A Case #f Fracture of the Thyroid Cartilage Recovery Without Tracheotomy, BY THOMAS B. EASTMAN, A.B., M.D. INDIANAPOLIS, IND. REPRINTED FROM THE JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. FEBRUARY -2. 1895. CHICAGO: American Medical Association Press. 1805. A CASE OF FRACTURE OF THE THYROID CARTILAGE—RECOVERY WITHOUT TRACHEOTOMY. BY THOMAS B. EASTMAN, A.B., M.D. Of the thirty cases of fracture of the thyroid car- tilage reported by Durham, but ten of these recovered and most of them after a tracheotomy. Indeed, most authorities unqualifiedly condemn any delay in ope- rating, Cohen saying: “Unless forestalled by pre- cautionary tracheotomy and insertion of a tube, suf- focative phenomena may intervene at any time from edema, displacement of fragments, or occlusion of the caliber of the air tube with blood clots.” 1 He further says, “ better far that an unnecessary trache- otomy should occasionally be performed without det- riment to the patient than that a number of cases should be allowed to terminate fatally for the want of it.” Stimson says :2 “ It is not safe to wait until it (dyspnea) has become extreme, for its increase at the last is often so rapid and so sudden that death takes place before relief can be given. It is therefore the part of prudence to interfere early and before the interference is made actually necessary by the defec- tive breathing.” Hunt3 recommends tracheotomy when bloody ex- 1 International Encyclopedia of Surgery, Vol. v, page 255, 2 Fractures and Dislocations, Vol. i, page 298. 2 pectoration or emphysema accompanies the other symptoms. Hamilton, however, counsels waiting until respiration is seriously interfered with. I de- sire to report a case of undoubted fracture of the thyroid cartilage recovering without tracheotomy, and thus add one case to the limited number which have recovered without operative interference. At no time during the first few days was I certain that an operation would not prove necessary, yet I was determined not to interfere until it was demanded by symptoms graver than were at any time present. I believe that the result justifies my course. On Dec. 14, 1894, Mr. K., aged 38, foreman in a foundry, was struck' in the “ throat” by a heavy piece of timber hurled from a buzz-saw at which he was working. The timber also cut a gash in his chin which had been sewed up previous to my first exam- ination, some six hours after the' accident, when I found him with a temperature of 99.6, pulse 86, res- piration 24. There was almost complete aphonia, dyspnea and cough which gave the patient excruci- ating pain. At each paroxysm of coughing he ejected bloody mucus from the mouth. Dysphagia was com- plete, even an attempt at swallowing saliva giving him much pain. His face was livid. The skin was discolored and the tissues about the larynx much swollen. Inspection showed that the pomum Adami, rather prominent before the accident, was wellnigh obliterated, and that the thyroid cartilage was dis- placed to the right. Manipulation showed abnormal mobility and on pressure inward the patient made me understand that he felt something stick him. A 3 American Journal Medical Sciences, Vol. li, page 880 3 diagnosis of fracture of the thyroid cartilage was made. As nearly as could be determined by manipu- lation, the line of fracture extended from the highest point of the upper margin of the right ala of the thyroid cartilage in an almost straight line downward to the crico-thyroid membrane. In spite of the other grave symptoms the respiratory function was fairly well maintained, and on the strength of this symp- tom I decided to await developments. No attempt was made to restore the normal relation of the parts. Antiphlogistic measures were resorted to, believing that if the inflammation was kept within bounds much would be accomplished. A Fothergill poultice was ordered placed over the seat of injury together with morphia sulphate gr. by the rectum, to be re- peated as often as necessary to subdue the pain. On the morning of the second day he was able to take a little nourishment by throwing his head back and allowing broth to run down his gullet, but any exer- cise of the muscles of deglutition still caused him great pain. In this way he was fed for four days. For five days he was unable to speak above a whisper, and at this time (twenty-four days after the acci- dent), his voice is still impaired and the larynx much displaced to the right. There is still abnormal mo- bility of the right ala of the cartilage. Dr. G. V. Woolen, Professor of Rhinology and Laryngology, Central College of Physicians and Sur- geons, of this city, saw the case on the seventh day after the acc-ident, and I herewith append his report: “ Dr. Thomas B. Eastman brought Mr. K. to my office for special laryngoscopic examination, with statement that patient had received a stroke from 4 piece of flying wood across larynx, followed by vio- lent inflammation, aphonia, hemoptysis, etc. There was yet remaining a distinct depression in a perpen- dicular direction across the right wing of the thyroid cartilage with mobility from pressure. Internally there was found considerable congestion of larynx, especially of region of right cord and ventricular band, both of which bulged into cavity of larynx and met opposite parts prematurely in efforts at phonation.”