28 Mr. Gabriel Stokes on Asphyxia,

but the less experienced are liable to find themselves in embar- rassing circumstances from the very great diffleulty they occa- sionally meet in introducing that instrument; to such the simple plan now proposed may, perhaps be found of not a little advan- tage.

ART. IV.--On Asphyxia, resulting from Wounds in the Neck. By GAaamL S*OK~% M. D.

IT appears to be the general opinion of writers on the subject of suicidal cutting of the throat, that death in such a case may either take place immediately, or that the individual escaping from the first danger may live, in some instances days, in some weeks, and then die of some of the after consequences of the wounds ; and that when death takes place immediately on the infliction of the injury, it is from h~emorrhage, the result of a wounded bloodvessel. Numerous cases are on record of trans- verse wounds of the neck, dividing the trachea completely across, and even the oesophagus where death was not an imme- diate consequence; and when death was immediate in these eases, it has been heretofore uniformly attributed to a wound of some of the large bloodvessels producing a fatal h~emor- rhage. Every surgeon of experience knows that the suicide is frequently foiled in his attempt on his life in this way, in consequence of inflicting the wound too high up in tlle neck, when the great vessels from their retreating direction escape injury ; and it is consequently said, that suicidal wounds in the upper part of the neck are not so likely to be immediately fatal as those situated lower down : this, as far as death from ha~morrhage is concerned, is true ; but it ap- pears to me, that when a deep transverse wound is made between the thyroid cartilage and the os hyoides, although none of the larger vessels of the neck are touched, that death takes place as certainly and as instantaneously as if the carotid artery and jugular vein were divided; and that in this case

resulting from Wounds in the Neck. "29

death is the result of asphyxia, induced by the fall &the epi- glottis on the rima, where, acting as a valve, it eflbetually puts a stop to respiration. This aecident was first noticed and put upon record by Mr. Houston, ill the fifth vol. of the Dublin Hospital Reports. His ease is as follows, page 315 :

" In Mareh, 1828, a servant out of place, residing in Duke- street, during a fit of delirium brought on by intoxieatlon, at- tempted to destroy himself by eutting his throat with a razor. I saw him in about ten minutes after, and found him almost life- less. The pulsations of the heart were impereeptible, the pulse at the wrist had eeased to beat, the limbs were cold, and all feeling and consciousness lost. The wound, which was fright- frilly deep, extended more towards the left than the right ear. The razor had entered between the os hyoides and the thyroid cartilage, and disunited them so completely as to allow the for- mer to ascend with the tongue into the mouth. The pharynx was laid wide open, and the epiglottis severed from its attach- ments to the tongue and os hyoides, and left hanging by its pediele to the back of the pomum adami. The carotids had escaped untouched, and the bleeding was inconsiderable. It appeared difficult at the moment to account for the sudden ex- tinction of life ; the symptoms were evidently those of suffoca- tion, but the cause was not at first understood. I passed my finger into the wound, and found, to my surprise, that the epi- glottis, loosened from its upper and lateral attachments, had fallen back over tile rima glottidis, and completely intercepted the passage of air to the lungs. I raised the obstructing body and drew it forwards; the chest soon after began to heave, respiration returned, the heart and pulse again beat, and con- sciousness and sensibility were re-established.

It required some effort of my fingers to hold up the epi- glottis, as the air at every inspiration tended to force it back again to its unnatural and dangerous position.

While thus occupied with the patient, Surgeon Porter en- tered the room ; I explained to him the singular nature of the

30 Mr. Gabriel Stokes on Ylsphyxia,

case, and how between my fingers and thumb I held the regu- lation of the man's life or death. The top of the epiglottis was then brought over the edge of the thyroid cartilage, and secured to its anterior surface by a single stitch. The man in a short time sat up and attempted to speak, but was unable to articulate. He was taken into the Meath Hospital under tile care of Mr. Porter, from whom I learned that he never reco- vered from the delirium which led to the perpetration of the act, and died in about a week after, of erysipelatous inflamma- tion of the neck and throat.

The circumstance which had so nearly extinguished the life of this individual the instant after the wound was inflicted, is too plain to require comment; but the fact of its occurrence, and of the facility with which the immediate danger arising fi'om it may be averted, is too important not to be made gene- rally known. A respite of life for even a few hours, in cases such as this, may be often of infinite value."

Now, but for the knowledge of this case, I would, in all probability, have overlooked the nature of that which occurred to myself, and which I shall now give :

On the morning of the 29th of July, 1840, I was called in haste to visit Stephen Kelly, in Moira Place, who had, in a fit of delirium, cut his throat a few minutes previous to my being called upon ! on entering the house I was told that he was dead. Not more than twelve or fifteen minutes had elapsed, as well as I could ascertain, since he had committed the deed ; I found the body lying on a bed, several persons in the room, among whom were Surgeon Williams, and Mr. O'Reilly, the apothecary to the South Eastern Dispensary. A gaping lace- rated wound was seen across the upper part of the neck ; not more than eight or ten ounces of blood appeared to have been lost, which was collected into one spot on the floor; the face was livid, ttle lips blue, and tlle eyes bright and shining ; under these circumstances it immediately occurred to me that the man had died not from ha~morrhage, but from suffocation, and that

resulting from Wounds in the Neck. 31

it might be a case similar to that described by Mr. Houston. I proceeded to examine the wound, which was about three inches in length, much lacerated, and passing obliquely between the thyroid cartilage and the os hyoides, the right ala of which was severed from the rest of the bone.

The attachment of the epiglottis to the hyoid bone was completely divided, and this cartilage was laid down over the rima quite flat, with the apex resting on the back of the pha- rynx; all the superior connexions of the epiglottis were divided also, and when lifted off the rima glottidis it immediately, on being set free, fell back again.

As far as I could then see, no large bloodvessels had been divided.

On inquiry, I found that Mr. O'Reilly had seen him a very few minutes after the wound had been inflicted, and he stated to me that when he first arrived the heart was still beating, though feebly, and that there were slight convulsive efforts to breathe, during which the veins in the neck were seen to swell consider- ably, but that these appearances soon ceased.

Through the kindness of Surgeon Williams I was allowed to be present at the dissection made at tile coroner's inquest five hours after death.

The face was still livid, the surface of the body quite cold, cadaverie rigidity considerable. On examining the wound it was found to extend obliquely across the upper part of the neck, being about three inches in length ; and the structures connect- ing the thyroid cartilage to the body of the os hyoides were di- vided ; the right ala of the bone itself was cut off; the attach- ment of the epiglottis to the hyoid bone was divided, while that to the thyroid cartilage remained untouched ; the fr~enum epiglottidis was cut, and the epiglottis lay upon the rima, com- pletely closing that opening.

On dissecting off the inleguments from the side of the neck, the external jugular veins were found untouched, and enor- mously distended with dark venous blood, so as to resemble

32 Mr. Gabriel Stokes on Asphyxia,

in point of size the internal jugulars ; the carotid arteries, with their accompanying veins and nerves, were found uninjuredj the veins greatly distended, the lingual and superior thyroid arteries were divided, as also the lingual nerve.

On opening the thorax the lungs collapsed, and the air escap- ing raised the epiglottis. The lungs were healthy, and but little engorged ; the right auricle was much distended with black coloured blood~ as was also in a less degree the right ventricle, the coronary veins were remarkably distended, and stood out in relief on the surface of the heart, their dark colour forming a remarkable contrast to the natural red colour of the heart.

The abdominal viscera were healthy, the stomach and intes- tines remarkably contracted.

The head was not examined. The cause of the fall of the epiglottis upon the rima in

these wounds ot" the neck which divide the parts between the thyroid cartilage and the os hyoides, will be at once understood by an examination of the anatomy of the part ; we see the epi- glottis to be attached to the thyroid cartilage and to the os hyoides by two ligamentous cords, that connecting the epi- glottis to the os hyoides, possessing a great degree of elasticity. Now the epiglottis is retained in its upright position by the action of this ligament, and also by the folds of mucous mem- brane which are reflected on it from the root of the tongue, these are put on the stretch when the epiglottis is laid over the rima by the passage of the alimentary bolus, and the liga- ment then, by its elastic reaction, restores the fibro-cartilage to its natural position. In wounds then inflicted in this part of the neck this ligament is divided, the epiglottis falls loose into the pharynx, and on the first inspiration is laid down over the rima glottidis.

This accident appears to have escaped the observation of all the systematic, surgical, and medico-legal writers with which I am acquainted.

Beck, indeed, gives a case in a note abstracted from the

Resulting fi'om Wounds in the Neck. 33

third vol. of the Boston Medical Magazine, of a man who in a state of delirium attempted to strangle himself, being unable to effect this, he went to the window and having broken out a piece of glass, wounded himself with it under the angle of the lower jaw, and by a rapid succession of cuts, extended it from side to side, but fell immediately into the arms of his com- panion, and after gasping two or three times was dead. Not more than sixteen ounces of blood were lost. On dissection no injury was found to have been done to the trachea or large vessels ; a superficial vein iu the neck was found to be wounded, and which, as stated by tile reporter, was probably the external jugular from which tlle bleeding arose ; and the suddenness of the death in this case is ascribed to tile entrance of air into this wounded vein, but I am strongly inclined to think that this was one of these cases where death results from asphyxia, pro- duced by tile fall of tile epiglottis.

Blandine, in his Anatomie Topographique, anticipates the occurrence of this accident in speaking of wounds of the neck ; he says, " the epiglottis, however, being thus detached, may, by its fall on tlle larynx, be productive of serious danger ;" but it does not appear that such a case ever came under his obser- vation. Now it appears to me that the importance of a know- ledge of ttlese cases to the practical surgeon is obvious. Had not Mr. Houston, by a remarkable degree of tact, detected what was the cause of asphyxia in his case, the man must have perished before him instantly, and had the gentleman who first saw the case which I have reported, been aware of its nature, he migtlt probably have for the time preserved tile life of the

patient. But to the medical jurist a knowledge of these cases is of

the tlighest importance. It frequently happens that persons are found dead with the throat cut, when it becomes a question wtlether the cutting of the throat was the cause of death.

Now, if ha~morrhage be the only cause of sudden death in these cases recognized by medical men, it is obvious that where

voL. x/x. No. 55.

34 Mr. Hamerton's Cases of Venereal Disease,

this has not taken place in any fatal quantity, they will feel dis- posed to give it as their opinion that death was produced in some other way, and thus may fall into a very serious error, from an ignorance of the fact which I think must now be ad- mitted, namely, that in some cases of cutting of the throat sud- den death is produced by asphyxia.

AnT. V.--Cases of the Venereal Disease, illustrative of the Introduction of the Venereal Poison into the System, through other Channels than by sexual Intercourse. By CLEMENT HA~EaTOr~, Surgeon to the Castletown Dispensary, Nobber.

CASE ].--Anne Gerrard, ret. 25, married in 1834. In the fourth month of pregnancy she was infected by her husband, and in a few weeks afterwards was covered over with a papular eruption ; at parturition she had a sore breast ; her child, when born, was in a very weak and sickly state, and in four days it died. Soon after her delivery, she and her husband went to Dublin, where her husband remained six weeks under mercu- rial treatment ; she returned home after one week's stay in town. In June, 1838, [ first saw her, she had miscarried five times since her husband was salivated, at periods extending from the sixth week to the seventh month. By my advice she took blue pill for some weeks ; her mouth became fully affected. In June, 1839, she again became pregnant, and in March, 1840, gave birth to a healthy and plump child. Up to the present time (January, 1841) the child is healthy. Her husband did not take any mercury from me.

CAsE II.--Mary Duffy, a~t. 30, sister to Anne Gerrard, living in the next cabin, finding her sister suffering from a sore breast, and her weakly infant not able to draw it, gave her strong and healthy child to draw it for her, at the same time taking her sister's weakly infant to her own breast. In a fortnight after- wards her breast became sore, and her child, previously a plump, healthy infant, became weak, sickly, emaciated, and covered with a copper-coloured rash. In August, 1837, she first con-