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A CASE OF GUNSHOT WOUND OF THE LARYNX
27 articulation and removed. (See Fig. 2. actual size.) The muco-perichondrium of the wings of ;he thyroid cartilage having been drawn together with silk the tracheotomy tube was removed, the whole wound being closed except two sutures threaded, but untied at the lower angle of the wound. These were tied 48 hours later. The further progress of the case was uneventful. Following the operation patient developed slight bronchitis for a few days, but the voice was much stronger than before operation. For 48 hours there was slight air leakage through the lower part of the wound, but this rapidly closed ; there was no
;rico-arytenoid
Clinical N
otes :
fine
MEDICAL, SURGICAL, OBSTETRICAL,
AND
THERAPEUTICAL. A CASE OF
GUNSHOT WOUND OF THE LARYNX IMPACTED
WITH
FOREIGN
BODY.
OPERATION ;
dysphagia.
RECOVERY.
BY J. WALKER WOOD, L.R.C.P. & L.R.F.P.S. GLASG., LATE
CIVIL
SURGEON, HAMPSTEAD MILITARY HOSPITAL,
AND
CAPTAIN, R.A.M.C.
GUNSHOT wounds of the larynx with impacted foreign bodies not immediately fatal are of sufficient interest to justify the recording of the following case recently under my care. Private L. J. W., 3rd Grenadier Guards, age 35. Wounded on 3/9/18. On admission to Hampstead 1VIiIitary Hospital on 8/9/18 his condition was as follows: small healed wound on right side of neck with some surgical emphysema around the wound, complete loss of voice, and t a marked inspiratory and expiratory stridor. Laryngoscopic examination (see Fig. 1).-Swelling of the left ventricular band, obscuring a view of the left vocal cord; swelling and oedema of left arytenoid and
ary-epiglottic fold, partially closing glottic aperture. The right vocal cord was represented by a grey sloughy band. injured hv the projectile
nn
ite
passage HfrnHs
the
larynx from right to left. The left side of the larynx was immobile and the movement of the right cord was limited. I decided that the foreign was somewhere in
body
Ftc. 1.-1. Laceration, right vocal cord. 2. Swelling and œdema, left ventricular band. 3. Swelling and œdema, left arytenoid and ary-epiglottic fold.
Frcr.
2.-Foreign Actual body. size. 8 mnl.x 9 mm.
the region of the left arytenoid. An X ray examination revealed the presence of a metallic foreign body in the region of the left crico-arytenoid articulation.
For the following reasons I decided to attempt removal of the fragment : (1) the chance of septic perichondritis and oedema of the glottis occurring ; (2) the possibility of dislodgment of the fragment with the grave danger of glottic spasm ; (3) interference with the function and mobility of the left vocal cord. The only operation which would give the necessary after
access a
as
or
our
anaesthetist,
daily. Anœsthetic Note (by Captain A. G. WILKINS). Intra-rectal ether advised in order to avoid (1) interference with surgeon, (2) post-operative bronchitis and :sickness, (3) risk of cardiac muscle failure owing to sepsis and a dilated heart (patient had other very septic wounds) : these conditions made chloroform inadvisable. Pot. brom., gr. xx., given at 8 P.M., Sept. 15th. At .9 A.M., Sept. 16th, hypodermic injection: morphine, 1/6 gr., hyoscine, 1/150 gr., atropine,. 1/100.gr.; at 9.15 A.M., enema of paraldehyde, i., ether, iv., and olive oil, &xgr;ii., given as slowly as possible (eight minutes) ; catheter passed three inches within bowel. Enema At 9.30 A.M. satisfactory anaesthesia, only retained. faint corneal reflex. Colour and respiration satisfactory and patient removed to theatre. At 10.15 A.M.; operation commenced, anaesthetic deepened by covering mouth and nose with towel. At 10.30 A.M. when larynx opened pledget of wool soaked in 10 per cent. cocaine and adrenalin swabbed round interior of larynx. Diminution in stridor followed. Pulse good. Breathing quicker. 11 A.M., operation completed. The bowel was then washed out to get rid of remaining ether. At 1.30 P.M. patient opened his eyes but was still dazed. 2 P.M., completely conscious and could understand, and reply to, remarks made to him. There was no sickness.
Remarks. This is the first occasion that I have done a thyrotomy with rectal ether, and I cannot speak too highly of it as the anaesthetic for this operation. Its advantages are : 1. The anaesthetist is out of the way and the surgeon is not hampered with anæthetic 2. During the gear about the field of operation. operation there is less coughing, which is apt to be troublesome when chloroform va,pour is pumped in through the tracheotomy tube. 3. There is no struggling while the patient is coming round ; a prolonged period of rest is followed by a good natural sleep without sickness. 4. There is less risk of post-operative pneumonia and bronchitis than when the anæsthetic is administered through the tracheotomy tube. I desire to record my thanks to Captain Wilkins for the excellent anaesthetic and for his notes
thereon; and to Dr. A. R. Roche, of Hampstead, for his assistance with the operation. fissure, laryngo
A. G. Wilkins, decided upon rectal the best anaesthetic. The operation was
consultation with
R.A.M.C., ether
being thyrotomy
Present condition, 11/10/18.—The movements of the cord are normal. There is still some impairment of movement of the left vocal cord. Swelling of the left arytenoid has almost disappeared. The voice is still weak, but very much stronger than immediately after the operation and before it, and is strengthening
right vocal
S. EDIN.,
Captain
we
performed on 16i9/18. Operation.—Thyrotomy incision.
A CURIOUS CASE OF
EXTRUSION OF AN INHALED FOREIGN BODY. BY GEORGE W. JOHNSON, M.A., M.B., B.CH. OXF.
Median tracheotomy through isthmus of thyroid. There was considerable ALTHOUGH it is well recognised that a foreign emphysema of tissues of neck, which increased the body after entering the air-passages may occasionhaemorrhage at this stage of the operation and delayed make its exit from an abscess in the chest wall, its initial stages. Thyroid cartilage split from above ally the occurrence is sufficiently unusual to render the after with interior were and, cocaine, sponges sponging packed down on convexity of tracheotomy tube and up following case of interest, in which the foreign body into pharynx. The foreign body was located in the left was a head of grass.
;rico-arytenoid
Clinical N
otes :
fine
MEDICAL, SURGICAL, OBSTETRICAL,
AND
THERAPEUTICAL. A CASE OF
GUNSHOT WOUND OF THE LARYNX IMPACTED
WITH
FOREIGN
BODY.
OPERATION ;
dysphagia.
RECOVERY.
BY J. WALKER WOOD, L.R.C.P. & L.R.F.P.S. GLASG., LATE
CIVIL
SURGEON, HAMPSTEAD MILITARY HOSPITAL,
AND
CAPTAIN, R.A.M.C.
GUNSHOT wounds of the larynx with impacted foreign bodies not immediately fatal are of sufficient interest to justify the recording of the following case recently under my care. Private L. J. W., 3rd Grenadier Guards, age 35. Wounded on 3/9/18. On admission to Hampstead 1VIiIitary Hospital on 8/9/18 his condition was as follows: small healed wound on right side of neck with some surgical emphysema around the wound, complete loss of voice, and t a marked inspiratory and expiratory stridor. Laryngoscopic examination (see Fig. 1).-Swelling of the left ventricular band, obscuring a view of the left vocal cord; swelling and oedema of left arytenoid and
ary-epiglottic fold, partially closing glottic aperture. The right vocal cord was represented by a grey sloughy band. injured hv the projectile
nn
ite
passage HfrnHs
the
larynx from right to left. The left side of the larynx was immobile and the movement of the right cord was limited. I decided that the foreign was somewhere in
body
Ftc. 1.-1. Laceration, right vocal cord. 2. Swelling and œdema, left ventricular band. 3. Swelling and œdema, left arytenoid and ary-epiglottic fold.
Frcr.
2.-Foreign Actual body. size. 8 mnl.x 9 mm.
the region of the left arytenoid. An X ray examination revealed the presence of a metallic foreign body in the region of the left crico-arytenoid articulation.
For the following reasons I decided to attempt removal of the fragment : (1) the chance of septic perichondritis and oedema of the glottis occurring ; (2) the possibility of dislodgment of the fragment with the grave danger of glottic spasm ; (3) interference with the function and mobility of the left vocal cord. The only operation which would give the necessary after
access a
as
or
our
anaesthetist,
daily. Anœsthetic Note (by Captain A. G. WILKINS). Intra-rectal ether advised in order to avoid (1) interference with surgeon, (2) post-operative bronchitis and :sickness, (3) risk of cardiac muscle failure owing to sepsis and a dilated heart (patient had other very septic wounds) : these conditions made chloroform inadvisable. Pot. brom., gr. xx., given at 8 P.M., Sept. 15th. At .9 A.M., Sept. 16th, hypodermic injection: morphine, 1/6 gr., hyoscine, 1/150 gr., atropine,. 1/100.gr.; at 9.15 A.M., enema of paraldehyde, i., ether, iv., and olive oil, &xgr;ii., given as slowly as possible (eight minutes) ; catheter passed three inches within bowel. Enema At 9.30 A.M. satisfactory anaesthesia, only retained. faint corneal reflex. Colour and respiration satisfactory and patient removed to theatre. At 10.15 A.M.; operation commenced, anaesthetic deepened by covering mouth and nose with towel. At 10.30 A.M. when larynx opened pledget of wool soaked in 10 per cent. cocaine and adrenalin swabbed round interior of larynx. Diminution in stridor followed. Pulse good. Breathing quicker. 11 A.M., operation completed. The bowel was then washed out to get rid of remaining ether. At 1.30 P.M. patient opened his eyes but was still dazed. 2 P.M., completely conscious and could understand, and reply to, remarks made to him. There was no sickness.
Remarks. This is the first occasion that I have done a thyrotomy with rectal ether, and I cannot speak too highly of it as the anaesthetic for this operation. Its advantages are : 1. The anaesthetist is out of the way and the surgeon is not hampered with anæthetic 2. During the gear about the field of operation. operation there is less coughing, which is apt to be troublesome when chloroform va,pour is pumped in through the tracheotomy tube. 3. There is no struggling while the patient is coming round ; a prolonged period of rest is followed by a good natural sleep without sickness. 4. There is less risk of post-operative pneumonia and bronchitis than when the anæsthetic is administered through the tracheotomy tube. I desire to record my thanks to Captain Wilkins for the excellent anaesthetic and for his notes
thereon; and to Dr. A. R. Roche, of Hampstead, for his assistance with the operation. fissure, laryngo
A. G. Wilkins, decided upon rectal the best anaesthetic. The operation was
consultation with
R.A.M.C., ether
being thyrotomy
Present condition, 11/10/18.—The movements of the cord are normal. There is still some impairment of movement of the left vocal cord. Swelling of the left arytenoid has almost disappeared. The voice is still weak, but very much stronger than immediately after the operation and before it, and is strengthening
right vocal
S. EDIN.,
Captain
we
performed on 16i9/18. Operation.—Thyrotomy incision.
A CURIOUS CASE OF
EXTRUSION OF AN INHALED FOREIGN BODY. BY GEORGE W. JOHNSON, M.A., M.B., B.CH. OXF.
Median tracheotomy through isthmus of thyroid. There was considerable ALTHOUGH it is well recognised that a foreign emphysema of tissues of neck, which increased the body after entering the air-passages may occasionhaemorrhage at this stage of the operation and delayed make its exit from an abscess in the chest wall, its initial stages. Thyroid cartilage split from above ally the occurrence is sufficiently unusual to render the after with interior were and, cocaine, sponges sponging packed down on convexity of tracheotomy tube and up following case of interest, in which the foreign body into pharynx. The foreign body was located in the left was a head of grass.