Frank Hastings Hamilton.

A practical treatise on fractures and dislocations online

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Malgaigne thus describes his procedure: ''With the left hand seize the
anterior portion of the jaw, for the purpose of drawing it horizontally
forwards, while you carry the index finger of the right hand to the
lateral and superior part of the pharynx. Tou will meet at first the
projection formed by the styloid process, but, moving your finger for-
wards, you will find soon the posterior border of the ramus of the jaw ;
and following this border from below upwards, you will arrive at the
inner side of the condyle, which you will push outwards in such a
manner as to engage it upon the other fragment. This manoeuvre
cannot be made without causing nausea, as the finger always does
when carried into the posterior part of the pharynx ; but this is a
slight inconvenience. The reduction obtained, bear the jaw upwards
and backwards in order to press and fix the condyle between it and
the glenoid cavity, then fasten it in place with a sling." The frag-
ments were thus easily brought into apposition in the case reported
by Ribes, and the patient was cured without any deformity.

In addition to these means, the angle of the jaw ought to be pressed
permanently forwards bv means of a compress placed between it and
the mastoid process, ana held in place by a suitable bandage ; or we
may adopt the method which proved so successful with Fountain,
namely, wire the front teeth of the lower jaw to the front teeth of the
upper in such a manner as to draw the chin forwards, and thus main-
tain apposition.

If the coronoid process be alone broken, it is sufficient to close the
mouth with any form of sling or bandage which may be most con-



M. Obfila has reported the case of a man, aged sixty-two years, who
had been hanged, and whose os hyoides was broken through its body
on its right side.* M. Cazauvieilh has also seen a fracture of this
bone in two persons who had been hanged : in one of which the frac-
ture was probably in the body of the bone, and in the other through
one of its cornua.*

Lalesque published in the Journal Hehdomadaire for March, 1838, a
case which occurred in a marine, sixty-seven years old, " who, in a
quarrel, had his throat violently clenched by the hand of a vigorous
adversary. At the moment there was very acute pain, and the sensa-

> Traits de M6d. legale, troisi^me 6d., torn. ii. p. 428.
* Cazauyieilli, da Suicide, etc., p. 221.

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tion of a solid body breaking. The pain was aggravated by every
effort to speak, to swallow, or to move the tongue, and when this
organ was pushed backwards, deglutition was impossible. The patient
could not articulate distinctly ; and he was unable to open his mouth
without exciting a great deal of pain. He placed his hand upon the.
anterior and superior part of his neck to point out the seat of the
injury. This part was slightly swollen, and presented on each side
small ecchymoses; one above, more decided, immediately under the left
angle of the lower jaw. " The large cornua of the os hyoides was very
distinctly to the right side," and it could be felt on the left deeply seated
by pressing with the fingers ; in following it in front toward the body
of the bone, a very sensible inequality near the point of junction of
these two parts could be perceived. By putting the finger within the
mouth, the same projections and cavities inverted could be felt, and
even the points of the bone which had pierced the mucous membrane,
&c., were evident. Having bled the patient, and placed a plug between
his teeth to keep the mouth open, the broken branch was brought by
the finger back to the surface of the body of the bone, and easily re-
duced. The position of the head inclined a little back; rest, absolute
silence, diet, and some saturnine fomentations, composed the after-
treatment. To avoid a new dislocation by the eflforts of swallowing,
the oesophagus tube of Desault was introduced, to conduct the drinks
and liquid aliments into the stomach ; this sound was allowed to re-
main until the twenty-fifth day ; at this time the patient could swallow
without pain, and began to take a little more solid nourishment, and
at the end of two months the cure was complete. By placing a finger
within his mouth, a slight nodosity could be felt in the place where,
in the recent fracture, the splintered points were perceptible.^

DieflFenbach has also recorded a fracture of the great right horn, pro-
duced in the same manner, by grasping the throat between the thumb
and fingers, which occurred in a girl only nineteen years old. Very
slight pressure upon the side of the bone was sufficient to move the
fragment inwards, and to produce a crepitus, but it immediately
resumed its place when the pressure was removed. There being,,
therefore, no displacement, the cure was effected in a short time
without resort to any remedies except tisans and antiphlogiatics. She
was not even forbidden to speak.*

Auberge saw a similar case, in a person fifty-five years old, occasioned
by grasping the throat. The fracture was in the great horn of the right
side, and the displacement was so complete that crepitus could not be
felt, and the mucous membrane of the pharynx was penetrated by the
broken bone.'

The following example is reported by Dr. Wood, of Cincinnati,
Ohio, as having come under his observation in the year 1855 : —

"Through the kindness of our friend Dr. P. G. Fore, of this city,
we were invited to examine a case of fracture of the os hyoides, that

> Amer. Joum. Med. Bd., vol. xiii. p. 250.

* Medic. YereiDBzeitung fur Preussen, 1888, No. 8; Gazette M^., 1834, p. 187.

» Revue M^d., July, 1886.

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bad occarred about one week before we saw it^ in one of his patients.
The patient was a female, about thirty years of age, who had fallen
down the cellar steps, striking the prominent parts of the larynx and
hyoid bone against a projecting brick, severely injuring the larynx as
well as fracturing the bone.

" The fracture was on the left side, and near the junction of the
great horn with the body of the bone. Crepitus was distinctly felt
on pressing the bone between the thumb and finger ; or when the pa-
tient would swallow ; though, at this time, the severe symptoms that
followed the accident, and (Continued for several days, had somewhat

" Immediately after the accident there was profuse bleeding from
the fauces, and she experienced great difficulty and pain in the act of
swallowing, and the power of speech was almost entirely lost. On
attempting to depress or protrude the tongue, she felt distressing
symptoms of suffocation. Considerable inflammation and swelling of
the throat and larynx ensued, and continued in some degree up to the
time of our visit.

" To-day (about four weeks since the accident) Dr. F. informs us
that the patient has so far recovered as to be able to converse, though
tbe voice is somewhat impaired. She is yet unable to swallow solid
food, and is wholly sustained by fluids."*

Marcinkovsky saw a woman in whom both the lower jaw and the
left horn of the os hyoides were broken by a fall from her carriage
against a wall. She died in about twenty-four hours, from suffocation.^

Dr. Grundef reports the following : —

'' A laborer, set. 63, fell from a wagon on his face, and discharged
a large quantity of blood by the mouth. He found he could not swal-
low, and when seen twelve hours afterward, complained of severe pain
in the neck and nape, with inability to turn his head, though no in-
jury of the vertebraa could be detected. His voice was hoarse and
difficult. On attempting to drink, the fluid was rejected with violent
coughing, the patient declaring he felt it as if entering the air-passages.
An examination of the fauces led to no explanation of this condition.
The epiglottis did not, however, appear to completely close the larynx,
or to be in its exact position. The tongue was movable in all direc-
tions, and pressing it down with a spatula caused no inconvenience.
The hyoid seemed to possess its continuity. No crepitation or abnor-
mal movability could be perceived, and no pain at the root of the tongue
occurred on attempting to swallow. After repeated examinations, the
case was concluded to be one in which the functions of the nervus
vagus had undergone great disturbance, or the muscles of the larynx
had become torn or paralyzed. Medicine and food were administered
by means of an elastic tube. The patient had a good appetite and
slept well ; the pain of the neck was lost, and its motion recovered ; a
hectic cough, from which he had long suffered, alone remaining. After

' Western Lancet; also N. T. Jonm. Med., vol. xv. p. 152.
« Medic. Vereinszsitung fur Preussen, 1838, No. 15 ; Gazette M^dicale, 1888,
p. 854.

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continuing, however, to go on thus well for six days, the cough in-
creased ; the appetite failed ; strength was lost ; the voice was scarcely
audible; and in five more days the patient died exhausted. At the
autopsy a fracture of the os hyoides was found. One of the large
cornua was broken, and had become firmly imbedded between the
epiglottis and rima glottidis, inducing the raised position of the epi-
glottis, loss of voice, and difficulty in swallowing. The fracture was
probably produced by muscular action, a cause first assigned in a case
occurring to Ollivier d'Angers."*

I think it more probable that this fracture was the result of a direct
blow, than of muscular action. In the case referred to, however, as
having been reported by Ollivier, there can be no doubt that the
fracture was due to muscular action alone.

A woman, fiflby-six years old, made a misstep and fell backwards^
and at the same moment that her head was thrown violently back, she
felt distinctly a sensation as if a solid body had broken, in the upper
part of her neck and upon its left side. An examination showed that
she had fractured the great left horn of the os hyoides. Inflamma-
tion and suppuration followed, and finally, after about three months^
the posterior fragment made its way out in a condition of necrosis,
and the fistula promptly healed, but there remained for many years
a sense of uneasiness about these parts when she swallowed, sometimes
amounting to pain.'

Etiology. — Of the ten cases which I have found upon record, three
were produced by hanging ; three by grasping the throat between the
thumb and fingers ; three by direct blows, or by falls upon the front
of the neck; and one by muscular action alone.

The observation of Mr. South, that fracture of the bone ''is almost
invariably found"* in persons executed by hanging, is probably incor-
rect, since although a large proportion of these subjects are submitted
to dissection both in this and other countries, yet I know of but these
three examples which have been published.

Pathology, Symptomatology, and Diagnosis — The body of the bone
seems to have been broken in all of those cases which resulted from
hanging; while in all of the other examples the fracture has oc-
curred in one of the great horns, or at the junction of the horns with
the body. Generally the displacement inwards of one of the frag-
ments has been so complete that crepitus could not be detected. It
was present, however, in the examples mentioned by Dieffenbach and
Wood. In two instances the mucous membrane has been penetrated,
and in one the fragment was projected between the epiglottis and rima

The accident has been characterized by a sudden sensation as if a
bone had broken ; in a few instances^ by profuse bleeding from the
fauces ; by difficulty in opening the mouth ; by impossibility of de-

1 Schmidt's Jahrbuch., Yol. Izyiii.; also Amer. Joum. Med. Bci., yoI. zlix. p.
258, Jan. 1862.

* Malgaigne, op. cit., p. 405.

* Note to Chebus' Surgery, Amer. ed., vol. i. p. 581.

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glntition, and by loss of voice in others; with great pain in moving
the tongue, the pain being especially at its root; in one instance the
tongue was perceptibly drawn to one side. There is usually more
or less swelling and soreness about the neck, with ecchymosis ; and
at a later period, cough, expectoration, hoarseness, &c. The circum-
stances which, however, indicate certainly the nature of the accident,
are preternatural mobility of the fragments, with or without crepitus,
and the angular, inward projection, which may in most cases be dis-
tinctly felt in a careful examination of the pharynx.

In the case related by Griiner, the only symptoms were a loss of
voice, difficulty of deglutition, and a sensation, when the attempt was
made to swallow, as if the fluids passed into the windpipe ; with also
an imperfeot closure of the epiglottis upon the rima glottidis. No
preternatural mobility or irregularity in the fragments could be de-
tected, nor was there crepitus, and it was concluded that the bone was
not broken, yet the autopsy showed that the fragment was jmbedded
deeply between the epiglottis and the rima glottidis.

Prognosis. — It is only in view of its complications that this acci-
dent can be regarded as serious ; where the severity of the injury has
been such as to fracture the lower jaw at the same time, as in the case
related by Marcinkovsky, or such as to bury the fragment deep in
the tissues about the rima glottidis, as in the case mentioned by
Griiner, a favorable termination could scarcely have been expected ;
and these are the only cases yet published in which the death was in
any way connected with the fracture. One-half of the whole number
have died, but of these, three have died by hanging, and the remain-
ing two from the causes named. Of the three in which the accident
resulted from a direct blow, only the patient of Dr. Fore, of Cincin-
nati, has survived ; while of the three whose fractures resulted from
lateral pressure upon the cornua, all recovered ; so, also, did the pa-
tient in whom the fracture was produced by muscular action.

Treatment. — ^No doubt when the fragments are displaced an attempt
ought to be made to replace them by introducing one finger into the
mouth, while with the opposite hand the fragments are supported from
without. Lalesque found this a matter of some difficulty, but Auberge
experienced no aifficulty at all. I suspect, however, that the amount
of difficulty will very much depend upon the degree of displacement,
and the consequent lacerations of the soft tissues about the bone. But
however this may be, it must be altogether another thing to be able
to keep in exact apposition the broken ends of a bone whose diameter
is so inconsiderable, and upon which it is quite impossible to apply
any apparatus or dressings to retain the fragments in place. Lalesque
threw the head of his patient slightly back, with the view of making
'' permanent extension" upon the fragments through the action of the
muscles and ligaments attached to the bone, and he recommends this

S^sition as that whitsh is best calculated to preserve the coaptation,
algaigne, on the contrary, without having himself seen any example
of this fracture, believes that the position of flexion of the neck, with
entire relaxation of the muscles, would be most suitable.
In all cases it will be proper to enjoin silence, and to adopt suit-

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ablo measures to combat inflammation; such as general or topical
bleeding, fomentations, moistening the month with cool water, or per-
mitting small pieces of ice to rest in the mouth until dissolved, withoat
in general allowing the fluid to be swallowed ; but in some examplea,
no doubt, the patient may be permitted to swallow.




The examples of fracture of the larynx which may be found upon
record are also very few. M. Ladoz examined the larynx of a man
who had been assassinated, and upon whose neck he found a hand-
kerchief bound so tightly as to leave, after its removal, a deep furrow ;
but the neck showed also distinct marks produced by the fingers and
thumb. There was a fracture of the thyroid cartilage which extended
obliquely downwards and outwards through its right wing. The whole
of the larynx was very much ossified, although the subject was only
thirty -seven years old.*

In 1823, M. Ollivier communicated to the Academy of Medicine a
casoiin which, this cartilage being broken, the patient died of suffo-

M. Marjolin says : '' Two women at the hospital being engaged in a
quarrel, one of them seized her antagonist by the throat, and griped
her so strongly that she broke the thyroid cartilage from its upper to
its lower margin. You will imagine that it was not very difficult to
determine the existence of a fracture, and that no retentive apparatus
was demanded. Silence, regimen, a small bleeding, and the cure was

Habicot operated successfully, in 1620, by introducing a leaden
tube into the trachea in a case in which the thyroid was ''damaged."
Gibb, Norris, N^laton, and Kenderline have each reported examples
of fracture of this cartilage alone.^

§ 2. Thyroid and Cbicoh) Cabtilaobs.

Plenck saw a fracture of both the thyroid and cricoid cartilages
produced by falling upon the rim of a pail.^ Morgagni also says
that he had seen fractures of the larynx ; and Bemer mentions a frac-

1 Gazette Mddicale, 1888, p. 698.

' Archives G^n^rales de M4decine,,tome ii. p. 807.

> Maijolin, Cours de Patholog. Chir., p. 896.

* Hunt, Frac. of Larynx, &c. Am. Joum. Med. Sci., April, 1866.

* Malgaigne, op. cit., p. 409.

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ture of the larynx found in a person who had been hanged;^ but in
neither case is it said in which cartilage the fracture occurred, or
whether it had not occurred in both.

Dr. O'Brian, of Edinburgh, reports in vol. xyiii. of the Edinburgh
Med. and Surg. Jburn,, a case of fracture of both cartilages, involving
the trachea also, in a woman who had received a kick under the jaw,
and who died on the following day. Hunt has collected other cases,
some of which involved the arytenoid cartilages, the hyoid bone, the
trachea, &c.

I am able to furnish, from my own observation, another example
of fracture of both the thyroid and cricoid cartilages : —

John Calkins, of Collins, Erie Co., N. Y., set. 41, is supposed to have
been kicked by a young horse on the 10th of Nov. 1856. He was
alone in the stables when the accident occurred, and, being stunned
by the blow, he could not himself give any account of the manner in
which the injury was received. When found, he was sitting upright,
bat unable to articulate except in a whisper. Drs. Barber and Davis,
of Colden, saw him about two hours after. His countenance was
anxious; his pulse feeble; extremities cold; and he was breathing
with great difficulty. A small quantity of blood was issuing from his
fauces. His upper lip was cut, and a few of his teeth dislocated ; the
wound appearing as if inflicted by one of the corks of the horse's
shoes. There was no other wound ; biit over the lefl wing of the
thyroid cartilage there was a slight discoloration, pressure upon which
produced intense pain and sufitbcation, and disclosed the fact that the
thyroid prominence was depressed very much and broken. Cold
lotions were directed to be applied, and as the thirst was excessive,
but deglutition impossible, he was permitted to hold pieces of ice in
his mouth. This plan, with but slight modifications, such as the sub-
stitution of warm fomentations to the neck for the cold lotions, was
continued until the following evening, when, at the request of the
attending physician, Dr. Barber, I was called to see him. The
symptoms remained nearly the same as at first. He was unable to
speak audibly, or perform the act of deglutition ; his breathing was
difficult, and at times threatened sufTocation. The lateness of the
hour, with other circumstances, determined me to defer surgical
interference until morning. At daybreak of the 12th I made the
operation of lafyngotomy, and introduced a large double canula into
the crico-thyroidean space. This operation was rendered difficult by
the great amount of swelling about the neck, due both to emphysema,
and bloody with serous infiltrations. The breathing immediately
became easy, and gradually the appearance of asphyxia disappeared
from his face; but after about six or seven hours he began percepti-
bly to fail in strength, and died at 3 o'clock P. M. of the following
day, apparently from exhaustion rather than from suflbcation ; having
survived the accident about seventy-two hours, and the operation
about thirty-four hours.

1 Morgagni, de Sedibas, etc., Epist. 19, num. 18, 14, et 16; Remer, Annales
d' Hygiene, tome iy. p. 171 ; from Malgaigne.

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The autopsy disclosed a comminuted fracture of the thyroid carti-
lage, with a simple fracture of the cricoid. The thyroid was broken
almost perpendicularly through the centre; the line of fracture being
irregular, and inclining slightly to the left side. The left inferior horn
was broken off about three lines from its articulation with the cricoid
cartilage. The right ala was broken also in a line nearly vertical, but
irregular, at a point about six lines from its posterior margin. The
pomum Adami was depressed to the level of the cricoid cartilage,
and the left ala, being completely detached, was thrown inwards and
upwards several lines. Underneath the perichondrium, especially
upon the inner side, there was pretty extensive bloody infiltration.
Ossification of the cartilages had commenced at several points, but it
bad made but little progress. The central fracture of the thyroid
was through cartilage alone. The fracture of the right ala was
through cartilage until it reached a bony belt comprising the two
inferior lines of its course. Th« left lower horn was ossified, and the
fracture was through this bony structure. The fracture through the
cricoid cartilage commenced close upon the margin of a bony plate,
but in its whole course it traversed only cartilage. It was on the left
side. There was also an incomplete fracture on the right ala of the
thyroid cartilage, commencing in the line of the principal fracture
and extending obliquely downwards about three lines, until it was
arrested by the bony plate which constituted the lower margin of
this wing.

A ragged, lacerated wound in the back of the larynx, above the
cricoid cartilages, communicated directly with the oesophagus.

§ 3. Cbicoii) Cartilage.

Both Valsalva and Cazauvidilh have each met with a single exam-
ple of this fracture, without fracture of the thyroid cartilage; and
Weiss has found the cricoid cartilage broken into numerous frag-
ments, and at the same time separated from the trachea.^

General Etiology of Fractures of the Laryngeal Carti-
lages. — ^As a predisposing cause, advanced age, with its usual con-
comitant, partial or complete ossification of the cartilages, has been
thought to occupy a prominent place. In the case reported by Plenck,
the cartilages were already very much ossified, although the subject
was only thirty-seven years old. Morgagni observed that in his
experience it nad occurred always in advanced life. In my own
case, however, the cartilages were only slightly ossified, the patient
being forty-one years old; nor did the lines of the several fractures
itidicate a preference for the bony plates; but it seems to me that they
rather avoided them, and in the case of the incomplete fracture the
bone appeared to have arrested the fracture. In fact, a few experi-
ments have satisfied me that the adult laryngeal cartilages are quite

» Malgaigne, op. cit., p. 408.

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as brittle as bone, and, consequently, that ossification in no way in-
creases their liability to fracture.

Hunt ascertained the age in fifteen cases, and but one of the whole
number was over 45 years ; five occurred in children, one of whom
was only four years old.

The inimediate causes have been direct blows, as falling upon the
edge of a pail, a kick from a horse, or pressure, as in hanging, or in
grasping the larynx strongly between the thumb and fingers.

Genebal Symptomatology, btc. — The signs of this accident are

Online LibraryFrank Hastings HamiltonA practical treatise on fractures and dislocations → online text (page 16 of 100)