DOES EXCISION OF THE LARYNX TEND

TO. THE PROLONGATION OF LIFE ?

A PAPER REAP BEFORE THE COLLEGE OF PHYSICIANS OP PHILADELPHIA,APRIL 4, 1883.

BY

J. SOLIS-COHEK, M.D.,HONORARY PROFESSOR OF LARYNGOLOGY IN JEFFERSON MEDICAL COLLEGE ;

AND PROFESSOR IN DISEASES OF THE THROAT AND NOSE, IN THE

PHILADELPHIA POLYCLINIC AND COLLEGE FORGRADUATES IN MEDICINE.

EXTRACTED FROMTHE TRANSACTIONS OF THE COLLEGE OF PHYSICIANS, VOL. VI

PHILADELPHIA:COLLINS, PRINTER, 705 JAYNE STREET

1883.

DOES EXCISION OF THE LARYNX TEND TO THEPROLONGATION OF LIFE I

That complete laryngectomy can be performedwithout sacrifice of life, there is now accumulativeevidence.

That every operation involving the removal of thelarynx imperils the immediate existence of the patient,the records of the procedure abundantly attest.

That a very large proportion of the subjectsoperated upon, say nearly fifty per cent, of them,succumb within so brief a period that their deathsmay be justly attributed to the operation, an exami-nation into its statistics renders only too obvious.

The writer owns to a prejudice against the opera-tion; he has never witnessed a laryngectomy, norseen a patient upon whom it had been performed. Itmay seem rather an assumption on his part, there-fore, to criticize an operation of the technical pro-cedure and after-management of which he is prac-tically ignorant.

Let us consult the statistics of the operation, andcontrast the average life of those who have beensubjected to it with the average life of patients insimilar condition intrusted to palliative treatment.

4

I have before me, as I write, more or less detailedrecords of sixty-five operations of complete “ extir-pation of the larynx,” as it is termed.

There are a number of partial excisions, which havenot been brought into the subjoined table becausethe partial operation is not included in the scope ofthis paper.

6

TABLEI.-—LISTOF

COMPLETELARYNGECTOMIES,

INCLUDINGAND

SUPPLEMENTINGTHETABLESOF

MACKENZIE,FOULIS,BLUM,

ANDBUROW.

No.

Operator.Date.Age.Sex.

Disease.Parts

removed.Result.

Reference.Remarks.

1

Watson,Pat-

rickHeron

(ofEdin- burgh).

186636M.Stenosisfromsy-

philis.

Larynxand

one

ringoftrachea.

Deathin3

weeksfrompneumonia.

Foulis;Transactions International

Med-

icalCongress,Aug.

1881,vol.iii.p.355.

Pneumoniawas

suspectedbe-

forethe

opera-tion.

3

Billroth (Vienna).1873Dec,

3136M,Carcinomaofthe

larynx.

Larynx,lowerthird

ofepiglottis,part

ofthe

uppertwo

ringsofthetra-

chea.

Deathfromrecur-

rence7monthsafter

theoperation.

Archivf.

klin.Chir-

urgie,Bd.xvii.H.

ii.p.

343.

Recurrencenoted

atendoffour

months.

3

Heine (Prague).1874Apl,

2850M.Carcinomaofthe

larynx.

Entirelarynx.

Deathfromrecur-

rence6monthsaf-

teroperation.

Arch.f.

klin.Chir.,

Bd.xix.p.584;

BohmCorresp.Bl.

1874.

4

Schmidt,M. (Frankfort).

18744ug.13

56M.

Epitheliomaof

thelarynx.

Thyroid,cricoid,

andbotharyte-

noidcartilages.

Deathon

thefourth

dayfrom

collapse.Arch.f.

klin.Chir.,

Bd,xviii.H.i.p.

189.

5

Maas(Breslau).1874 June

1

57M.“

Adeno-fibroma carcinomato- sum.”

Entirelarynx.

Deathfrom

pneumo-nia2

weeksafter

operation,“

On

fourthday,”

Blum.Arch.f.

klin.Chir.,

Bd.xix.p.

507.

6

Watson,P.

H.(Edin-burgh)

.

187460M.

Epitheliomaof

larynxextend-

ingtoleftvocal

band.

Larynx.

Deathfrom

pneumo-niain3

weeks.Foulis,

Trans.Int.

MedicalCongress,

1881.

7 8

Schonborn (Kouigs-berg).1875Jan.

3373M.Carcinomaofthe

larynx.

Entirelarynx.

Deathon

thefourth

day.

Berlinerklin.Woch.,

Sept.20,1875,p.

525.

Bottini (Turin).1875Feb.6

34M.Sarcoma(partly

round-celled,

partlyspindle-

celled)ofthe

larynx.

Entirelarynx.WellApril

19,1881,probablystill

alive.Communicazione letta

Junanzi,la

R.Academiadi

MedicinadiTorino,

April30,1875.

Let-

terfrom

Prof.Bot-

tinitoDr.

Foulis.Theoperationen-

tailedcopioushemorrhage, and

wasfol-

lowedbyse-

vereerysipelas.

6

tableI—

continued.

Wo.

Operator.Date.AgeSex.

Disease.Parts

removed.

Eesult.

Reference.Remarks.

9

Langenbeck187557M.Carcinomaof

up-Entirelarynx,hy-

oidbone,partof

Deathfromrecur-Berlin,klin.Woch.

j

(Berlin).July21

perpartoflar-

renceincervical

1875,No.33,p.453

ynx,oftheepi-

glottis,andof

thetongue,pha-

lymphaticglands,

Arch.f.

klin.Chir.,

rynx,and

oeso-phagus.

4monthsafter.Bd.xxi.Supplem

10

Multanow- ski(St.Pe- tersburgh).

1875 July27

thehyoidbone.

p.136.Centbl.f.

Chir.,1883,

No.25,andletter

59M.Carcinoma.Entire

larynx.Deathfrom

croupouspneumonia3

mos.

I

afteroperation.fromDr.A.Schmidt

to

Prof.Burow

(Arch.Laryng.,

N.Y.,April,

1888).

Asabove.

11

Multanow- ski(St.Pe-

1875Aug.9

47M.Carcinoma.Entirelarynx.

Deathfromrecur-

rence3

months

13

tersburgh).Billroth (Vienna).1875Nov.

1154M,

Diffusecarcino-

maofthelar-

ynx.

Entirelarynx.

afteroperation.

Deathon

thefourth

dayfromextensive

broncho-pneumo-Billroth’s

ClinicalSurgery,

London,1881,p.133.

Hadnotbeen

pre-

cededbytrach-

eotomy;wound

nia.

didwell,withbutlittlefebrile

13

Maas(

Freiburg).1876Feb.

5

50M.

Epitheliomaof

thelarynx.

Entirelarynx,with

exceptionofthe

Deathfromrecur-

rence6

monthsArch.f.

klin.Chir.,

Bd.xx.

p.535.Pri-

reaction. Recurrencein

posteriorpor-

tionof

tongue

epiglottisandof

aftertheoperation.vate

communica-

asmallpieceof

thecricoidcartil-

tionfrom

operatortoDr.

Foulis,about3

monthsafter

operat’n.

age.

Trans.Int.

Med.

C.,London,

1881.Deathbyhe-

morrhagefrom

theulcerated

14

Gerdes(Jeyer).1876Mar.

3076M.Carcinoma.Entirelarynx.Death

onthefourth

dayfromcollapse.

Arch.f.

klin.Chir.,

Bd.xxi.H.ii.p.

mass.

15

Reyher1876

60M.Carcinomaofthe

Entirelarynx,with

Deathonthe

eleventh473. St.

Petersburghermed.Woch.,

1877,

Nos.17

and18.

(Dorpat).May

1

vocalbands.

exceptionofepi-

glottis.

dayfromhyposta-

ticpneumonia.

7

tablei—

continued.

No.

Operator.Date.Age.Sex.

Disease.■Parts

removed.Result.

Reference.Remarks.

16

Watson,P.

H.(Edin-burgh).

187660F.

Epitheliomaof

larynx,with

en-

largementof

someadjacent

glands.

Larynxand

en-

largedglands.

Deathinone

week

frompulmonary

embolism.Letter

fromoperator

toDr.

Foulis.Thelingualand

facialveins

werecutinthe

operation.

17

Kosmski (Warsaw).1877Mar.

1536F.

Epitheliomaof

thelarynx,with

perforationof

theskin.

Entirelarynx.Deathfrom

recur-rence9

monthsafter

operation.Centbl.f.

Chir.,1877,No.xxvi.p.401.

Privatecommuni-

cationfrom

opera-

torto

Dr.Foulis.

18

Fonlis (Glasgow).1877Sept.

1038M.Sarcoma,“

part-

ly

papilloma,partlyspindle-

celledsarco-

ma.”

Entirelarynx,with

exceptionof

su-

periorcornuaof

thyroidcartilage

andhalftheary-

tenoidcartilages.

Deathfromtracheal

andpulmonaryphthisis,

March1.

1879.

Lancet,Oct.

13,1877,andMar.29,

1879.

19

Wegner(Berlin).1877Sept.

1652F.Carcinomaofthe

larynx,sizeof

walnut,origin-

atingfromright

ventricle.Entire

larynx,with

epiglottis,but

leavinglowerhalf

ofthecricoid

car-

tilage.

WellApril13,

1878.Verb,der

DeutscheGesellsch.f.

Chir.,

1878.Private

com-municationfrom

operatortoDr.

Foulis.

20

Bottini (Turin).1877Aug.

3948M.

Epitheliomaof

thelarynx.

Entirelarynxand

portionof

oeso-phagus.

Deathon

thethird

dayfromdouble

pneumonia.Annalesdes

maladiesde

Poreilleetdu

larynx,July1,

1878;'Centbl.f.

Chir.,1878.

Performed “

bloodlessly,”withgalvano-

cauteryblade.

21

Bruns,Vic-

torvon(Tubingen).

1878 Jan.29

54M.

Epitheliomaof

thelarynx(of

5

years’dura-

tion).

Entirelarynx.

Deathfromrecur-

rence9

monthsafteroperation.

•

Wien.med.

Presse,Nov.

17,1878.Com-

municationfrom

Prof.PaulBrunsto

Dr.Foulis.

1

Preliminary tracheotomy notperformed. Collapse

afteroperation,and hyperpyrexia

fora

week. Voicetubeem-

ployedinfive

weeks.

8

tableI

—continued.

•

No.

Operator.Date.Age.Sex.

Disease.Parts

removed.Result.

Reference.Remarks.

33

Rubio (Madrid).1878May

1141M.

Perichondritisof

thethyroid

car-tilage,withne-

crosis.

Entirelarynx.

Deathon

thefifth

dayfrom

maras-mus.

Observacionclinica,

etc.RealAcademia

de

Med.,Madrid,

1878.

33

Czerny(Heidel- berg).

1878Aug,34

46M.Sarcomainand

undervocal

bands,andper-

foratingthe

thyroidcartil-

age;

alsoin-

volvingthe neighboring glands.

Entirelarynx,and

thediseased glands.

Death15months

afteroperation(as

theresultofanew

operation?).

Letterfromoperator

toDr,

Foulis.Schid-

ler,die

Tracheoto-mie,

Billrothund

Liicke’sDeutsche

Chirurgie,1880,p.

300.

Repeatedremov-

alsof

recurring masses.

34

Billroth (Vienna).1879Peb.

3743F.

Epitheliomaof

pharynx,lar-

ynx,andthy-

oidgland.

Entirelarynx,with

partof

pharynxand

oesophagus.Death

duringseventh

weekfrom

passageofbougieintome-

diastinum.Private

communica-tionfrom

operatortoDr.

Foulis.

25Gussenbauer(Prague).1879 May

3434M.Carcinoma.Entirelarynx.

Death3

monthsafter

operationfromtu-

berculosispulmo-

num.

Letterfrom

operatorto

Prof.Burow.

Arch.Lar.,April,

1883.

26

Macewen,Wm.(Glas- gow).

1879 July31

56M.Carcinomaoflar-

ynxandupper

endofgullet;

alsoa

glandu-lar

massatleft

sideofneck.

Larynx,partofgul-

let,andtheglan-

dularmass.

Deathin3

daysfrom

pneumonia.Foulis,

Trans.Int.

Med.Con.,

Lon-

don,1881.

37CaselliAzzio (Reggio-Em- ilia).

1879Sept.30

19F.Sarcomaoflar-

ynx,pharynx,

palate,andbase

oftongue.

Entirelarynx,pha-

rynx,baseof

tongue,soft

pa-

late,andtonsils.

WellAugust,

1881

(probablystillliv-

ing).

Bui.del

Scien.Med.,

Bologna,1880,vol.

v.;Centbl.f.

Chir.,

1880;CasellPsRe-

print,Bologna,

1880.CasellPs statement

atmeet-

ingInt.Med.Con.,

London,1881.

Operationoccu-

piedmorethan

3

hours,was

largelydone

withthegal-

vano-caustic

blade,and

wasattendedwith

butlittlehe-

morrhage.

9

tableI—continued.

No.

Operator.Date.Age.Sex.

Disease.Parts

removed.Result.

Reference.Remarks.

28

Lange,F.

187974M.Sarcomaoflar-

Larynx,right

cor-Deathfrom

astheniaArchivesof

Laryngo-

(NewYork)Oct.12

ynxinvolving

thegullet.

nuaofhyoidbone,

partofgullet.

nearlysevenmonths

afteroperation.Re-

logy,N.Y.,

1879,

p.36.

29Multanow-

currence.

187960M.Carcinoma.Entirelarynx.Death

onfifthday

Centralbl.f.

Chir.,

ski(St.Pe- tersburgh).Dec.4

frompneumonia.

1882,No.25.

Let-

terfromDr.A.

Schmidtto

Prof.

Burow,Arch.

Lar.,

80

Langenbuch1879

Anaged female.

Deathon

thirdday

fromcollapse.

April,1883.

Verh.der

DeutscheGes.f.

Chir.,Bd.

x.Onlymetby

com-pilerin

Blum’slist,Arch.Gen.

demed.,

1882,

31

Reyher,Carl

188048M.Carcinoma.Larynx.

Deathon

seventhday

Wolner’sMed.

Jour.,ii.p.79.

(St.Peters- burgh).

fromseptic

bron-1880.H.i.

Letter

cho-pneumonia.fromoperatorto

32

Thiersch (Leipsic).1880Feb.

2636M.Carcinoma,Entirelarynxand

tworingsoftra-

chea.

Well18

monthsAFTEROPERATION.

Dr.Foulis. Deutsch.

Ztschr.f.

Chir.,1881,

xvi.p.

149.Centbl.f.

med,Wiss.,Sept.

23,1882.

Revuemens,de

Laryn.,No.82,p.350,but

accreditedto

Lan-Tracheotomy,Sept,

27,1879.Laryngotomy

foraccessto

growths,Feb.

3,1880.

33

Thiersch(Leipsic).1880 April

1552M.Carcinoma.Entirelarynx.Were17months

AFTEROPERATION,

derer. Asabove.

Tracheotomy, Mar.2,1880.

34

Czerny1880

47M.

Epitheliomaof

Larynxandsoft

Deathfromexhaus-

Letterfrom

operator

(Heidel-Oct.11

larynxand

su-tissuesinfrontoftionandhemor-toDr.

Foulis.

berg).

perjacentsoft

parts.

it.

rhage5

months(March25,

1881)

after.

10

tablei—

continued.

No.!

Operator.Date.AgeSex

Disease.Partsremoved.Result.

Reference.Remarks.

35

Hahn (Berlin).1880Oct.

2367M.

Carcinoma.Larynx,all

excepta

portionofthe

thyroidcartilage.

Freefrom

recur-rence3

YEARSafter

operation.Letter

fromoperatoi

toProf.Burow.

Archivesof

Laryn-

36

Thiersch(Leipsic).1880 Nov.

1045

1

F.

Carcinomaof

pharynxand

larynx.

Larynxandpartof

pharynx.Deathfromrecur-

rencein4

months(March

16,1881).gology,April,

1883.

Deutsch.Ztsch.f.

Chir.,1881,xvi.p.

149.

Tracheotomy,Oct.17,1880.Recurrence noted

within6

weeksafter

37

Bircher,H. (Aarau).

188049F.ScirrhusoftheThyroid

glandex-

Deathin16days

Letterfrom

operatortoDr.

Foulis.Trans.

Int.Med.Congress,

operation.

Dec.3

thyroidgland,

involvingthe

cised;6

monthslaterthe

cancerfrompneumonia

andgangreneof

larynx.

recurred,andthethelung.

1881.

larynxwasex-

cisedwithpartof

38

Pick (London).1881 Jan.

1639M.

Epitheliomaof

larynx(preced-

thegullet.

Larynxandepiglot-

tis.

Deathin5

daysfrom

pleurisyandperi-

Lancet,April3,1881,

p.541,

Brit.Med.

edby

papillo-mata).Carcinoma

of

pharynxand

carditis.

Journ.,April9,

39

Thiersch(Leipsic).1881 Jan.

1757F.

Entirelarynxand

partofpharynx.

Deathon

seventhday

fromsecondaryin-

1881,p.563.

Deutsch.Ztsch.f.

Chir.,1881,

Bd.Tracheotomy,Dec.

9,1880.

40

Toro (Cadiz).1881 March

9

larynx.Epitheliomaof

laryrwx.

Hyoidhone,

base

of

tongue,and

fectiouspneumonia

Deathon

fourthday

frompulmonary

xvi.p.149.

Med.Record,N.Y.,

August6,

1881,p.

41Winiwarter (Liege).

1881April55F.

Carcinoma,larynx.Entire

larynx.

emphysema.NO

RECURRENCE11

167.CliniqueChir.Univ.

MONTHSAFTER

OPE-

RATION.

Liege;

Monatschr.f.

Ohrenheilk,1882,

No.9.

Burow’s

43

Poulis (Glasgow).1881April

3050M.

Epitheliomaof

larynx(preced-

edby

papillo-mata).

Larynx.

WellandstrongAu-

gust,1881.

list.Brit.Med.

Jour.,May1

7,June11,

1881;

Trans.Int.

Med.

Congress,London,

1881,

11

tableI—continued.

No.

Operator.Date.AgeSex

Disease.|

Partsremoved.

Result.

Reference.Remarks.

43

Czerny(Heidel-) berg).1881May

1347M.

Epithelioma.Larynx

andupper

tworingsoftra-

chea.

Wellandstrong

Au-

gust,1881.

Letterfrom

operatoito

Dr.Foulis.

Ver-

balreporttoInt.

Med.Cong,,

Lon-

44

Beyher,Carl

(St.Peters-

1881May14

57M.Carcinoma.Larynx.

Deathon

fifthday

don,1881.Letterfromoperator

burgh).

•

fromseptic

bron-toDr.

Foulis.Trans.

cho-pneumonia.Int.Med.Congress,

45

Kocher (Berne).1881 May

1659M.Carcinoma.Entire

larynx,ex-No

RECURRENCE16

1881.Letterfromoperator

Patientwearsa

cepta

pieceoi

thecricoid

car-

tilage.

MONTHSAFTER

OPE-

RATION.

toProf.Burow.

Arch.Laryn.,N.Y.

April,1883.

self-madearti-

ficialepiglottis

toovercome choking

inde-

glutition,re-

sultof

excision

46 47Tilanus(Am- sterdam

).Gussenbauer(Prague).1881 May 1881May

1951 48M. M.

Epithelioma. Carcinoma,Entire

larynx.Entire

larynx.Deathin36hours

fromcollapse.

Well19

monthsCentbl.f.Chir.,

1882,

.No.34.

Letterfrom

operatorof

epiglottis.

AFTEROPERATIONJ

doingdutyasa

toProf.Burow.

Arch.Laryn.,N.Y.

48

Volker (Bruns- wick).1881May

2844F.Carcinomaepi-

thelioides.Entirelarynx.

riding-master. Deathfromsuffoca-

tion5

monthsafter

April,1883.Academisch

Proef-schrift,

Amsterdam,Suffocated

whilepatienthad

operation.

1883,pp.

84and

113.withdrawnca-

llulatocleanse

49

Albert (Vienna).1881 July

6

45M.Carcinoma,al-

mostfillingright

halfoflarynx.

Entirelarynx,

ex-

ceptepiglottis;

alsosmallsection

ofadherent

cesophagus.

deathon

eighthday

fromdiffuse

bron-

chitisandlobular

pneumonia.Wienmed.

Presse,1881,xxii.p.

1373.it. On

13th,hemor-

rhagefromin-

ternalcarotid,

arrestedbyli-

gatureabove

andbelow

pointof

ero-sion.

Collapsesame

evening;deathnextday.

12

tablei—continued.

No

Operator.Date.

AgeSex.

Disease.Partsremoved.Result.

Reference.Remarks.

50 51

Hahn (Berlin). Mare-ary(Turin).1831Aug.i;

1881Sept.29

46 36M. F.Carcinoma. Epithelioma

o:

oesophagusand

larynx.

Entirelarynx.

Larynx,firstringoi

trachea,thyroid

body,partoi

Deathin25daysfrom

putridbronchitis.

Letterfromoperate]

toProf.

Burow.Arch.Ital.di

Lar.

Jan.15,

1882.Recurrence

at

endof3

mos.

pharynx,and

oesophagus.Entirelarynx.

52Gussenbauei(.Prague).

1881Oct.63M.Carcinoma.

STRONGANDWELL

Letterfrom

operator

14MONTHSAFTERto

Prof.Burow.

53.Reyher,

Carl(St.Peters- burgh).

1881Oct.10

73M.Carcinoma.Larynxand

upperthreeringsof

OPERATION.Deathfromrecur-

rence,9

monthsSt.

Petersburg!!med.

Ztschr.,1883,

No

trachea.

afteroperation.28.

Letterfrom

•

operatorto

Prof.

54

Reyher,Carl

(St.Peters-

15

urgh).1881Oct.

1065M.Carcinoma.

Larynx.

Deathon

seventhday

fromsepticpneu-

monia.Recurrenceinfour

months.Excision

ofright

lobeof

thyroidglandand

Burow. Asabove.

55

Novaro.1881

63M.Carcinoma.Entirelarynx.

Giorn.diR.

Acad,di

med.diTorino,vol.

xxxix.1881,p.

39;

Arch.Ital.di

Lar.,

partof

pharynx.July15,

1882.

Deathfromhem-

orrhageon11th

66

Schede.188154M.Cancroid.Larynx,hyoid

day.Twomonthslater

Deutschemed.

bone,andthy-

roidgland.

thepatient

wasWoch.,

1883,No.

fittedwithan

arti-33,p.45.

57

Reyher,Carl

(St.Peters- burgh).Kocher (Berne).

1882April7

55M.Carcinomaepi-

thelioides.Entire

larynx,pha-

rynx,andparts

of

oesophagus.Entire

larynxand carcinomatous

*

glands.

ficiallarynx.

Death14days

after

operationfrom

ex-setterfrom

operator

58

1883 May13

54M.Carcinoma.

haustion.Letter

fromoperator

toProf.Burow.

Recurrenceseven

months,after

operation.

13

tableI—

concluded.

No.

Operator.Date.Age.Sex.

Disease.Parts

removed.Result.

Reference.Remarks.

69

Whitehead,Wm,(Man-

188346M.

Epitheliomaol

ThyroidandcricolcWell

January31,

Lancet,Nov.4,

1883

May27

rightvocal

bandcartilagesandtwo

1883.Probably

p.741.

Letterfrom

Chester).

andpartssub-

ringsoftrachea,

leavingepiglottis

stillalive.

operatortocom-

jacent(asfar

piler,datedJan.31,

downasupper

intact.

1883.

portionoftra-

60

1883 June13

54

chea).

Bergmann, von(Wurz- burg)

.

M.Carcinoma.(Adeno-sarco-Entirelarynx.Speaks

wellwith

artificial(Bruns)

Sitzungsb.Wurzburg

Phys.Grcsell.,1882,

ma?).

LARYNXSOMEMOS.

AFTEROPERATION.

47-56.

Deutschemed.

Woch.,1883,

No.35.;Centbl.f.

Chir.,Aug.19,

61

Burow1883

44M.Carcinoma.

Entirelarynxwith-

Deathfrom

sudden1883.Archives

of

Laryn-

63

(Konigs-berg).Kocher (Berne).July7

1883 Sept.38

43M.

Carcinoma.out

epiglottis.Entire

larynxand

a

portionof

oeso-suffocation

mos.

afteroperation.

gology,April,

1883.

Sammlungklin.Vor-

tragev.

Volkmann,

63

Maydl(Vienna).188350M.Carcinoma.Larynx,

exceptcri-

coidcartilage.

Excisionofa

gland,sizeofa

dove’segg.

Norecurrences mos.

afteroperation.

No.334,p.1944.

Wienmed.

Presse,1883,xxiii.

1673;

Wienmed.Woch.,

1883,No.44.Let-

terfrom

operator

64

Ruggi.188310M.

Polypiofthela-

Entirelarynx.

toProf.Burow.

Centbl.f.

Chir.,1883,

No.45;

Raccogli-toremed.-,

1883,“Recoveryin88

days.”Burow’s

list.

65I

McLeod(Calcutta).188335M.

Papillomaofla-

rynx.

Entirelarynxand

thyroidgland.

Ingood

conditiononemonthlater.

xviii.p.36.

Ind.Med.Gaz.,

1883,

xviii.,34-86.

14

Of the above complete operations, fourwere performed in non-malignant cases; one forcicatricial syphilitic stenosis, with death “ some weeksafter from pneumonia” (Case 1) [Watson] ; one fornecrosis, the case terminating fatally by marasmusfive days after the operation (Case 22) [Rubio] ; onetor polypi of the larynx (Case 64) [Ruggi] ; and onefor papilloma of the larynx (Case 65) [McLeod].

Of the sixty-one operations remaining in this list,five were performed for sarcoma; in two of which theresults were so remarkably exceptional, that attentionshould be especially directed to them.

I. Bottini, of Turin, on Feb. 6, 1875, removed theentire larynx from a male subject twenty-four yearsof age, with a laryngeal sarcoma, partly round-celled,partly spindle-celled. Notwithstanding copioushemoi i ha

&e and severe erysipelas, the patient re-

covered. He was reported well in August, 1881, ormore than six years after the operation, and I haveseen no notice of his death. He had been perform-ing the duties of a postman, and walking eight milesa day. This is the most successful case on record.

11. Caselli, of Reggio-Emilia, on Sept. 20, 1879,removed the larynx, pharynx, base of the tongue,soft palate and tonsils, from a female subject nineteenyears of age, lor a sarcoma of the larynx, pharynx,palate, and base ol tongue. The patient was reportedwell in August, 1881, practically two years after theoperation, and I have seen no notice of her death.This is the second best case on record.

The remaining three patients operated upon forsarcoma died at the periods of seven, fifteen, andseventeen-and-a-halfmonths, respectively.

15

TABLE lI.—CASES OF SARCOMA.1 (Lange) lived nearly 7 months.1 (Czerny) “ “ 15 u1 (Foulis) “ “ 171 u

} was alive Aug.’lSSl, nearly 2 years after operation.1 (Bottom) was alive and well Aug. 1881, years after operation.Taking for granted, as we are bound to do, thatdeath Avas imminent in these five cases of sarcoma

when the operation was resorted to, we have a con-siderable prolongation of life in every instance, anda remarkable prolongation in two, or in forty per cent.A,s fai as these limited statistics go, therefore, theoperation of excision of the larynx in hopeless casesof sarcoma is worthy the serious consideration of thesurgeon.

The history of the remaining fifty-six operationspresents a much more gloomy account. They wereall for carcinoma, if we may include under that headSchede’s case (56) of “ cancroid.”

Let me read the list of deaths as far as reported:—-

TABLE 111. RECORDED DEATHS AFTER LARYNGECTOMY FORCARCINOMA.

1.2.3.

Tilanus,Macewen,Bottini,

Case 46.“ 26.“ 20.

Death in 36 hours from collapse.3 days “ pneumonia.

“ 3 “ “

4.5.

Langenbuch,Schmidt,

“ 30.“ 4.

4 444

34

4 4

4 44 4

4 4collapse.

446. Gerdes, “ 14. 4 4 4 4 4 4 4 4 47.Q

Billroth,Toro,Schbnborn,

“ 12. 4 4 4 4 4 4 4 pneumonia.O.

9.“ 40.“ 7.

i 44 4

44

44

4 4

<4

4 4pulmonary emphysema.

?

pneumonia,septic broncho-pneumonia.

10.11.12.

Multanowski,Reyher,Pick,Reyher,Reyher,Watson,Thiersch,

“ 29.“ 44.

4 4

4 456

4 4

4 444

4 4

13.14.15.1G.

“ 38.“ 31.“ 54.“ 16.“ 39.

4 44 4

4 44 4

57777

44

4 44 4

44

4 4444 4

4 44 4

pleurisy and pericarditis,septic broncho-pneumonia,septic pneumonia,pulmonary embolism,“secondary infectious”

17. Albert, “ 49. 4 4 8 4 4 4 4pneumonia.

“diffuse bronchitis andlobular” pneumonia.

16

table in.—continued.

To this list may be added the cases of—Margary, Case 51, in which recurrence was reported at 3 months.Ivocher, “ 58, “ “ “ 7 u

In the following cases neither death nor recurrence has been reported:

Of the forty reported deaths, seventeen, or forty-two-and-a-half per cent., occurred within eight days,

lg. Reyher,19. Reyher,

Case 15.“ 57.

Heatht 6

in 11 days from “hypostatic” pneumonia.14 “ “ exhaustion.20.

21,Maas,Watson,

“ 5.“ 6.

4 444

2 weeks2 “

44

44pneumonia.

1 122. Bircher, “ 37. 44 16 days 44 pneumonia and ‘ £ pulmo-23. Hahn,

Billroth,“ 50. 44 25 4 4 44

nary gangrene.”putrid bronchitis.

24. “ 24. 44 6 weeks 44 passage of bougie into25. Multanowski, “ 11. 44 2 mos. 44

mediastinum.recurrence.26. Gnssenbauer, “ 25. 44 2 4 4 44 tuberculosis pulraonum.‘ ‘ croupous’ ’ pneumonia,

recurrence.27.28.

Multanowski,Langenbeck,

“ 10.“ 9.

44

4 434

4 444

4 44 4

29. Thiersch, “ 36. 4 4 4 44 4 4 44

30. Novaro, “ 55. 44 4 44 44 recurrence and hemorrhageconsequent upon addi-tional operative proced-

31. von Burow, ures.“ 61. 4 4 U. 44 44 sudden suffocation.32, Czerny, “ 34. 4 4 5~ 44 4 4 recurrence.

33. Volker, “ 48. 44 5 44 44 suffocation.34. Heine, “ 3. 44 6 4 4 44 recurrence.35. Maas, “ 13. 4 4 6 44 44 4436. Billroth, “ 2. 44 7 44 44 4437. Bruns, “ 21. 44 9 4 4 4 4 4 438. Kosinski, “ 17. 44 9 44 44 44

39. Reyher, “ 53. 44 9 4 4 4 4 4440. Czerny, “ 23. 44 15 4 4 4 4 4 4

1. F oulis, case 42, alive 5 weeks after operation.2. Czerny, 44 43, “ 6 “ “

56, artificial larynx adjusted 2 months after operation.3.4.

Schede,Mayal,

44u

5. von Bergmann. u1

iikj i ccuiit/iiGty o mourns alter operation.60, alive “some” “ “

6. Wegner,Whitehead,Winniwarter,

u 19, “ 7 months after operation.7.8.

444 4

59, “no recurrencealive 8 months after operation.41, “ “ “ 11 “ u

9. Gussenbauer, u 52, well 14 months after operation.10. Kocher, 4 4 46, no recurrence 16 months after operation.11. Thiersch, 4 4 33, well 17 months after operation.

32, “ 18 “ “12. Thiersch, 44

13. Gussenbauer, 4 4 47, “ 19 “ “

14. Hahn, 44 35, “ 2 years “ “

17

and five more succumbed within the second period ofeight days.

The danger during the first few days is from shockand from pneumonia. Very few have perished fromdirect shock, very many from pneumonia. The pneu-monia has been attributed generally to the ingress ofblood, aliment, and septic materials into the air-pas-sages ; but, if I may form an opinion from what I havewitnessed in many other operations upon the neck,theie is a certain amount of risk of pneumonia in allsurgical interferences in the cervical region, evenwhen the air-passage is not opened. Thus I haveseen it follow extirpation of the thyroid gland, ex-tiipation of cervical neoplasms, and even exploratoryincision into the region. It may be that the reduc-tion of temperature to which the pneumogastricnerve is subjected leads to pneumonia, and that themanipulations within the wound render it especiallysensitive. When we reflect that the majority of theseoperations of laryngectomy consume from one to threehours in their performance, we can fairly presumethat the pneumogastric nerve is subjected to sufficientordeal to excite an early pneumonia, quite independ-ently of access of foreign matter to the lungs; a sequelof the operation against which every available pre-caution is taken.

The danger from pneumonia does not seem to existlonger than two weeks, for we have but one recordof death from this cause after the sixteenth day, andthat from “croupous pneumonia” (Case 10) at theend of three months. This important fortnight safelypassed, the life of the patient appears comparativelysecure up to the fourth month. At the fourth month

18

death begins to be imminent from recurrence, and wehave, in our table, three at four months; one, and pos-sibly several, within five months ; two at six months;one at seven months; three at nine months; and one atfifteen months. One death from recurrence (Case 11)is reported at two months after operation. Nine casesare reported living at seven, eight, eleven, fourteen,sixteen, seventeen, eighteen, nineteen, and twenty-four months, respectively. Thus forty-two-and-one-halt per cent, of the forty cases, recorded as termi-nating fatally, or more than thirty per cent, of the entirenumber operated upon for carcinoma, perished withineight days; and at the end of six months, thirty-fiveof the forty were dead, or eighty-seven-and-one-halfper cent.; making sixty-two-and-one-half per cent, ofthe entire fifty-six operations for carcinoma; with greatprobability of a still higher percentage had all thedeaths been reported.

Let us contrast this record with the average life ofcarcinoma of the larynx not subjected to the radicaloperation of laryngectomy.

Of a number of cases of carcinoma of the larynxunder my own care, who agreed to submit to exsec-tion of the larynx should I so determine, and in whomI performed tracheotomy in preference, one lived sixmonths, two lived seven months, one lived thirteenmonths, and one eighteen months, respectively, afterthe tracheotomy.

Had laryngectomy been practised in these fivecases, with equal tenure of existence, the result wouldhave been accredited to the radical procedure. Hadthe operation been performed, one life might possiblyhave been prolonged; the majority, however, wouldprobably have been shortened. At the period a

19

the end of which eighty-seven-and-a-half per cent,of the recorded deaths after laryngectomy had oc-curred, i. e., six months, all my tracheotomized caseswere living ; and hut two of the entire number offifty-six excisions for carcinoma outlived the longest-lived instance in my tracheotomized list. It is notimprobable that a complete series of collated statis-tics would present a far better exhibit for the casesmerely subjected to tracheotomy and palliative pro-cedure. It is generally believed that the naturalhistory of carcinoma of the larynx comprises anaverage existence of about two years and a half;tracheotomy becoming requisite at a period varyingfrom nine to eighteen months, according as the dis-ease is wholly intra-laryngeal or more parietal.

In laryngectomy, the initial shock is severe, and sureto carry off a large percentage of cases by collapse,or by pneumonia. A certain number of lives aresacrificed; and the condition of the survivors, withtheir artificial substitutes for the larynx, is often de-scribed as pitiable in the extreme.

In tracheotomy, there is little shock, very slightdanger of pneumonia, and much less risk of septicinfection. Life is not likely to be sacrificed in anyinstance; and existence is much more comfortableafter the operation than after laryngectomy.

For these reasons, excision of the larynx for carci-noma does not, in my opinion, tend to the prolonga-tion of life; for the prolonged existence of a very fewseems purchasable only at the sacrifice of the rem-nants of existence of many others. The greatest goodto the greatest number appears better secured by de-pendence on the palliative operation of tracheotomy.