648 ROYAL SOCIETY OF MEDICINE: LARYNGOLOGICAL SECTION.

suffer from nocturnal incontinence of urine and complainedof passing a very large amount of water.On admission the patient looked acutely ill and appeared

very drowsy. His face was "pinched" and quite" abdo-minal " in character. The whole body seemed wasted andthe skin was noticeably dry and thin, and could be easilyraised from the subcutaneous tissues. He complained ofthirst and a nasty taste in the mouth, the tongue being dryand slightly furred. The pulse-rate was 120 per minute,weak, and of low tension ; the respirations were 28 ; andthe temperature was 97’40 F. The abdomen moved freelywith each respiration, and there was no distension. Thewhole abdomen was tender on palpation, and this was mostmarked in the right iliac region, but no swelling could befelt. There was no tenderness in the loin, and nothing wasfound on examining per rectum. Within an hour of the timeof admission the patient became more drowsy and the

respirations became quite" sighing" " in character. Thedrowsiness, the respirations, and the history given by themother suggested the possibility of diabetes, and on obtain-ing a specimen of the urine shortly afterwards the specificgravity was found to be 1030, and sugar and diacetic acidwere present. The boy was immediately put on large dosesof sodium bicarbonate, both by the mouth and rectum, butin spite of treatment he sank into typical diabetic coma nextmorning and died 20 hours later. During the last 24 hourshe had passed 80 ounces of pale urine containing 1400grains of sugar.At the post-mortem examination the appendix was found

to be quite normal, and there were no macroscopic changesin the abdomen except some fatty infiltration of the liverand kidneys. Unfortunately permission was not granted toexamine the brain, and through a mistake no microscopicsections were cut of the pancreas, &c.

This case illustrates extremely well how abdominal painmay be a premonitory symptom of diabetic coma and hownecessary it is to make a systematic examination of the urinein all cases.

I am indebted to Dr. H. Harris, honorary surgeon to theinfirmary, for permission to communicate these notes.Rochdale.

NOTE ON A CASE OF FRACTURE OF THE LARYNX.

BY JAMES ANDREW, M.D. GLASG., D.P.H. CAMB.

FRACTURES of the larynx are fortunately extremely rare,and are usually the result of very severe violence caused bycrushing or pressure directly over the cartilages. They areusually followed by very serious results, due, no doubt, to theextensive damage, not only to the cartilages, but also to themucous membrane of the larynx. The following case is ofinterest, both on account of its exceptional causation andalso because of its complete and rapid recovery.On Oct. 9th, 1911, an engine driver, aged 43 years, called

at my surgery complaining of pain in the throat and difficultyin swallowing. He gave the following history. On Oct. 6thhe was following his usual occupation. While endeavouringto open the throttle of the engine he was seized by a violentattack of sneezing. He turned his head to one side, awayfrom the fire-box, and immediately afterwards felt some-

thing crack in his throat," and he could not sneeze owingto "cramp in the muscles of the throat." Daring the re-mainder of the day his throat was very painful, and hehad difficulty in swallowing, but he was able to finish hisday’s work. On the 8th the pain was very severe, and hehad great difficulty in swallowing. He complained also ofsalivation.When seen by me on Oct. 9tb there was no evidence of

external injury. The neck appeared slightly swollen. Thevoice was husky, and swallowing was difficult and painful.Salivation was profuse. On lightly grasping the larynxbetween the finger and thumb and gently moving it fromside to side, distinct crepitus was felt in the region of thethyroid cartilage, and I was of opinion that it was locatedin the right thyroid cartilage, though it was extremelydifficult to define its origin exactly.

Dr. J. Walker Downie kindly examined the patient at theWestern Infirmary, Glasgow, on Oct. 13th, and reported thatthere was crepitation on both sides of the pomum, chiefly atthe lower border of the thyroid and upper border of thecricoid cartilages. He was of opinion that there was

fracture of the cricoid cartilage. Two skiagrams wereprepared, and from them it was seen that there was distinctfracture of the cricoid cartilage. There was also a line

running obliquely across the thyroid cartilage near its lowerborder, which would seem to indicate fracture of that

cartilage also (see figure).

Reproduction of skiagram of thyroid reg on. a-a indicatesline of fracture.

The treatment consisted in wearing for 21 days a poro-plastic splint moulded to the neck. During that time thepain in the throat completely disappeared, and the difficultyin swallowing and salivation gradually passed away.The case is of interest chiefly on account of its causation.

The muscles of the arms and chest were fixed in the man’sendeavour to open the throttle of the engine, and in turningthe head to one side he also fixed the muscles of the neck.The attack of sneezing brought the larynx into suddencontact with his collar, so that he fractured his larynx overthe comparatively sharp edge of the collar.

I am indebted to Dr. Walker Downie and to Dr. W. F.Somerville, of the Western Infirmary, Glasgow, for reportand skiagram of the case.Coatbridge.

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Medical Societies.ROYAL SOCIETY OF MEDICINE.

LARYNGOLOGICAL SECTION.Exhibation of Cases and Speoimens.

A MEETING of this section was held on March 1st, Dr.STOLAIU THOMSON, the President, being in the chair.The PRESIDENT exhibited: 1. A Larynx showing Epi-

thelioma removed post mortem from a man aged 23. Thecase had been shown before the section a year ago, andattention was drawn to the early age at which the diseasehad appeared. 2. A case of Combined Tuberculosis andSyphilis of the Larynx in a woman. The patient had nophysical signs in the chest, but the Wassermann testwas positive, and tubercle bacilli had been found in her

sputum. The larynx showed deposits of tubercle andsyphilis each in typical form. 3. Double Abductor Paralysisin a man, aged 42, in whom a skiagram indicated amediastinal tumour.

Dr. H. J. DAVIS showed a case of Double AbductorParalysis in which he proposed to perform thyrotomy withthe object of removing completely the left arytenoid andvocal cord. (A conflict of opinion arose in the discussion onthe question of the advantages which such an operationwould have over tracheotomy, the majority of the speakersexpressing themselves as favouring the latter.) Dr. Davis alsoexhibited the following series of cases and specimens : 1. AGrain of Indian Corn which had been retained in the nose for

649LIVERPOOL MEDICAL INSTITUTION.

14 years. It had been expelled from the left nostril of a girlaged 19. 2. A Foreign Body, a pearl collar-stud, impactedin the Glottis of a Child, aged 3. The larynx and trachea,with the stud resting iln s2t7c, its lower disc caught in thechinks of the ventricles, were exhibited. 3. Injury to the

Larynx by Cat-throat in a man aged 41. The vocalcords had been destroyed, but a growth of granulation andcicatricial tissue had taken their place, and the patient wasable to speak with a fair amount of phonation. 4. Anunusual case of Functional Aphonia in a child aged 6. Theloss of voice had followed tracheotomy at the age of twoyears. Faradisation and tonics had brought about a cure.5. A Double Acute Frontal Sinusitis following influenza in aboy aged 15. Dr. Davis had operated twice, laying openand draining a large abscess in the forehead, which led intothe right frontal sinus by a fistula in the anterior wall; sub-sequently both sinuses were freely opened and drained into thenose. Discussing the case several members drew attention tothe fact that in acute frontal sinusitis with fistula formationit is usually the anterior and not the inferior wall that givesway. 6. A Temperature Chart of a Case of Acute Sphenoidaland Maxillary Sinusitis before and after operation. Atten-tion was drawn to the necessity for routine examination ofthe nasal accessory sinuses in cases of unexplained pyrexia.(The PRESIDENT also related a case similar to this in whicha persistent pyrexia was cured by draining the sinuses.) 7.A girl, aged 16, with Lupus of Hard and Soft Palate,Epiglottis, Larynx, and both Nasal Cavities, and LupusErythematosus on both Cheeks.

Mr. HERBERT TILLEY showed a male. aged 59, who hadbeen tracheotomised 16 years ago for Fixation of Cords inthe middle line caused by (?) perichondritis of each crico-arytenoid joint.

Dr. W. JOBSON HORNE exhibited a case of Extensive andRapid Destruction of the Soft Palate by Specific Disease.

Dr. W. H. KELSON showed a woman from whose trachea a

Neoplasm, probably a Papilloma, had been removed.Dr. ANDREW WYLIE showed a boy, aged 7, with a Cystic

Condition of the Left Arytenoid, possibly tuberculosis.Mr. G. WILKINSON reported a case of Severe Epistaxis

Associated with Multiple Hereditary Telangiectases in a man,aged 62, in which the haemorrhage prcceeding from theseptum had been controlled by cauterisation.

Mr. WILKINSON also showed : 1. (?) Papilloma Removedfrom the Posterior End of the Right Inferior Turbinal.

(The pathological nature of the growth aroused some dis-cussion.) 2. A Molar Tooth which he had removed by upperbronchoscophy from the right bronchus ; the foreign body hadfound its way into the trachea during extraction by a dentist.

Dr. W. IRONSIDE BRUCE gave a lantern demonstration ofX Ray Photographs illustrating diseases of the accessorysinuses.

Mr. W. G. HOWARTH showed : 1. A case in which anIntrinsic Carcinoma of the Larynx had been removed underinfusion anaesthesia with hedonal, to bring to notice the

great advantages that this method of anaesthesia affords inlaryngeal operations. 2. A case of Tuberculous Ulcerationof the Pharynx and Larynx. 3. A man with a peculiarBulbous Swelling on the end of the nose, ascribed by somemembers to a cyst, by others to a lipoma. I

Mr. ARTHUR EvANS showed a patient with Paralysis of Ithe Right Vocal Cord following an operation on the isthmusof the thyroid gland. Mr. Evans suggested the possibilityof treating the case by suture of the ends of the recurrent

laryngeal nerve, or, failing that, by nerve anastomosis withthe hypoglossal branches.

Dr. J. DUNDAS GRANT showed microscopical sections froma case of Tuberculous Ulcer of the Larynx the first section

suggestive of epithelioma, the second of non-bacillary tuber-culosis, ? lupus.

Dr. WYLIE exhibited a case of Ulceration at the Base ofthe Tongue in a syphilitic subject.

Mr. F. F. MUECKE showed (1) a large Gumma of theThyroid Cartilage causing considerable swelling in the neck ;(2) a case of Laryngeal Swelling and Ulceration of Specific orTuberculous Nature ; and (3) a patient with Cystic SwellingsProjecting from the Sides of both Anterior Nares, probablydental cysts.

Mr. G. W. BADGEROW presented an instance of whatlooked like Vincent’s Angina of the Tonsil in a boy aged5 years.

Mr. C. W. M. HOPE showed a case of Herpetic Vesiclesaffecting the mucous membrane of the soft palate.

LIVERPOOL MEDICAL INSTITUTION.

Treatment of Wry-neck -Stones in the Bladder.-Eaeperienoeswith Salvarsan.

A MEETING of this society was held on Feb. 22nd, Mr.ROBERT JONES. the President, being in the chair.The PRESIDENT referred to the loss that had been sus-

tained bv the death of Lord Lister. A vote of condolencewith the relatives of the deceased peer was passed by themembers standing.

Mr. W. THELWALL THOMAS read a note, illustrated by acase and by lantern slides, on the Treatment of Wry-neck,based on six cases recently treated. Mr. Thomas claimedfor his method that, while he got good results, it did awaywith the long and tiresome after-treatment, as he did notuse any retentive apparatus. The operation was on the sameprinciple as that for lengthening tendons. An incision wasmade transverselv over the lower third of the sterno-mastoid muscle, the skin and platysma were retracted,the anterior margin of the sterno-mastoid was freed and cuthalf through, then the muscle was divided vertically enoughto give the length equal to the difference between thetwo sides, the posterior part of the muscle was then under-mined by a director to guard the deep structures andcut. It was often found necessary to divide also bands of deepfascia and in one case other muscle fibres. The ends of themuscle were sutured with 30-day chromic gut without strainand then the superficial wound was closed. The line of theincision did not correspond with the deep wound.-In thediscussion that followed Mr. R. W. MURRAY said that hethought the condition was not due to traumatism, but tosome defect in ante-natal position, and on this point therewas considerable difference of opinion expressed by thosewho spoke.-The PRESIDENT said that the swellings hadbeen incised soon after birth and found to be cedematous ;also the rule was that in rupture of muscle elongationfollowed. Lorenz was still using the subcutaneous incisionwith over-correction of the deformity, which could not bedone with the sutured wound. He thought the success ofthese cases depended on careful after-treatment.-Mr. R. C.DUN, Dr. G. C. E. SiMPSON, Mr. D. DOUGLAS CRAWFORD,Mr F. T. PAUL, and Dr. A. STOOKES took part in thediscussion.Dr C. THURSTAN HOLLAND read a note on Stones in the

Bladder, which he illustrated by many lantern slides of radio-graphs of cases, in several of which an examination by thesound had given negative results, although a stone or stoneswere found by the X rays. In a large number of cases

examined he had never found a stone of pure uric acid in the

kidney or ureters, but in the bladder these had been invisibleto the X rays. With these rare exceptions he had found theradiographic method much the most trustworthy diagnosticmeans they possessed. Dr. Holland considered the soundineffective and dangerous; he thought the cystoscope, also,had much the same objections, but might be useful as con-firming the X ray findings. There were a few cases of uricacid stone that did not give enough shadow to be madeevident by a radiograph

Dr. G. S. STOPFORD-TAYLOR and Dr. R. W. MACKENNAread a paper on their Experiences with Salvarsan. They hadtreated 92 ca-es. At first they had used the intramuscularinjection, but in the later 74 cases had found the intravenousmethod preferable. No bad results had been seen, but it wasimportant that the patient should be properly prepared. A

purgative was given the night before the injection, and nextmorning a light breakfast, the salvarsan being injected fivehours after. It was important to make the solution fresh foreach injection, to use saline solution freshly made of waterdistilled in glass vessels. With these precautions there hadbeen no reaction in most cases, in a few slight sickness orloose motions from the bowels. Elimination took placeby the urine in four or five days after a dose of 0-3 grm. andin seven to nine days after a dose of 0 - 6 grm. The effect

! on the lesions was immediate. Photographs and lanternslides were shown illustrating the effect on a case of skineruption. No lesions yielded more rapidly than mucous

; patches and condylomata ; headache at once disappeared ;I adenitis was the most persistent lesion. In tertiary cases

where KI and mercury had failed salvarsan was most valu-I able. Lesions of the mouth and throat healed rapidly.Iritis was much improved. There was improvement in cases

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