A System of Operative Surgery Part 78

_Recurrence_, in Semon's cases, occurred in 13.6%, which is not a large proportion. It usually occurs early or not at all. Semon and Jackson noted that none of their patients suffered from recurrence after the lapse of the first year. This is a point of great importance; and in this connexion Semon points out, as an additional advantage of thyrotomy, 'that even in the cases in which either the operation has not been complete, or in which unfortunately genuine recurrence has taken place, the operation does not bring us to the end of our resources; but that, on the contrary, by a repet.i.tion of the operation, or by hemi-laryngectomy, or by total extirpation of the larynx, a lasting cure may still be obtained, where the minor operation has failed.'

_Cures._ I hope it will soon become generally recognized that the radical operation of thyrotomy for removal of early intrinsic malignant disease is attended by a remarkable number of complete cures, and compares favourably with almost any other operation for similar conditions in other parts of the body. Butlin (see Table, p. 507), Semon, and C. Jackson have all obtained, in recent years, from 60 to 80% of lasting cures. In Semon's twenty-five cases,[20] one died of the operation, three cases recurred within a year, and one was too recent to be included, the remaining twenty were cured for varying periods, namely:

1 case over 15 years.

4 cases between 10 and 15 years.

4 cases between 5 and 10 years.

2 cases over 4 years.

3 cases over 3 years.

2 cases over 2 years.

1 case just 2 years.

1 case 1 year and 10 months.

1 case died 5 years after operation from pulmonary embolism.

1 case died 4 years after operation from pneumonia.

In both the last cases recurrence was excluded.

[20] _Trans. Med. Soc._, London, 1907, vol. x.x.x, p. 130.

The _condition_ of the patient after thyrotomy. The voice results are often surprisingly good even when a free excision of soft parts, including one or both vocal cords, has been required. In from 40 to 60% of cases that are cured, the voice is practically normal, though rough and reduced in volume and range. Of the remainder, the majority recover sufficiently to produce a considerable whisper, and only a few suffer complete loss of voice. The causes of a complete loss of voice, when it occurs, are chronic inflammation, cicatricial contractions, or improper union of the cartilage. Further, a loss of voice is probable in the event of a recurrence of the growth.

The breathing is not affected unless the operation is followed by stenosis. The power of swallowing is soon regained, and the general condition of those who are cured is one of complete happiness and general excellence of health.

These results may now be briefly compared with those obtained by laryngectomy, whether partial or complete.

=Hemi-laryngectomy.= The immediate _mortality_ of this operation also has been greatly reduced. Sendziak collected 108 cases, up to 1894, showing a mortality of 26.3%; von Bruns 106 cases, between 1890 and 1898, with a mortality of 17%; Gluck has performed thirty-five such operations with only three deaths--8.1%. The number of cases reported in England is too small to be of value, chiefly because thyrotomy or total extirpation has been considered better. Taking, therefore, the best published results, it appears that the mortality is at least twice as great as with thyrotomy.

The danger of _recurrence_ is also greater, partly because the glands are affected. Statistics show that recurrence occurs in at least one-fourth of the cases, possibly more, and is generally fatal. It is impossible to give a prognosis as to cure in the early stages after operation, but there are instances of life being prolonged for many years; a case of Gluck's lived for eleven years.

The _after-condition_ is not unsatisfactory. The permanent wearing of a tracheotomy tube is rarely necessary. Swallowing is soon recovered, and the voice is often good.

=Total laryngectomy.= Although the mortality of this operation has been greatly reduced by many improvements in recent years, it still remains higher than that of thyrotomy. As far as can be judged from the small number of cases that have been reported by English surgeons, there seems to be a direct mortality of at least 20% from these operations. C.

Jackson[21] has, however, performed eight consecutive total laryngectomies without a death in the first thirty days. He writes: 'Of eight total laryngectomies done by me, three were hemi-laryngectomies followed by recurrence and the total operation. Of the eight laryngectomies, one lived seven years. I felt justified in claiming a cure, but upon inquiry a few weeks ago I was informed by relatives that he died of cancer of the stomach. One case lived three years without recurrence, dying of cerebral haemorrhage, and one eight months, dying of alcoholism. Of the remaining five, three recurred within a year, one apparent cure was lost to observation after a year, and one is too recent to record: one of the three prompt recurrences had metastases in the lungs, liver, and pancreas. Thus, of eight laryngectomies, no absolute ultimate cures can be claimed, though three were apparent cures at the end of one year.'

[21] _Brit. Med. Journ._, 1906, vol. ii, p. 1480.

Butlin has performed total laryngectomy upon seven patients, only one of whom died from the operation. He says: 'I first removed a large ma.s.s of glands on both sides, and later took out the larynx, which was so diseased, that the surrounding parts were infiltrated for a considerable distance. He lived six weeks after the second operation, and then died of double pneumonia, which was attributed to an attack of influenza when he was up and about his room. I do not know whether the pneumonia was due to that cause or to sepsis of the lungs, for we had on several occasions some difficulty in feeding him, and in getting a tube properly down his sophagus.'

The following is a table showing Butlin's operations since the year 1890, from a paper which was read at the Second Congress of the International Surgical Society at Brussels in 1908:--

_Operations._

23 Thyrotomy[1] 21 patients 1 Hemi-laryngectomy 1 patient 7 Laryngectomy[2] 6 patients -- -- 31 operations on 28 "

Died of the operation (1 thyrotomy, 1 laryngectomy) 2 Died of recurrence 4 Died of intrathoracic disease, probably cancerous glands, within 2 years 1 Died of cancer of tongue[3] 1 Lost sight of after operation 1 Alive after operation for recurrence 2 Well within 3 years 3 Died of other disease after 3 years 1 Well after 3 years[4] 13 -- 28

[1] In two patients the operation was repeated.

[2] In one patient thyrotomy was followed by laryngectomy, but the patient was included amongst the thyrotomies only.

[3] This was regarded as a second attack of cancer, for the disease of the tongue was some distance from the larynx, and there was no sign of cancer of the intervening parts. Also more than a year elapsed before he began to suffer from cancer of the tongue.

[4] Periods during which patients remained well lasted from 3 to 15 years.

Recurrence after laryngectomy is, therefore, more frequent than after thyrotomy, and it is difficult to estimate the proportion of cases that are cured by this operation. Butlin writes: 'Of the six patients who survived the operation, one died of probable cancerous glands in the mediastinum, one had inoperable recurrence in the cervical glands, three were alive within three years, and one was well three years after the operation.' He says: 'I began to perform laryngectomy three years ago on account of Gluck's success, and of the excellent modification due to Solis Cohen. I wish I had begun to perform it earlier. I am sure that several of the cases on which I performed thyrotomy were much better fitted for laryngectomy, and I cannot help thinking I might have saved one or two patients in whom recurrence took place if I had then removed the larynx. I think the glands ought to be removed in every case in which there is extensive carcinoma of the larynx, even if it be intrinsic, unless the disease is limited to the middle zone of the interior of the larynx. Even in these cases it would probably be a wise precaution to remove the glands. I have never removed the glands and the larynx at one sitting.' Von Bruns,[22] from statistics of all total operations since 1890, gives the following proportions:--

Cure, over 3 years 8.6% Cure, 1 to 3 years 17.4% Cure, under 1 year 32.0% Recurrence 23.4% Death due to operation 18.5%

[22] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 245.

_The voice_ after laryngectomy. Many efforts have been made to replace the lost voice. The artificial larynx, as first devised by Gussenbauer, consisted of three distinct parts: a tube for the trachea through which the patient inspired; a tube communicating with the pharynx so as to allow of expiration through the mouth; and a phonation canula which fitted into the former. This canula was supplied with a valve which closed during expiration so as to allow of breathing through the mouth, and a phonation apparatus for production of the voice. A large number of modifications of this larynx have been made at different times but have rarely been successful. The irritation and pain caused by the pharyngeal portion, the difficulty in swallowing and in keeping the tubes clean, and the exhaustion caused by prolonged use, have combined to make the apparatus unsatisfactory.

As the result of recent improvements in laryngectomy, most surgeons isolate the trachea as already described, and thus entirely shut off all communication with the mouth. The patient then has a choice of two methods--(1) the bucco-pharyngeal voice, or (2) a phonetic apparatus such as that described by Gluck, consisting of (_a_) an external tracheotomy canula for breathing, (_b_) an internal canula, possessing a valve which closes during expiration and causes the air to pa.s.s upwards to another compartment containing a small rubber band or tongue, the vibration of which forms the voice, and (_c_) a third tube of rubber, which is easily fitted to the upper part of the inner canula and is of sufficient length to reach the mouth. When the patient wishes to speak, the upper end of the last-mentioned tube is either placed in the angle of the mouth or pa.s.sed through the nose to the back of the pharynx, and the air which has been made to vibrate in the inner tube is thus carried to the mouth. This instrument is easy to adjust and clean, produces remarkable phonetic effects, and is much the most ingenious and serviceable device that has so far been invented. In some cases, however, a patient can make himself understood without an instrument of any kind. 'A whispered voice remains even after the pharynx has been completely shut off from the air-pa.s.sages and, as shown by experience, may be developed by practice until it is quite sufficient for the demands of the patient. Hans Schmidt's case has become more or less celebrated, in which, under conditions of this sort, a loud though rough and monotonous voice was developed. One of Mikulicz's patients was even able to sing. Gottstein explains the development of a pseudo-voice by the formation of an air-chamber in the pharynx and sophagus, which is voluntarily inflated and emptied by the patient' (von Bruns).

_Swallowing_ after laryngectomy is satisfactory, and the general health in many cases improves. The mental condition of the patient is often disappointing. 'Even in favourable cases, when the tumour does not recur after laryngectomy, the patient finds himself in such a condition of inferiority to his fellows, that he may, with some reason, ask himself (at least in certain cases) whether death would not have been preferable to such an existence as is left to him' (Moure[23]). With recurrence of the disease the patient's life is terribly sad.

[23] _Brit. Med. Journ._, 1903, vol. ii, p. 1148.

It must therefore be admitted that laryngectomy is at present an operation of necessity, suitable for certain cases only, capable of prolonging life, and, rarely, of curing the patient. It is difficult to foreshadow the future of this operation; but, in the words of Gluck, 'our first object must be to save life; our next, to leave the patient in such a physical condition that the life so saved is worth living.'

The above statistics are sufficient to show that the results of laryngectomy for extrinsic disease compare unfavourably with the results obtained by thyrotomy in intrinsic forms of cancer. In this country there have not been sufficient cases to estimate accurately the percentage of recoveries. The disease may recur at any period after the operation, and the prospect of a cure is always doubtful.

It is, however, to be hoped that, with improved methods of examination, earlier diagnosis, and a careful selection of the cases, better results will in future be obtained. Authorities such as Butlin and Semon support this view, and agree that further attempts must be made to make this operation successful.

INFRATHYREOID LARYNGOTOMY

In order to avoid confusion with other operations included under laryngotomy, this term is used to denote the operation in which the larynx is opened through the crico-thyreoid membrane. The operation is an easy one in adults, but in children the crico-thyreoid s.p.a.ce is so small that it is almost impossible to introduce a tube without division of the cricoid cartilage (see Crico-tracheotomy, p. 529).

[Ill.u.s.tration: FIG. 264. INFRATHYREOID LARYNGOTOMY. Position of the incision.]

A tube introduced through the crico-thyreoid membrane lies in the subglottic s.p.a.ce well below the vocal cords, and the latter should not be injured when the operation is performed with care. If inflammation supervenes, there may be a swelling of the subglottic region, making the tube difficult to manipulate; and for this reason the operation is particularly suited to cases which require a tube for a short period only, such as--

=Indications.= (i) Sudden laryngeal obstruction due to impaction of food or other foreign body. This is more common in adults: in children dyspna is rarely so urgent as to necessitate an operation.

(ii) Sudden dema of the larynx caused by trauma, fracture, or acute inflammation, when the equipment for tracheotomy is not obtainable; or,

(iii) As a preliminary to major operations upon the upper air-pa.s.sages, in order to prevent blood from pa.s.sing down into the trachea.

This last method of treatment marks a distinct advance in the surgery of the throat. Attention was first directed to it by Bond[24], who has used the method for the past sixteen years with intent to make such operations less dangerous to life, and to increase, therefore, the number of cases that could be operated upon. His objects were to prevent respiration through the pharynx, thus obviating the coughing and struggling due to imperfect anaesthesia and making the anaesthetic easier and safer to administer; to shorten the operation and make it easier for the surgeon; and to get rid of preliminary tracheotomy whenever possible.

[24] _Brit. Med. Journ._, 1907, vol. i, p. 7.

The value of this practice is well recognized by many surgeons. Butlin writes: 'I do not know how many times I have employed this preliminary laryngotomy, but certainly more than a hundred times, so that I am now in a position to urge the importance of it on the profession.' It has now been adopted at many of the hospitals in England before removal of tumours in the naso-pharynx, the upper and lower jaw, the tongue, palate, floor of mouth, and tonsil, in those cases where bleeding is likely to be severe.

In order to ascertain the feeling of my colleagues on this subject I have collected, with the a.s.sistance of Mr. Boyle, all the major operations performed upon the upper air-pa.s.sages during the last six years at St. Bartholomew's Hospital. These are tabulated below.

TABLE SHOWING OPERATIONS UPON THE UPPER AIR-Pa.s.sAGES DURING THE YEARS 1902-7 INCLUSIVE AT ST. BARTHOLOMEW'S HOSPITAL

-----------------------------+------------------+------------------ _With _Without Laryngotomy._ Laryngotomy._ +--------+---------+--------+--------- _Cases._ _Deaths._ _Cases._ _Deaths._ -----------------------------+--------+---------+--------+--------- Excision of Tongue 20 3 13 2 -----------------------------+--------+---------+--------+--------- " " half Tongue 25 2 46 1 -----------------------------+--------+---------+--------+--------- " " Floor of Mouth 13 13 1 -----------------------------+--------+---------+--------+--------- " " Tongue and Floor 5 1 1 1 of Mouth -----------------------------+--------+---------+--------+--------- " " Palate 8 1 -----------------------------+--------+---------+--------+--------- " " Upper Jaw 12 13 -----------------------------+--------+---------+--------+--------- " " Lower Jaw 1 9 -----------------------------+--------+---------+--------+--------- " " Tumour of Gums 1 -----------------------------+--------+---------+--------+--------- " " Tonsil 2 1 -----------------------------+--------+---------+--------+--------- " " Naso-pharyngeal 3 Tumour -----------------------------+--------+---------+--------+--------- Total 90 6 97 5 -----------------------------+--------+---------+--------+---------