On Traumatic Fractures of the Larynx. 307

building appropriated as a residence for midwives sent up for instruction from the country, and thus supply the greatest desiderata to our school.

Patients can be more generally attended at their own homes, and appliances, medicines, and even food supplied. In fact, all that is here insisted upon except the isolated huts is, and has been, for years in operatlon--ever since my establishment of the female disease ward ; and all we want is to extend these and add the huts. I long foresaw file necessity of these changes, and have been gradually pressing them on the attention of the governors.

I t becomes a trying effort to look on at avoidable loss of human llfe, when the responsibility of preventing this rests upon our own shoulders. In this painful position have I been for the last 30 years. As a governor and ex-master of the Lying-in Hospital my impressions have been confirmed as to the necessity of the change I now advocate. I feel that, with my knowledge and convictions, silence on this subject would be cruel, heartless, not to say criminal. This feeling of dissatisfaction increases with age and experience; so do our apathy and listlessness. Life runs on apace, but misery and redress of wrong lag. These convictions must plead my excuse for so tardily calling public attention through the influence of our common profession to this great grievance. I have now done what I conceive to be my imperative duty in this matter, and confidently leave the issue in the hands of a profession who have ever made the public good its first object,

ART. X V I . - - 0 n Traumatle Fractures of the Larynx. By WILLIAM STOXES, Jun., Surgeon to the Richmond Surgical Hospital; Lecturer on Surgery, Carmichael School of Medicine ; Fellow of the Royal Medico-Chirurgical Society of London, &c,

AS fractures of the cartilages of the larynx are a class of injuries which so rarely come under the observation of the surgeon, the particulars of the following case of comminuted fracture of the cricoid, presenting features which, I may say, render the case almost unique in the history of these injuries, must doubtless be held to be of considerable surgical value.

On the 22nd of last September, I was summoned to the Richmond Hospital to perform tracheotomy for a female who had just been admitted, suffering from extreme dyspnea, which had come on

x 2

308 On Traumatic Fractu~,es of the ,Larynx.

rapidly after receiving a kick in the throat from her husband. The account that was obtained from the patient's friends was, that she had a dispute with her husband relative to some money which she had about her, and of which the husband wished to get possession. Al l persuasion to obtain it From her failing, he had recourse t violence, and threw her down on the floor. On attempting to rise he kicked her on the throat, which had the effect of again prostrating her. I presume that some symptom she had then alarmed him, for he offered her no further violence, and she shortly after rose and stated that she would charge him for this brutal assault. While in the street, looking For a policeman, the dyspnea commenced. I t rapidly increased in intensity, and she was immediately brought to the Richmond Hospital. On her admission she was almost inarti- culate; there was a cold sweat on her forehead; her pulse slow and weak; her face much flushed, and her lips livid Her respiration was laboured and difficult, but not so much as to make those about her think that the case was about to terminate so suddenly as it did. I was immediately summoned, and lost no time in getting to the hospital ; but on my arrival, I learned that the patient had just expired. I found considerable flattening, and abnormal breadth of the throat. There was no apparent ecchymosis, but much effusion and infiltration among the soft structures were distinctly felt. From these appearances, as well as from the abnormal mobility of her laryngeal cartilages, and also an obscure crepitation, the diagnosis of" fracture, with displacement of one or more of the cartilages, of the larynx, was made--a diagnosis which the post mortem examina- tion verified. All the soft tissues about the larynx were found profusely infiltrated with blood, although no laceration of a large vessel could be determined; it was more copious and extended further back on the right side than on the left. On taking out the larynx I found that there was a double fracture of" the cricoid cartilage. These two fractures were symmetrical, each being situated at about half a quarter of an inch From the middle line. There was displacement backwards and slightly inwards of the left fragment, separation of its articulation with the inferior cornu of the thyroid, and considerable laceration of the crico-thyroid muscle on that side. The displacement of the fractured portion of the cricoid was not observed on the right side. Here, posterior and external to the thyroid and cricoid cartilages, and by the side of the epiglottis, there was a considerable effusion of blood, of itself contributing in no small degree, by its pressure f~om without, to the closure of the

By MR. W. STOKES, Ju~. 309

larynx. The obstruction, however, was chiefly caused by the effusion of" blood beneath the mucous membrane of the larynx, especially under the aryteno-epiglottidean tblds, and in the ven- tricles of the larynx, which produced almost complete occlusion of' the glottis, and consequent apnea. There was no laceration of the mucous membrane, and consequently no emphysema.

The occlusion, therefore, was caused hy the existence of the four following conditions :--

1. Effusion of' blood external to the larynx. 2. Effusion under the lining membrane causing closure of the

glottis. 3. Displacement inwards of left fragment of cricoid. 4. Displacement of arytenoid on right side. The accompanying woodcut is a faithful representation of the

appearance the ericoid cartilage presented. In this case, therefore, we had an injury of the larynx which, as

far as I can determine, is unique in its character, viz. : a multiple or comminuted i~acture of the ericoid, and also a double displacement, one of a fragment of the crlcoid, and the other of the right arytenoid.

I t is very remarkable how few recorded cases of traumatic laryngeal fractures are to be found in surgical literature. M. Cavasse, in whose valuable memoir on laryngeal fractures will be found an exhaustive account of the different characteristic signs of these injuries, gives--excluding the cases of fractures of the larynx produced by hanging, and those of the os hyoides, the particulars of only nine cases. In one of them the fracture involved the cricoid, thyroid, and arytenoid on one side ; the two others the thyroid and cricoid were fractured and in the remaining six the thyroid alone. In Sir Duncan Gibb's most valuable memoir on Disease,~ of t]~e Throat and Windpipe, will be found the particulars of three most interesting cases of fracture of the thyroid cartilage, two of which occurred in his own practice. He also gives the history of a case of fi'acture of the cricoid, accompanied by the rare complication of emphysema, which Mr. Prescott ttewett has recorded in the first volume of the Transactions of the Pathological Society of London. The following is the case as given by Sir Duncan Gibb in the work I have alluded to above :--" A man aged twenty-seven, fell from a scaffold fifty feet high, and although his fall was broken, he sustained various injuries for which he was admitted into St. George's Hospital, under Mr. Cutler's care. Urgent dyspnea was present, with emphysematous crackling about the root of the neck. The

310 On Traumatic Fractures of the Larynx.

latter spread rapidly in the cellular tissue of the upper part of the body, the tongue was swollen and protruded between the teeth, the emphysema spread to the lower extremities, and he died three days after the accident, never having rallied from the head symptoms. The lungs and ribs were sound, but on examining the trachea and larynx the right side of the cricoid cartilage was found to be broken in two places on its anterior surface, a portion of the cartilage two lines in length being thus separated from the other parts. The angles of this fragment were so sharp, that the superior had pene- trated through the mucous membrane, producing a jagged opening, the size of a pea, which communicated freely with the cellular tissue of the neck, and gave rise to emphysema. Ecchymosed spots surrounded the vocal cords, and the brain was found extensively lacerated."

M. Cavasse has classified the signs of these injuries into the functional and physical. Among the Former continuous dyspnea constituted, in seven out of the nine cases recorded by him, a characteristic symptom; in my case it was extreme, so that in eight out of ten cases it was present. In the two cases in which it was not present, which were recorded respectively by MM. Piedagnol and Marjolin, there was no dyspnea ; and it is remarkable that in these two cases, the force which produced the lesion was applied on the side of the larynx, and not immediately in front of it. I t is hard to say if this circumstance was accidental or not, but it was one which might possibly be of some importance in a medico- legal point of view. The causes of the dyspnea are--first, sub- mucous effusion of blood; secondly, effusion of blood external to the larynx; thirdly, displacement of the cartilages; fourthly, defor- mity of the glottis; and lastly, abnormal mobility of the point of attachment of the vocal cords. These arc mentioned by M. Cavasse, with the exception of the second, the effusion external to the larynx, which was so well marked in the case which fell under my observation. I t was so extensive as to partially displace the larynx to one side.

The second important sign is facial lividity as indicating an impeded respiration.

Another frequent, but not invariable, symptom is alteration in the voice. Sometimes there is complete aphonia, as in the case which came under my observation. In other cases the voice was hardly affected. There is, therefore, great difference in the intensity of this sign, which appears to be due to the varying etiological

By MR. W. STOKES, Ju~. 311

conditions producing these lesions, and also to the mechanism of them. From the recorded cases it seems that the fractures pro- duced by lateral pressure, are less liable to be accompanied by aphonia than those produced by force applied directly in front. This is, in truth, what we would expect, as injury to the vocal cords or their points of attachment would not be as likely to follow after the direct application of lateral force, as, in this case, the resistance is so much less than when it is applied directly in front.

T h e remaining functional sign of these injuries is pain, which also is not invariable, but in some cases is extreme, and may be either spontaneous or be induced by manipulation, by attempts to speak, or by the act of swallowing.

The physical signs of these injuries are-- 1. Alteration in form of the neck. 2. Increase of volume of the neck. 3. Abnormal mobility of the cartilages. 4. Ecchymosis. 5. Crepitation. 6. Emphysema (rare).

The principal alteration in the tbrm of the neck is flattening anteriorly, produced by the obliteration of the pomum Adami, in cases--namely, when the force is applied from before backwards. M. Cavasse observes that as yet no one has noticed the change in the form of the neck when the fracture is produced by lateral pressure. The flattening in cases of fracture produced by antero- posterior pressure appears to him to be more marked when the cartilages are ossified. When they are not, the elasticity of the cartilages ought to restore the larynx to its normal form. There are two ways of establishing abnormal mobility--first, by making lateral pressure there is little resistance ibund in approaching the cartilages of the larynx; and secondly, in passing the fingers down the mesial line a vertical depression is easily perceived. This latter manoeuvre indicates much better than the first, the situation and direction of the fracture.

There are in these cases two situations for the ecchymosis. One is subcutaneous, and acts chiefly in producing alteration in form and increase in volume of the neck; the other is deep in the immediate vicinity of the lesion, and may, if very extensive, assist in no small degree in producing dyspnea by pressure on the wind- pipe. These two hemorrhagic effusions never communicate, being prevented from doing so by the cervical layers of fascia.

312 On Traumatic Fractures of the Larynx.

Another physical sign of great moment is crepitation, which, however, is more often absent than present. Its absence may be due to many causes, among which may be mentioned the fracture being incomplete, the cartilages not being ossified, and also it may be impossible to produce it in consequence of the extensive hemor- rhagic effusion immediately external to the fi'acture. This must necessarily produce considerable difficulty in moving separately the fractured portions of the cartilage or cartilages.

The last physical sign I would mention is emphysema, which is extremely rare. I t did not occur in my case, and in only one of those recorded by M. Cavasse. I t was a case which was under the care of M. Laugier, one of the surgeons of the Hbtel Dieu. The fi'acture occurred from a faU down a flight of stairs. The patient was a man aged forty-eight, and was admitted into the HStel Dieu on November 20, 1858. Immediately after the accident (9 a.m.) there was considerable oppression of breathing, and at 2"30 a.m. the fbllowing morning he walked to hospital. His gait was slow; head thrown slightly backwards; face anxious; mouth open; face pale ; lips cyanotic ; body covered with a cold sweat ; pulse frequent and feeble ; respiration stertorous and blowing ; considerable aphonia. The oppression increased on the slightest effort to speak. He would not remain in hospital, but six hours after returned with a marked aggravation of all his-previous symptoms, and, in addition, the existence of a deep-seated emphysema was easily determined. Shortly after this the patient died suddenly. The post mortem examination revealed a vertlcalfracture ofan ossified thyroid cartilage; extensive hemorrhagic effusion ; laceration of crico-thyrold membrane ; vertical and dentated fracture on right side of cricoid cartilage; fracture of right, superior cornu" of thyroid cartilage; laceration of ligaments of right crico:thyroid articulation ; fracture of' great cornu on right side of os hyoides; luxation of' arytenoid, and laceration of mucous membrane; ecchymotic effusion in sub-mucous cellular tissue.

The only other case that I witl allude to, and that very briefly, is the case which was under M. Maisonneuve's care in the I-Ibpital de la Piti~, May 10th, 1857. The patient was a young man, aged twenty-four, by occupation a mason, who was thrown down by a dairy- man's cart, One of the wheels of which crushed the larynx in passing over the anterior portion of the neck. On his admission he was in a staie of semi-apnea, with all the other usual signs and symptoms of an impeded respiration. Apnea was warded off by a veneseetion, but its good effects did not last; a second was perfbrmed, and a

Cases of Hemorrhage from the Ears, ~yes, ~fe. 313

third the day after. On the fifth day the dyspnea became so urgent that tracheotomy was performed. The operation, owing to the crushed and flattened condition of the larynx, and the neighhouring soft parts being swollen and contused, was accomplished with extreme difficulty. The case did very well ; but the patient, owing to contraction of the larynx, which became permanent, was obliged ever afterwards to wear a tracheotomy tube.

The successful result of tracheotomy, which was obtained in this remarkable case of M. Maisonneuve, makes it a source of unceasing regret to me that I did not arrive at the hospital sufficiently early to perform tile operation, and in all probability save the life of the patient whose case is the theme of this communication.

ART. XVII.--Cases of Hemorrhage from the Ears, Eyes, ~'c. By ROBERT LAW, M.D., King's Professor of the Institutes of Medicine; Physician to Sir P. Dun's Hospital; and Consulting Physician to the Adelaide Hospital.

THERE arc few subjects connected with pathology more interesting, more important, and we would add more curious than the vicarious or supplementary hemorrhages that occur with females, and through which nature seeks to relieve the system in case of suppressed or insufficient menstruation. The points of especial interest connected with the subject are the situation of these hemorrhages, their extent, and the frequency with which the most important and most delicate organs are their seat, without eventually sustaining any permanent injury.

While it often happens that a physiological relation exists between the seat of the hemorrhage and the organ from which the suppressed or diminished discharge should come, this is not always the case. While there are few if any organs of the body that have not been the vicarious outlet of this discharge, it appears to exhibit an especial predilection for a weak or suffering organ. We often tremble for a delicate female the subject of extensive hemoptysis, or rather puhnonary hemorrhage occurring at the period that may be said to be the crisis of the constitution, and especially should the subject inherit a phthisical tendency. Although there be substantial grounds for alarm and anxiety for the future of such a case, yet we have often seen such escape unhurt, and attain to peri~et health.