth tube of a fuitable fize, introduced down the 

 pharynx. In one cafe of paralyfis of the oefophagus, 

 which occurred in this country, a fmaU frefli eel-(kin 

 was pafFed down this canal, by means of a whale-bone pro- 

 bang, in order that medicines and food might be injefted 

 into the ftomach. ( Hunter, in Tranf. for the Improve- 

 ment of Med. and Chirurgical Knowledge.) The many 

 cafes, however, in which Default advantageoufly employed 

 an elaftic gum catheter for the fame objefts had a principal 

 influence in eftabhftiing the praftice. The inftrument was 

 introduced through one of the noftrils, and was often left 

 in the cefophagus for feveral days together. ( See CEuvres 

 Chir. de Default par Bichat, torn. ii. ) The introduftion 

 of elaftic gum catheters down the pharynx and oefophagus 

 is not only highly neceflary in examples of paralyfis, and 

 wounds of thofe paffages, but it is an exceedingly ufeful prac- 

 tice in wounds of the trachea, where the convulfive aftion 

 of the mufcles in deglutition would otherwife create a very 

 hurtful difturbance of the injured parts. (Firft Lines of 

 Surgery, p. 38, 39. edit. 3.) The praftice is alfo fometimes 

 abfolutely neceflary in many complicated wounds about the 

 face, fuch as thofe produced by the difcharge of a piftol 

 into the mouth, and attended with extenfive laceration of 

 the tongue, cheeks, and fauces, and a comminuted frac- 

 ture of the lower and upper jaw-bones. We believe, in- 

 deed, that in all fraftures of the lower jaw, the introduftion 

 of a flexible catheter from one of the noftrils into the oefo- 

 phagus is an extremely judicious meafure, becaufe the 

 aftion of deglutition has a greater effieft in difplacing the 

 broken bone and difturbing the procefs of union than aiiy 

 other circumftance. 



5 B 2 Gun- 



