CHAPTER II

EXTRA-LARYNGEAL OPERATIONS

THYROTOMY

=Indications.= This operation is performed for two purposes:

(i) To obtain access to the cavity of the larynx when the diagnosis is uncertain, or as a preliminary to other operations.

(ii) As a method of eradicating certain diseases, of which the following are important:--

1. _Malignant tumours_, both carcinoma and sarcoma, in which an early diagnosis has been made, and so long as they remain intrinsic.

It is advisable to follow Krishaber in the separation of all forms of laryngeal cancer into two classes, the _Intrinsic_ and the _Extrinsic_. The term ‘intrinsic’ implies a growth springing from the vocal cords, the ventricular bands, the ventricles, or the subglottic space, and the growth must lie entirely within the laryngeal cavity. ‘Extrinsic’ is the term used for a growth affecting the arytenoids, the posterior part of the cricoid cartilage, the aryteno-epiglottidean fold, or the epiglottis. Such a growth is not entirely limited to the larynx, but also involves some part of the pharynx.

2. _Extrinsic localized malignant tumours_ which are attached to the epiglottis, or to the aryteno-epiglottic fold.

3. _Innocent tumours_ which are too extensive for endolaryngeal operation or of a doubtful character. In either of these cases it is justifiable to perform an external operation, which may be thyrotomy, or occasionally, an atypical operation: thus Semon[12] removed a large fibromatous tumour of the larynx by submucous resection, without opening the cavity of the larynx.

[12] _Brit. Med. Journ._, 1905, vol. i, p. 6.

4. _Stenosis_ following syphilis, trauma, acute exanthemata, scleroma, and other rare diseases. C. Jackson has reported twenty-four cases falling under this head, nineteen of which lived for more than a year after the operation with useful voices. If the surgeon is satisfied that the disease is quiescent, he should point out to the patient that it may be possible to cure the obstruction by thyrotomy. It must, however, be remembered that tertiary syphilitic lesions may again become active as the result of operative interference. It is probable that slight cases of stenosis can be treated better by intubation than by thyrotomy. Thyrotomy has also been suggested to relieve stenosis caused by double abductor paralysis of the vocal cords, but such cases are better treated by tracheotomy or intubation.

5. _Foreign bodies._ Thyrotomy is rarely necessary, and should be reserved for irregular or sharp-pointed bodies, such as tooth-plates or bones, which are so firmly jammed that removal by other methods is impracticable. If there has been much laceration of the soft parts, a tracheotomy tube should be retained for a few days until the swelling has subsided.

6. _Tubercle._ Thyrotomy has been successfully performed in such cases, mostly under the impression that the disease was malignant. The differential diagnosis between tuberculous and malignant growths is sometimes very difficult until the tumour has been explored. In cases that are known to be tuberculous, the feeling prevails that thyrotomy is not to be recommended. It should be remembered that the external wound is liable to become tuberculous.

=Instruments.= Scalpel, curved scissors, dissecting forceps, pressure forceps, aneurism needles, double hook retractors, bone shears (Waggett’s) or bone scissors, tenaculum forceps, needles on handles, catgut in various sizes, a Hahn’s tube, and tracheotomy equipment. A head-light is required for illumination of the deeper parts during removal of tumours.

=Operation.= In England, owing to the fact that the administration has been in skilled hands, chloroform is not considered dangerous, and the operation is well tolerated even for three or four hours (_e.g._ in laryngectomy). On the Continent, however, Kocher, von Bruns, and others advocate local anæsthesia with cocaine or novocaine. Jackson suggested rectal etherization as an alternative, but this has many dangers. In my opinion a general anæsthetic should be given, as it enables the operation to be performed more thoroughly and is followed by less shock. It must nevertheless be borne in mind that, if the growth is intrinsic and of large size, it is difficult to administer chloroform, and the patient is liable to suffer from urgent dyspnœa. In such a case i[t] is advisable to perform preliminary tracheotomy with novocaine alone (see p. 544).

As regards the operation, the important question arises whether tracheotomy ought to be performed several days prior to the main operation, in order to accustom the patient to the tube and the new method of breathing. The following reasons are advanced in favour of this: the main operation is shortened, and relief is given to the larynx and lungs, so that congestion subsides and broncho-pneumonia is less likely to supervene. The objections are also important, namely, that there are two operations instead of one, and perhaps two anæsthetics (though this can be avoided if local anæsthesia is used for the tracheotomy); that the tracheotomy wound becomes septic, and infection of the trachea and bronchi is apt to occur, with consequent bronchitis; that the air which passes into the lungs is devoid of moisture and heat; that the trachea becomes surrounded by adhesions; and that it is altogether unnecessary. The objections in my opinion outweigh the advantages claimed; it is better to perform tracheotomy as a first stage in the operation of removal, except in cases where there is great laryngeal obstruction, where dyspnœa is present, or where bronchitis fails to yield to other forms of treatment. In such cases tracheotomy should be performed first, and the second operation should be carried out a week or ten days later when all the conditions are favourable.

When operating upon the larynx the surgeon must use every precaution to prevent blood from running into the lower air-passages, and this may be accomplished by a tampon in the trachea or by keeping the head of the patient lower than the body. The former method appears to me to be more reliable than the latter; and I prefer to use a Hahn’s canula, although the sponge requires from ten to fifteen minutes to swell. This canula is more reliable than Trendelenburg’s, whose inflated bag is apt to slip or collapse suddenly. As soon as the thyreoid cartilage has been opened, a second sponge should be inserted above the canula, and by this means the air-passages are completely blocked.

If an ordinary tracheotomy tube be used, the operation must be performed either with the head lower than the body (Rose’s position), or with the whole body inclined (Trendelenburg’s position), or with a combination of the two; and in any case a sponge should be placed in the upper part of the trachea after the thyreoid has been opened. Many surgeons prefer the combined method. Under no conditions must blood be allowed to pass below the tube. Whatever form of canula is used, it should be fitted with a Hahn’s tube and funnel (Fig. 266), so that the anæsthetist can give the chloroform without interfering with the surgeon. The patient should lie upon the back on a flat table, the head extended slightly over a small cushion in the position for tracheotomy.

_First stage._ A vertical incision is made in the middle line from the hyoid almost to the sternum, so as to expose the thyreoid cartilage and the pretracheal muscles; these are retracted, so that the anterior aspect of the trachea is exposed; the isthmus of the thyreoid gland is completely divided, and search made for bleeding points until the wound is quite dry. A large opening is made accurately in the middle line of the trachea; this will be at least two rings below the cricoid cartilage in order that the tube may be well away from the region of the growth. In adults, if a Hahn’s tube be employed, the section should include at least three rings of the trachea.

_Second stage._ The anterior aspect of the thyreoid cartilage, and the crico-thyreoid membrane, are freely exposed, the infrahyoid muscles being separated by at least one inch and, if necessary, retracted. Ten minutes after the tube has been inserted, the crico-thyreoid membrane is punctured, exactly in the middle line, in order to admit the inner blade of the bone forceps; the latter is pushed upwards, slowly and without force, between the posterior portions of the vocal cords, until the whole length of the thyreoid cartilage is included between the blades; the forceps are then forcibly closed, great care being taken that the outer blade is cutting exactly in the middle line. By quickly opening the cartilage in this manner, there is practically no danger of destroying the anterior attachments of the vocal cords, or cutting through the substance of one of them. The two halves of the larynx are forcibly separated and retained in this position by hooked retractors, so that the interior of the larynx is exposed. In order to give a free exposure, it is necessary, as a rule, to divide with a knife the crico-thyreoid membrane; but the thyreo-hyoid membrane should not be touched, nor should the attachments of the epiglottis be disturbed. The separation must be performed carefully in order to avoid a fracture of the cartilages. The pharynx is plugged with gauze, so that no saliva can enter the wound, and after all secretion has been removed from the larynx a small sponge or plug is inserted into the upper end of the trachea. Cocaine, 20%, is freely applied with a swab of wool to every part of the larynx in order to constrict the vessels; persistent hæmorrhage can be controlled by plugging the cavity with wool soaked in cocaine; ‘this fully suffices ... and the employment of adrenalin, as I have personally experienced in one case, increases the risk of secondary parenchymatous hæmorrhage’ (Semon). Further, and this is of importance, by the use of cocaine the irritability of the larynx and the laryngeal reflex are destroyed. The tumour can now be inspected; it must be thoroughly exposed by cutting through the soft or hard structures (cricoid if necessary) so that its limits can be determined, thus enabling the surgeon to decide whether it is possible to obtain a satisfactory result by local removal.

_Third stage._ In the words of Butlin[13]: ‘an incision is carried around it (the tumour) with knife or scissors, including more than half an inch of the surrounding apparently healthy tissues, without respect to the after use of the voice or any other consideration except the complete removal of the disease. The included area is cut out right down to the cartilage, which is laid bare and finally scraped absolutely bare with Volkmann’s sharp spoon.’ The cavity is then plugged for a few moments until the bleeding has been controlled. The hæmorrhage is never serious, and can be controlled by catgut ligature if necessary. The wound must be completely dry. It is then dusted with a powder such as orthoform; the retractors are removed, and the alæ of the thyreoid cartilage allowed to fall together. In relation to the removal of the tumour, Butlin has shown that there is ‘little liability of malignant disease infiltrating the cartilage of the larynx’, so that, as a general rule, the latter can be left if all the soft tissues, including the perichondrium, are removed from its surface; this is comparatively easy to accomplish in the case of the thyreoid, but more difficult with the arytenoids and cricoid cartilage. C. Jackson has criticized the use of a sharp spoon as likely to cause infection of the cartilage.

[13] _Op. Surg. Malig. Dis._, 2nd ed., p. 191.

_Fourth stage._ In some instances it is possible partially to unite the divided mucous membrane, and so to lessen the granulating area: when this is done it is of the utmost importance that the lumen of the larynx should not be constricted, as any constriction will increase the danger of stenosis. In many instances it is not advisable to attempt to repair the wound that has been produced.

In suturing the external wound the alæ of the thyreoid are brought accurately into the position which they occupied before division, in order that the anterior attachments (if left) of the vocal cords should heal at their proper level. In some instances the cartilages fall naturally into the desired position, especially if one or two catgut sutures are inserted into the thyreo-hyoid membrane; in other cases it may be advisable to insert one or two similar sutures through the cartilage itself and thus obtain correct apposition. These sutures should lie on the outer aspect of the mucosa, so as not to traverse the cavity of the larynx itself. In cases where only the anterior portion of a vocal cord has been removed, Semon recommends that the divided end be sutured to the ventricular band; it is reasonable to suppose that, by attention to this detail, a better voice will be afterwards obtained. The infrahyoid muscles are approximated with one or two catgut sutures in the upper part of the wound; the skin is united with a continuous silk suture, as far downwards as the lower part of the thyreoid cartilage. The lower part of the wound is left open, to procure free drainage through the crico-thyreoid and tracheal openings. The whole of this lower wound is packed very loosely with gauze, so that discharges are not retained. It is necessary to emphasize the importance of not plugging the cavity of the larynx. The Hahn’s tube is removed as soon as the operation is completed, and replaced by a tracheotomy canula; the whole wound is covered by a loose pad of antiseptic gauze, which is kept in position by tapes or loosely applied bandages. No dissection for removal of lymphatic glands is required.

The above may be called the typical operation for malignant disease in which the growth is intrinsic; it gives a better exposure of the parts than other operations such as transverse laryngotomy (division of the thyreoid cartilage at the level of the ventricles), subhyoid pharyngotomy, partial thyrotomy, cricotomy, and crico-tracheotomy; the removal of tumours is therefore easier, and better after-results are obtained. If the growth be found more extensive, it may be necessary to modify the procedure. For example:

(_a_) When the epiglottis is involved, an extensive dissection of the thyreo-hyoid membrane can be made in order to expose and remove the growth thoroughly together with any soft parts or cartilage which appear to be involved. Branches of the superior thyreoid arteries, or the hyoid branch of the lingual artery, will be ligatured. The superior laryngeal nerves should always be preserved whenever possible, as loss of sensation increases the liability of food passing into the larynx.

(_b_) When the aryteno-epiglottidean fold is involved, a transverse incision can be made through the thyreo-hyoid membrane, immediately above the thyreoid cartilage on the same side, and the wound enlarged until the tumour is exposed. In this manner I was able to remove the large carcinoma shown in Fig. 254, including the soft parts of the right half of the larynx, the right half of the epiglottis, the right arytenoid, and the wall of the pharynx in relation to the right pyriform fossa: the lymphatic glands were not removed. One year later the patient continued to enjoy good health with no signs of any recurrence. In this connexion it is important to emphasize that when the disease is very extensive, and particularly when the posterior portion of the cricoid and arytenoids is involved, such an operation is useless, and the surgeon must decide whether partial or complete laryngectomy should be performed. In rare instances the operation should be abandoned in favour of tracheotomy (palliative).

(_c_) When the tumour extends downwards into the subglottic region, it is necessary to split the cricoid anteriorly and divide the upper rings of the trachea, after which the tumour can be removed with as much of the structures as may be desirable.

(_d_) When the growth extends across the middle line in the anterior commissure, or when a second growth is situated directly opposite on the other side of the larynx, the whole disease must be removed regardless of damage to the tissues which are not affected.

(_e_) When the operation is performed for stenosis, it is necessary to remove freely all the fibrous tissue without attempting to preserve any part that is diseased. The hæmorrhage is generally severe and necessitates preliminary plugging of the trachea with a Hahn’s canula.

=After-treatment.= This must be conducted so as to prevent the chance of broncho-pneumonia and sustain the strength of the patient. With Butlin’s method the patient is placed on his side, or face downwards, with the head low and with only a small pillow, so that all secretions pass out of the air-passages through the external wound. This undoubtedly gives better drainage to the wound, and is less exhausting than the upright position during the early stages of convalescence. The dressings on the wound must be changed, especially in the early days, as often as they become soaked; it is also an advantage to insufflate an orthoform powder, or an antiseptic parolein preparation, with the object of cleansing the larynx. The tracheotomy tube should be retained, usually from ten to twenty days, until the patient can swallow well and as long as there is a flow of pus from the wound.

‘During the day of the operation nothing is swallowed, although fragments of ice may be kept in the mouth for the comfort of the patient. If there is fear of collapse and the patient is feeble and very old, brandy and beef-tea may be administered by the rectum. On the following morning the first attempt is made to swallow. The patient leans far forwards with the head down, and the dressing is taken off the wound, beneath which a basin is placed. Cold water is drunk out of a glass. If the experiment is successful, all the water passes down into the stomach; if it is only partially successful, some escapes into the larynx; but the posture of the patient ensures that the liquid runs out through the wound and does not pass into the air-passages. As soon as water can be readily swallowed, milk, beef-tea, and other liquids may be drunk, for the fear of “Schluck-pneumonie” is practically at an end. The wound is generally closed within ten or twelve days of the operation, and the patient is rarely confined to the house for more than ten days’ (Butlin). It is probable that the healing by this, which is called the ‘open’ method, is as rapid as with Moure’s, in which the whole length of the incision is closed; the open method would also appear to be safer and less often attended by complications.

=Complications.= (1) _Broncho-pneumonia_ is most to be dreaded. Death from shock or collapse, from hæmorrhage, from septic conditions of the wound, or from iodoform poisoning, is now rarely met with and can more easily be prevented. Even pneumonia is uncommon, owing to more scientific methods of treatment. It is still to be feared in very old patients; in those who already suffer from bronchial catarrh at the time of the operation; in alcoholics; and in cases with old-standing renal, pulmonary, or heart affections. The improvement in this direction is due to greater antiseptic precautions, and to the prevention of aspiration of blood and septic secretion during and after the operation by free drainage of the wound.

(2) _Stenosis._ It sometimes happens that a considerable mass of granulation tissue appears in the anterior commissure, or upon the surface of the cartilage that has been bared by the operation; if this be left untreated it may gradually enlarge in size until a prominent cushion is produced, which reaches to the opposite side and thus causes stenosis with definite laryngeal obstruction. Such a swelling may be mistaken for recurrence, but is nearly always of inflammatory character. It is by no means certain what is the causation of this condition, which appears to occur more with some surgeons than with others; it has been suggested that the presence of sutures in the region of the anterior commissure may cause an irritation, especially if silk is used. It appears to me, having in mind similar conditions in other surgical wounds, that the cause is to be found in some form of sepsis, and that it can be prevented to a great extent by precautions at the operation and by proper after-treatment. If there be any obstruction to breathing, the larynx is inspected and the projecting granulations are removed by intralaryngeal forceps. The remainder of the mass generally shrinks and disappears. If the stenosis be troublesome (chiefly in syphilitic cases), the prolonged use of a laryngo-tracheal canula (Fig. 540), or of an intubation tube, or dilatation with bougies, may be necessary. In rare instances a permanent tracheotomy tube is required, with a valve to encourage expiration through the mouth.

HEMI-LARYNGECTOMY

This operation is suitable for certain cases of malignant disease which is strictly limited to one half of the larynx. The requirements and _first and second_ stages of the operation are similar to those for thyrotomy (see pp. 490, 491).

_Third stage._ A transverse incision is made on the side affected along the upper border of the thyreoid cartilage, through the skin and fasciæ; and, if necessary, a second transverse incision is made at the level of the lower border of the cricoid so that a skin flap can be turned back. The affected half of the larynx must now be considered as a tumour to be removed. The infrahyoid muscles are dissected away from the ‘tumour’ and retracted; the upper part of the lateral lobe of the thyreoid gland (the isthmus having been previously divided) is displaced outwards by blunt dissection, and the soft tissues above the thyreoid are similarly treated: the larynx should be pulled well over to the opposite side while this is being effected, great care being necessary to avoid wounding the carotid artery in the deeper part of the dissection. The branches of the superior thyreoid artery, the crico-thyreoid artery, and the veins of this region are ligatured with catgut. In some instances, when the growth has not perforated the cartilage, the separation can be performed subperiosteally. Superiorly, the thyreo-hyoid membrane is completely divided on the same side, and the mucosa is cut through above the upper limit of the growth. If the growth extends upwards, the epiglottis may be removed either totally or partially. Inferiorly, a transverse incision must be made through the crico-thyreoid or crico-tracheal membrane, or lower in the trachea. The inferior constrictor of the pharynx is divided as close to the attachment to the thyreoid as possible, and the cavity of the pharynx is opened behind the growth. The cricoid plate is split with bone scissors in the interarytenoid interval, and the final attachments are rapidly divided with a few touches of the knife.

In this operation, as with other operations for cancer, the main thought of the surgeon must be to remove the tumour thoroughly, including the soft tissues of the neck when these are diseased, the lateral wall of the pharynx, and the cervical glands upon the same side, whether they are known to be affected or not. In this respect the operation differs materially from thyrotomy; and I agree with Semon that, if hemi-laryngectomy is necessary, the lymphatic glands of the same side should in all cases be removed. The two dissections may be accomplished at the same time, or one may be performed later at a second operation; in the latter event an incision along the anterior border of the sterno-mastoid muscle is preferred. The operation must be very complete in order to be successful, and requires a knowledge of the anatomy of the lymphatics.

THE ANATOMY OF THE LARYNGEAL LYMPHATICS.

The following description is Cuneo’s[14] and has been confirmed by de Santi.[15]

[14] Poirier and Cuneo, _Lymphatics_, Eng. ed., 1903, p. 286.

[15] De Santi, _Malignant Disease of the Larynx_, 1904, p. 10.

The lymphatics which drain the mucous membrane of the larynx are divided into two distinct regions, namely, the supraglottic and the infraglottic zones. These regions are separated by the inferior vocal cords, and injection of the cords themselves generally passes into the upper zone. The upper region is most densely supplied, and covers the epiglottis, the aryteno-epiglottidean folds, the superior vocal cords, and the ventricles.

The lymphatics communicate freely in the posterior wall of the larynx (not in the anterior commissure), but though an injection into one half of the larynx easily passes into the mucous membrane of the other side, it is exceptional for it to pass as far as the corresponding glands of that side. The lymphatics of the larynx anastomose to a large extent with the networks of the adjacent organs (tongue, pharynx, trachea).

The supraglottic lymphatics perforate the thyreo-hyoid membrane where the superior laryngeal arteries enter, and end in (1) a substerno-mastoid gland under the posterior belly of the digastric; (2) glands on the internal jugular vein opposite the bifurcation of the carotid artery; and (3) glands on the same vein opposite the middle of the lateral lobes of the thyreoid gland. The glands in the front of the thyreo-hyoid membrane receive lymphatics from the pharynx, but none from the larynx.

The subglottic lymphatics perforate the crico-thyreoid membrane in two places (_a_) anteriorly, near the middle line, ending in (1) a prelaryngeal gland which lies in the V-shaped space between the crico-thyreoid muscles or under one of the same (a gland above the isthmus of the thyreoid gland is rarely present), and (2) a pretracheal gland (or glands) below the isthmus; (_b_) laterally, to end in (1) the glands which lie parallel to the recurrent laryngeal nerve, from which trunks run to (2) the substerno-mastoid group and (3) the supraclavicular glands.

It is important also to consider the question from the clinical aspect. With ‘intrinsic’ growths, involvement of glands is very uncommon unless the posterior (cricoid) zone is affected; it seems to be equally rare with tumours of both supra- and infraglottic zones; extension to the lymphatics of the opposite side is likewise improbable. With ‘extrinsic’ growths, the glands are rapidly involved; tumours that were originally intrinsic follow this rule as soon as they begin to affect the cartilages and extrinsic lymphatics of the larynx. These facts must be remembered because palpation of the neck may be quite misleading in early stages of the disease. On the other hand, in many advanced cases, such as those requiring palliative tracheotomy, the glands become massive and form definite tumours. The substerno-mastoid chain is, clinically, the situation that is specially affected; and any of its glands, from the digastric muscle above to the supraclavicular region below, may be involved. The prelaryngeal gland is rare, as are likewise the pretracheal and recurrent forms; nevertheless, the recurrent glands become attacked by advanced disease, affecting the upper part of the trachea.

TOTAL LARYNGECTOMY

=Indications.= This operation is performed for malignant tumours which have affected (_a_) the whole of the interior of the larynx, including the cartilages, or (_b_) the posterior portion of the larynx, including the arytenoid cartilages and pharyngeal aspect of the cricoid plate. In other words, it is employed in cases of extrinsic cancer in which the growth is not too advanced to render the prospect of its eradication hopeless. The operation should not be performed for tuberculosis.

It is essential that the patient should be in good health; one who is emaciated or who has organic disease, especially incurable bronchitis, is quite unsuitable for laryngectomy. On no account ought the operation to be undertaken unless the diagnosis of malignant disease has been confirmed, and unless the growth is known to be too extensive for thyrotomy. In many instances, therefore, thyrotomy is the first stage in the operation of total laryngectomy.

=Operation.= The instruments, anæsthetic, and position require the same consideration as with thyrotomy (see p. 489).

_First stage._ A vertical incision is made, in the middle line, from the hyoid to a point one inch above the sternum, and the anterior aspects of the thyreoid cartilage and trachea are exposed, with complete division of the isthmus of the thyreoid gland. The infrahyoid muscles are dissected from the larynx and widely retracted. By blunt dissection the upper part of the lateral lobes of the thyreoid gland is separated and bleeding arrested. The trachea, having been isolated in this manner, is divided obliquely from the front, upwards and backwards, as close to the cricoid cartilage as the disease allows without injury to the œsophagus; the lower end is carefully freed from the œsophagus, and two strong catgut sutures are passed through it with which the divided stump can be drawn forwards. If possible, a small transverse incision is made through the skin immediately above the suprasternal notch and made to communicate with the upper incision; the trachea is brought beneath the bridge of skin into the button-hole thus formed, and firmly attached by means of sutures. In some cases the trachea is sewn into the lower part of the original incision. A tracheotomy tube is inserted, through which the anæsthetic is continued. By this means the lower air-passages are completely cut off from the region of the tumour, and no blood or septic matter can pass into the lungs.

_Second stage._ The lateral aspect of the larynx is freely separated so that the attachment of the inferior constrictors is defined. The superior laryngeal artery is ligatured on each side, and divided, together with the internal laryngeal nerves. The thyreo-hyoid membrane is transversely divided, and the pharynx is opened so as to expose the upper limit of the growth; this may necessitate a transverse incision through the skin, or a vertical division of the hyoid bone in the middle line with retraction of its two halves. The larynx having been isolated above, below, and laterally, its removal can be completed according to the situation of the growth, in most cases from below. The lower end of the larynx is hooked forward, and dissected away from the œsophagus by means of scissors or a sharp scalpel (Fig. 262). While this is being effected, the extent of the growth must be constantly examined by inspection and palpation, so that the whole mass is removed, including, if necessary, the pharynx and upper part of the œsophagus. It is important not to drag upon the œsophagus; C. Jackson has shown experimentally that this causes severe shock by affecting the depressor fibres of the vagus, which may result in death. It follows, therefore, that this part of the operation, though easy in the dead body, requires the utmost care and detailed technique. The division of the constrictors should be as close to their attachment as possible, and the final division of the pharyngeal mucosa should be half an inch beyond the limit of the growth. The epiglottis should generally be removed.

_Third stage._ The toilet of the pharynx and œsophagus remains to be decided. In order to restore the cavity of the pharynx, the upper end of the œsophagus is brought upwards whenever possible and accurately united to the pharynx in the region of the hyoid bone, this being accomplished by a double layer of catgut sutures uniting the mucous membranes. The infrahyoid muscles are then brought together by a vertical row of stitches, so as to cover and support the line of union. The wound having been thoroughly packed with gauze, the skin is sutured, excepting the lower end, which remains open for drainage. In cases where the pharynx is thus completely closed, a tube must be passed previously through the nose into the œsophagus, and retained for purposes of feeding. This is preferable to sewing the tube into the wound itself, and is rarely troublesome if the tube is sufficiently stiff to prevent its displacement by retching. At the conclusion of the operation the tracheotomy tube is replaced by an ordinary silver canula, and the wounds are lightly dressed.

=After-treatment.= This is conducted upon similar lines to those adopted in the after-treatment of thyrotomy. During the first ten days, until the pharyngeal wound is firm, the patient must be fed through the tube and by rectal administration. Sterilized water may be sucked uphill, and, as swallowing improves, food may be administered by the mouth. In most cases a pharyngeal fistula results, which may require a later plastic operation. A second operation is necessary for the removal of lymphatic glands, probably on both sides of the neck.

The complications are similar to those following thyrotomy (see p. 494).

=Modifications.= The above operation, which in the main has been planned by surgeons in America (S. Cohen, Keen, &c.), is preferable to the numerous modifications, of which the following may be mentioned as examples:--

Gluck’s operation. In this there is no preliminary tracheotomy. A large rectangular flap is turned to one side to expose the front of the larynx and trachea, the latter being isolated laterally and the thyreoid isthmus divided. A transverse incision is made through the thyreo-hyoid membrane in order to expose the upper aperture of the larynx thoroughly. By plugging the pharynx and adopting a low position for the head, saliva and blood are prevented from running into the air-passages. The interior of the larynx having been cocainized, a tracheotomy tube is inserted between the vocal cords. This is sutured in position in such a manner that the cavity of the larynx is completely shut off from the pharynx. If a general anæsthetic be employed, it can be continued through the canula by a Hahn’s adjustment (Fig. 266). The larynx, and any part of the pharynx or œsophagus which is diseased, are separated from above downwards, the trachea being severed transversely as a final stage and sewn into a button-hole immediately above the sternum. A soft rubber tube having been introduced through the nose into the œsophagus, the walls of the latter are united over the tube by a double row of catgut sutures, completely isolating the gullet. The cavity is covered with gauze, and the skin flap is partially sutured into its original position. An ordinary canula is placed in the trachea and the wounds are dressed.

In cases where the pharynx has been extensively removed a fistula remains, but Gluck has devised a plastic operation by means of which this can afterwards be closed. In some cases this fistula may be obliterated by the natural falling in of the parts, without further operation, and in the meantime the patient is provided with a funnelled tube for feeding, placed in the œsophagus with the upper end below the base of the tongue.

The advantages claimed by Gluck for this operation are the avoidance of preliminary tracheotomy, the prevention of blood from passing into the trachea, the complete separation of the trachea from the gullet, and the early feeding through the mouth. These, however, are chiefly met by the former operation.

Chiari and le Bec perform the operation in two stages. In the first, the trachea is isolated and divided transversely, the lower end being sutured above the sternum. The second operation, undertaken one or two weeks later, consists of a complete removal of the disease.

Föderl suggests the possibility of uniting the lower end of the trachea (after laryngectomy is completed) to the tissues beyond the hyoid bone, and thus restoring the air-passages; but the method is not free from danger, and the trachea is apt to slough.

S. Handley[16] performed a complete transverse resection of the pharynx, with laryngectomy, for malignant growth in the following manner: Preliminary gastrostomy was performed; a week later, when the patient had recovered, a low tracheotomy was effected, the trachea being plugged with gauze above the tube. The whole of the larynx and a complete section of the pharynx were then removed as described in Gluck’s method; and, the trachea having been brought into the lower part of the wound, the pharynx and œsophagus were closed by sutures. The patient recovered with a pharyngeal fistula through which the saliva passed, the latter being led to the stomach through the gastrostomy opening. In a second similar case the result was fatal. ‘The patient died on the table, apparently from irritation of the vagus, after the operation was practically complete.’ Handley believed that the failure was due to a defect in his technique, and that, if he had frozen the two vagi below the point at which he was working, death would not have occurred.

[16] _Proc. Roy. Soc. Med._, London, vol. i, No. 4, 1908, Clin. Sect., p. 66.

COMPARATIVE RESULTS OF THE DIFFERENT EXTRA-LARYNGEAL OPERATIONS

In order to obtain a trustworthy idea of the value of the various operations for malignant disease, it is necessary to refer to the history of the operations.[17] Czerny, in 1870, was the first to demonstrate by experiments on dogs the possibility of removing the entire larynx, and various attempts were afterwards made by different surgeons, notably by Billroth, to accomplish the same in man. In 1881 Foulis was able to collect twenty-five cases of total laryngectomy, and found that not one of them was alive twelve months after the operation. Partly in consequence of this, thyrotomy was given a trial, and in 1887 P. Bruns collected nineteen cases, with two deaths and sixteen local recurrences. He therefore concluded that ‘attempts to extirpate the disease by means of thyrotomy have shown themselves to be altogether insufficient and useless’; and so it came about that all external operations, at this date, were considered by most authorities to be unsatisfactory. Much attention was, however, drawn to the subject by the illness of the German Emperor, and Semon particularly emphasized the great importance of early diagnosis. The result of this was marvellous. The importance of Krishaber’s division of carcinoma of the larynx into two forms, intrinsic and extrinsic, was recognized by Butlin, to whom the greatest credit is due for having first shown that thyrotomy ought to be reinstated. Butlin and Semon have since perfected this operation, which has rightly been described as the English operation. It is now recognized throughout this country as the operation which gives perfectly ideal results, so long as it is restricted to early stages of intrinsic malignant disease (in which an early diagnosis is indispensable) and is thoroughly carried out. As Semon concludes, ‘if these demands be complied with, the position of thyrotomy, as being the operation in the early stages of malignant disease of the larynx, will remain impregnable, so long as we have to fight malignant disease by operation.’ That this is true will be seen by the results mentioned later.

[17] An account of the history of these operations will be found in a paper by Sir F. Semon, _Brit. Med. Journ._, 1903, vol. ii, p. 1113.

It is also necessary to refer to the other side of the question, namely, the position of laryngectomy. Many well-known surgeons in Europe and the United States have been convinced that laryngectomy, partial or complete, is the only possible treatment for cancer in this region. Gluck[18] says:

[18] _Brit. Med. Journ._, 1903, vol. ii, p. 1123.

‘As showing the progress that has been made during the last fifteen years in this subject, I may mention that in my first series of ten cases only two were successful, and in nine cases of another series I had four deaths. Since then I have performed many operations with ever improving results. Thus in one series of thirty-five hemi-laryngectomies I had three deaths: one twenty-four days after the operation, of heart failure, when the wound was already healed; another independently of the operation, of phlegmon of the right gluteal muscle; the third of pneumonia five days after operation.

‘My most recent results show a series of twenty-two complete laryngectomies with one death, that of a man of seventy, who died on the eleventh day of iodoform poisoning. Of the partial extirpations of the larynx and pharynx, generally combined with removal of infected glands, I can point to a series of twenty-seven cases with only one death. This was a case in which the carotid had been tied, and death occurred from hemiplegia five days after the operation.

‘At present I could show you thirty-eight living patients who have been cured by these operations; the oldest case was operated on thirteen years ago. Of those already dead, a number have lived 11, 8, 6-1/2, 5-1/2, 4-1/2 and 3-1/2 years after the operation in good health, and some have died of other illnesses, not of recurrence. One man, nine years after hemi-laryngectomy, had recurrence in the other half of the larynx and in the glands; after the second operation he lived over two years, and died at seventy-six. The operations lengthened his life for eleven years.

‘A man of seventy-six had the larynx and pharynx extirpated, and lived 11-1/2 years after the operation. Twice I have performed complete laryngectomy for tubercle; one case died in spite of that of consumption; the other was done four years ago and the patient is perfectly well.

‘In all I have performed 125 of these operations since the year 1888, and the record is one of great progress, both in technique and also in the elaboration of plastic operations and mechanical appliances for the improvement of the post-operative condition.’

Many large operations of this description have undoubtedly been performed because of the statement that it is impossible to obtain a lasting cure by performance of thyrotomy. Even at the present day this opinion holds its ground, and so long as there is a general grouping of the cases, progress cannot be made.

=Thyrotomy.= I shall attempt to show that thyrotomy is the best operation for early malignant disease, whether carcinoma or sarcoma, so long as it remains intrinsic. No attempt will be made to separate the different forms of these diseases. The points to be considered are the following:--

The _mortality_ of the operation itself has been greatly reduced; von Bruns[19] states that ‘between 1890 and 1898 there was an immediate fatality of 15%’ in sixty cases collected by Schmiegelow and himself. In comparison with these figures, the recent results of English surgeons have been very favourable. Thus Butlin and Semon have performed forty-eight thyrotomies for malignant disease since 1890 with only two deaths. In Butlin’s case the patient was over seventy years of age, very obstinate, very intractable, and persisted in sitting up from the time of the operation. He died, in the course of three or four days, of septic pneumonia. The results of other surgeons have been excellent, but are not included for three reasons: There is still considerable confusion in the selection of cases suitable to this operation; the operation is often performed by those who are not conversant with the difficulties and dangers that may arise; and it has sometimes to be undertaken for a patient who is also suffering from bronchitis or constitutional disease. Moreover, the above figures are sufficient to show that the immediate mortality from this operation under favourable circumstances is not large.

[19] Bergmann, E. von, _Sys. Prac. Surg._, vol. ii, p. 245.

_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 repetition 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. xxx, 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 hæmorrhage, 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 mass 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 œsophagus.’

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 pass 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 passed 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-passages 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 œsophagus, 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 space is so small that it is almost impossible to introduce a tube without division of the cricoid cartilage (see Crico-tracheotomy, p. 529).

A tube introduced through the crico-thyreoid membrane lies in the subglottic space 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 dyspnœa is rarely so urgent as to necessitate an operation.

(ii) Sudden œdema 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-passages, in order to prevent blood from passing 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 anæsthesia and making the anæsthetic 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 assistance of Mr. Boyle, all the major operations performed upon the upper air-passages during the last six years at St. Bartholomew’s Hospital. These are tabulated below.

TABLE SHOWING OPERATIONS UPON THE UPPER AIR-PASSAGES 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 -----------------------------+--------+---------+--------+---------

This table shows that nearly half the cases were treated by laryngotomy. In sixty-three of these, where the tongue or floor of the mouth was concerned, no preliminary ligature of the lingual artery was performed; of the seventy-three similar cases treated without laryngotomy there was preliminary ligature of one lingual in thirty-one cases (42.5%), and of both arteries in twelve cases (16.4%).

From this it is apparent that lary[n]gotomy has to some extent taken the place of preliminary ligature of one or both linguals. The operation is simple, rapid in execution, and meets all requirements; it is not surprising to find, therefore, that in recent years the number of laryngotomies has proportionately increased.

TABLE SHOWING OPERATIONS AS PERFORMED IN DIFFERENT YEARS

+---------+----------+---------------+---------------+ | | | _With | _Without | | _Year._ | _Cases._ | Laryngotomy._ | Laryngotomy._ | +---------+----------+---------------+---------------+ | 1902 | 39 | 19 | 20 | | 1903 | 35 | 5 | 30 | | 1904 | 31 | 16 | 15 | | 1905 | 32 | 18 | 14 | | 1906 | 29 | 18 | 11 | | 1907 | 21 | 14 | 7 | +---------+----------+---------------+---------------+ | Total | 187 | 90 | 97 | +---------+----------+---------------+---------------+

=Operation.= In cases of extreme emergency the operation can be performed with almost any kind of knife, but the following instruments are preferred: a sharp-pointed bistoury or tenotome, a sharp-pointed dilator (Fig. 265, B), a tube and introducer. The tube should be small, short, with a fixed collar, and made of silver; an introducer such as Butlin’s is a great advantage (Fig. 265, A). As bleeding may occur, it is necessary to prepare dissecting forceps, retractors, pressure forceps and catgut.

A general anæsthetic is usually employed when infrathyreoid laryngotomy forms the first stage of the main operation, but it should be remembered that the amount of chloroform required is less when given through a tube.

The preparation of the skin and the position of the body are the same as for tracheotomy. A transverse incision one inch in length is recommended, and this should lie directly over the crico-thyreoid interval, which is easy to determine in the adult. The incision can be made quickly by pinching up a vertical fold of skin, transfixing immediately above the cricoid, and cutting outwards: with this method the anterior jugular veins are rarely wounded, but if any vessel has been pricked it should be seized and tied at once.

The sharp dilator, placed exactly in the middle line immediately above the cricoid, is pushed backwards between the infrahyoid muscles until the resistance caused by the crico-thyreoid membrane is reached. It is then firmly stabbed into the larynx and widely dilated so as to tear open the membrane: the dilator having been withdrawn, the tube, with tapes attached and mounted upon the introducer, is rapidly inserted, a proceeding which is made easier by first smearing the instrument with a small amount of glycerine. The whole operation can be performed in less than a minute, and is rarely attended by serious hæmorrhage; moreover, when the original puncture is immediately above the cricoid there is less danger of wounding the crico-thyreoid artery. The operation is attended by few difficulties, and is superior to one in which dissection or cutting is employed.

At this stage a prolonged period of apnœa is usually encountered, and this symptom is more marked than with tracheotomy; when seen for the first time it may be alarming, and it is therefore of practical importance. In a few moments, however, the patient settles down to the altered conditions of respiration; coughing may be excited but soon disappears. When the breathing becomes regular, the tapes are tied round the neck and a rubber tube is attached (Fig. 266) similar to that used with Hahn’s apparatus, and through the tube the chloroform is continued. This method has the following advantages: it gives far more room to surgeon and anæsthetist, and enables the latter to manipulate the laryngotomy tube and to prevent it from tilting in such a way that the lower end impinges against the front of the trachea with consequent obstruction; further, the opening into the larynx is completely blocked, blood and lotion being unable to enter from outside.

As soon as true anæsthesia with regular automatic breathing has been obtained, the lower part of the pharynx should be plugged with a soft marine sponge to which a piece of tape or silk is attached, this being pushed down behind the tongue and firmly wedged in position; it is advisable to use a large sponge, as this blocks the pharynx and pushes forward the tongue, an advantage to the surgeon when operating upon that structure. If the mouth be obstructed by a tumour, the same result can be obtained by two or more smaller sponges passed in succession; or, as suggested by Bond, a small sponge may be pulled down into the larynx. As soon as the pharynx has been completely shut off, the main operation can proceed, and those who have once used this method can appreciate how much more quickly it can be performed and how much more comfortably for all concerned.

At the conclusion of the operation, when all bleeding has been controlled, the laryngotomy tube should be removed. The wound should not be sutured or plugged, and only a light dressing should be applied: the latter can be kept in place by a bandage, which, however, must on no account be tight, owing to the danger of emphysema.

=Complications= may arise--(_a_) _During the operation._ There may be troublesome bleeding owing to pricking of a vein, superficial or deep, or of the crico-thyreoid artery; this occurred in eight of the cases mentioned above, and in four was severe. In one of the latter the bleeding continued for thirty minutes before the vessel was finally secured. The condition is simple to treat: the wound must be enlarged, and the infrahyoid muscles separated so that the crico-thyreoid membrane is thoroughly exposed; the bleeding vessel can then be seized and tied, after which the tube is inserted. This is preferable to attempting to stop the bleeding by the introduction of the tube.

Difficulty in introducing the tube may occasionally occur. It may be due to imperfect division of the membrane; thus in one case the tube was passed down between the coats of the larynx and not within its cavity; and another case is recorded where the mucous membrane was similarly pushed backwards owing to the dilator having split the cricoid cartilage. Care must be taken, therefore, that the membrane is properly punctured, and that the opening is thoroughly dilated before any attempt is made to introduce the tube. Replacement of the tube was necessary in only one case, on the second day, owing to recurrence of bleeding from the wound in the mouth.

(_b_) _After the operation._ Emphysema occurred in six of the ninety cases; in two it was slight; in three it was extensive and involved the chest, neck, and face; and in one, where death supervened twelve hours after the operation, there was emphysema of the mediastinum. In two of these cases the laryngotomy wound had been sutured; in two others the operation was attended with severe hæmorrhage, and the mouth was plugged with gauze to control it. It is probable that emphysema is more likely to occur if there is any obstruction to breathing through the mouth after the operation, such as may be caused by the falling back of the remaining part of the tongue. The following precautions should be observed to prevent it: The laryngotomy wound must always be left open, and covered by a loose piece of gauze which does not press upon the neck; the patient must be nursed on his side, not upon the back; suturing the remaining part of the tongue is not sufficient; if plugging is left in the mouth, the tube must be temporarily retained, and removed after a few hours when breathing is not obstructed; early removal, however, is preferred.

Bronchitis is mentioned in two of the cases already quoted, pneumonia in one case, pneumonia and empyema in one, and purulent mediastinitis in one, with three deaths in all. Of these five cases, four had operations upon the tongue. On the other hand, without laryngotomy, bronchitis was rather more common (seven cases) and broncho-pneumonia occurred in two, both of which died. In order to throw more light upon the subject, we have examined the charts of all the cases after the operation, and have found that in most of them there was a rise of temperature to 99° F., or slightly higher, which lasted for periods varying from one to seven days; the pulse and respiration were little affected. In laryngotomy cases there were only eighteen instances of temperatures of over 100° F., as against twenty-five where no laryngotomy had been performed. Here again the pulse and respiration were only slightly affected, so that the condition was probably due to local inflammation and not to involvement of the lung. The results are by no means conclusive, but justify the general feeling that laryngotomy does not increase, but probably diminishes, the danger of infection of the lungs.

Healing of the wound may take place in normal conditions in about five days, but the period is frequently longer--from ten to twenty days; suppuration is uncommon, and was only mentioned in two instances where the wound had been sutured. The scar left after laryngotomy is often depressed for several months, but eventually becomes loosened and is then scarcely noticeable.

Death occurred in six cases, but there was no evidence to show that there was any connexion with the laryngotomy; on the contrary, the operations were more severe, and infrathyreoid laryngotomy was performed partly for the very reason that the condition of the patients was less favourable.

From my experience, the advantages which were originally claimed by Bond, Butlin, and others have been completely upheld; the larger operations upon the upper air-passages are easier to perform and can be more thoroughly completed; and it is very possible that the after-results may be improved by the greater facility which is thus afforded. I would strongly urge laryngotomy in all large operations of this region; the tube should be removed early, and the wound should not be sutured.