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Extracted from the
TRANSACTIONS OF THE COLLEGE OF PHYSICIANS OFPHILADELPHIA.
THIRD SERIES, VOLUME VI.
DOES EXCISION OF THE LARYNX TEND TO THEPROLONGATION OF LIFE?
By
J. SOLIS COHEN, M.D.,HONORARY PROFESSOR OF LARYNGOLOGY IN JEFFERSON
MEDICAL COLLEGE.
[Read April 4, 1883.]
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 been
COHEN,
subjected to it with the average life of patients insimilar condition intrusted to palliative treatment.
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.
DOES LARYNGECTOMY PROLONG LIFE?
TABLEI.—LIST OFCOMPLETE
LARYNGECTOMIES,INCLUDINGAND
SUPPLEMENTINGTHETABLESOF
MACKENZIE,FOULIS,BLUM,AND
BUROW.
No.
Operator.Date.Age.Sex.
Disease.Parts
removed.Result.
Reference.Remarks.
1
Watson,Pat-
rickHeron
(ofEdin- burgh).
186636M.Stenosisfromsy-
philis.
Larynxand
one
ringoftrachea.
Deathin3
weeksfrom
pneumonia.Foulis;
Transactions InternationalMed-
icalCongress,Aug.
1881,vol.iii.p.
255.Pneumonia
wassuspected
be-
forethe
opera-tion.
2
Billroth (Vienna).1873Dec.
3136M.Carcinomaofthe
larynx.
Larynx,lowerthird
ofepiglottis,part
ofthe
uppertwo
ringsofthetra-
chea.
Deathfrom
recur-rence7
monthsafter
theoperation.
Archivf.
klin.Chir-
urgie,Bd.xvii.H.
ii.p.343.
Recurrencenoted
atendoffour
months.
3
Heine (Prague).1874Apl.
2850M.Carcinomaofthe
larynx.
Entirelarynx.
Deathfrom
recur-rence6monthsaf-
teroperation.
Arch.f.
klin.Chir..
Bd.xix.p.
584;
BohmCorresp.Bl.
1874.
4
Schmidt,M. (Frankfort).
1874Aug.12
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
June1
57M.“
Adeno-fibroma earcinomato- surai”
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-
ingto
leftvocal
band.
Larynx.
Deathfrom
pneumo-niain2weeks.
Foulis,Trans.Int.
MedicalCongress,
1881.
7
Schdnborn (Konigs-berg).1875Jan.
2272M.Carcinomaofthe
larynx.
Entirelarynx.
Deathon
thefourth
day.
Berlinerklin.Woch.,
Sept.20,1875,p.
525,
8
Bottini (Turin).1875Feb.
6
24M.
Sarcoma(partly
round-celled,
partlyspindle-
celled)ofthe
larynx.
Entirelarynx.
WellApril
19,1881,probablystill
alive.Comraunicazione letta
Junanzi,la
K.Academiadi
MedicinadiTorino,
April30,1875.
Let-
terfrom
Prof.Bot-
tinito
Dr.Foulis.
Theoperation
en-
tailedcopioushemorrhage,and
wasfol-
lowedbyse-
vereerysipelas.
COHEN,
tableI— continued.
No.
Operator.Date.Age.
Sex.
Disease.Parts
removed.
Result.
Reference.Remarks.
9
Langenbeck (Berlin).1875
July21
57M.Carcinomaofup-
perpartoflar-
ynx,oftheepi-
glottis,andof
thehyoidbone.
Entirelarynx,hy-
oidbone,partof
thetongue,
pha-
rynx,and
oeso-phagus.
Deathfrom
recur-renceincervical
lymphaticglands,
4monthsafter.
Berlin,klin.Woch.,
1875,No.33,p.453;
Arch.f.
klin.Chir.,
Bd.xxi.
Supplem.p.136.
10
Multanow- ski(St.Pe- tersburgh).
1875 July27
59M.
Carcinoma.Entirelarynx.
Deathfromcroupous
pneumonia3
mos.
afteroperation.
Centbl.f.
Chir.,1882,
No.25,andletter
fromDr.A.Schmidt
toProf.Burow
(Arch.Laryng.,
N.Y.,April,
1883).
11Multanow-
ski(St.Pe- tersburgh).
1875Aug.9
47M.Carcinoma.
Entirelarynx.
Deathfromrecur-
rence2
monthsafteroperation.
Asabove.
12
Billroth (Vienna).1875 Nov.
1154M.
Diffusecarcino-
maofthelar-
ynx.
Entirelarynx.
Deathon
thefourth
dayfromextensive
broncho-pneumo-
nia.
Billroth’sClinical
Surgery,London,
1881,p.133.
Hadnotbeenpre-
cededbytrach-
eotomy;wound
didwell,with
butlittlefebrile
reaction.
13
Maas(
Freiburg).1876Feb.5
50M.
Epitheliomaof
thelarynx.
Entirelarynx,with
exceptionofthe
epiglottisandof
asmallpieceof
thecricoidcartil-
age.
Deathfrom
recur-rence6
monthsafterthe
operation.Arch.f.
klin.Chir.,
Bd.xx.
p.535.Pri-
vatecommunica-
tionfromoperator
toDr.
Eoulis,Trans.Int.Med.
C.,London,
1881.Recurrencein
posteriorpor-
tionoftongue
about3months
afteroperat’n.
Deathbyhe-
morrhagefrom
theulcerated mass.
uGerties (Jever).1876Mar.
3076M.Carcinoma.
Entirelarynx.
Deathon
thefourth
dayfrom
collapse.Arch.f.
klin.Chir.,
Bd.xxi.H.ii.p.
473.
15
Revher (Dorpat).
1876May60M.Carcinomaofthe
vocalbands.
Entirelarynx,with
exceptionofepi-
glottis.
Deathonthe
eleventhdayfromhyposta-
tic
pneumonia.St.
Petersburghermed.Woch.,
1877,
Nos.17
and18.
DOES LARYNGECTOMY PROLONG LIFE?
tableI— continued.
No.
Operator.Date.Age.Sex.
Disease.Parts
removed.Result.
Reference.Remarks.
16
Watson,P.
H.(Edin-burgh).
187660F.
Epitheliomaof
larynx,withen-
largementof
someadjacent
glands.
Larynxand
en-
largedglands.
Deathinone
week
frompulmonary
embolism.Letter
fromoperator
toDr.
Foulis.Thelingualand
facialveins
werecutinthe
operation.
17
Kosinski (Warsaw).1877 Mar.
1536F.
Epitheliomaof
thelarynx,with perforation
of
theskin.
Entirelarynx.
Deathfromrecur-
rence9
monthsafter
operation.Centbl.f.
Chir.,1877,No.
xxvi.p.
401.
Privatecommuni-
cationfrom
opera-
tortoDr,
Foulis.
18
Foulis (Glasgow).1877 Sept.
1028M.
Sarcoma,“
part-
ly
papilloma,partlyspindle-
celledsarco-
ma.”
Entirelarynx,
with
exceptionofsu-
periorcornuaof
thyroidcartilage
andhalftheary-
tenoidcartilages.
Deathfromtracheal
andpulmonaryphthisis,
March1.
1879.
Lancet,Oct.
13,1877,andMar.29,
1879.
19
Wegner(Berlin).1877Sept.
1652 ■
F.Carcinomaofthe
larynx,sizeol
walnut,origin-
atingfrom
right
ventricle.Entirelarynx,with
epiglottis,but
leavinglowerhalf
ofthecricoid
car-
tilage.
WellApril12,
1878.Verb,der
DeutscheGesellsch,f.
Chir.,
1878.Private
com-munication
from
operatorto
Dr.
Foulis.
20
Bottini (Turin).1877 Aug.
2948M.
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.
Deathfrom
recur-rence8
monthsafteroperation.
*
Wien.med.
Presse,Nov.
17,1878.Com-
municationfrom
Prof.Paul
Brunsto
Dr.Foulis.
Preliminary tracheotomy notperformed. Collapse
afteroperation,and hyperpyrexia
fora
week. Voicetubeem-
ployedinfive
weeks.
COHEN,
tableI—
continued.
No.
Operator.Date.
Age.Sex.
Disease.Parts
removed.Result.
Reference.Remarks.
22
Rubio (Madrid).1878May
1141M.
Perichondritisof
thethyroid
car-tilage,with
ne-
crosis.
Entirelarynx.
Deathon
thefifth
dayfrommaras
mus.
Observacionclinica,
etc.RealAcademia
deMed.,Madrid,
1878.
23
Czerny(Heidel- berg).
1878Aug.24
46M.Sarcomainand
•undervocal
bands,andper-
foratingthe
thyroidcartil-
age;
alsoin-
volvingthe neighboring glands.
Entirelarynx,and
thediseased glands.
Death15
monthsafter
operation(as
theresultofa
new
operation?).
Letterfromoperator
toDr.
Foulis.Schiil-
ler,die
Tracheoto-mie,
Billrothund
Liicke’sDeutsche
Chirurgie,1880,p.
200.
Repeatedremov-
alsof
recurring masses.
24
Billroth (Vienna).1879Feb.
2743F.
Epitheliomaof
pharynx,lar-
ynx,andthy-
roidgland.
Entirelarynx,with
partof
pharynxand
oesophagus.Death
duringseventh
weekfrom
passageofbougieintome-
diastinum.Private
communica-tionfromoperator
toDr.
Foulis.
25Gussenbauer(Prague).1879May
2424M.Carcinoma.
Entirelarynx.
Death2monthsafter
operationfromtu-
berculosispulmo-
num.
Letterfromoperator
toProf.Burow.
Arch.Lar.,April,
1883.
26
Macewen,Wm.(Glas- gow).
1879 July31 ¥
56M.Carcinomaoflar-
ynxandupper
endof
gullet;alsoa
glandu-lar
massatleft
sideofneck.
Larynx,partofgul-
let,andtheglan-
dularmass.
Deathin3
daysfrom
pneumonia.Foulis,Trans,Int.
Med.Con.,Lon-
don,1881.
27CaselliAzzio (Reggio-Em- ilia).
1879Sept.20
19F.
Sarcomaoflar-
ynx,pharynx,
palate,andbase
oftongue.
Entirelarynx,pha-
rynx,baseof
tongue,soft
pa-
late,and
tonsils.WellAugust,
1881
(probablystillliv-
ing).
Bui.del
Scien.Med.,
Bologna,1880,
vol.
v.;Centbl.f.
Chir.,
1880;Caselli’sRe-
print,Bologna,
1880.Caselli’s statement
atmeet-
ingInt.Med.Con.,
London,1881.
Operationoccu-
piedmorethan
3
hours,was
largelydone
withthegal-
vano-causticblade,and
wasattendedwith
butlittlehe-
morrhage.
DOES LARYNGECTOMY PROLONG LIFE?
tableI— continued.
No.
Operator.Date.Age.Sex.
Disease.Parts
removed.Result.
Reference.Remarks.
28
Lange,F.
(NewYork)
1879Oct.12
74M.Sarcomaoflar-
ynxinvolving
thegullet.
Larynx,right
cor-
nuaofhyoidbone,
partofgullet.
Deathfrom
asthenianearly
sevenmonthsafteroperation.Re-
currence.Archivesof
Laryngo-logy,N.Y.,
1879,
p.36.
29 30
Multanow- ski(St.
Pe- tersburgh). Langenbuch1879Dec.4 1879
60 Ana fern
M. gedale.Carcinoma.
Entirelarynx.
Deathon
fifthday
frompneumonia.
Deathon
thirdday
fromcollapse.
Centralbl.f.
Chir.,
1882,No.25.
Let-
terfromDr.A.
Schmidtto
Prof.
Burow,Arch.Lar.,
April,1883.
Verb.der
DeutscheGes.f.
Chir.,Bd.x.
Onlymetby
com-pilerin
Blum’slist,Arch.Gen.
demed.,
1882,
ii.p.79.
31
Reyher,Carl
(St.Peters- burgh).
188048M.Carcinoma.
Larynx.
Deathon
seventhday
fromseptic
bron- cho-pneumonia.Wolner’sMed.
Jour.,
1880.H.i.
Letterfrom
operatorto
Dr.Foulis.
32
Thiersch (Leipsic).1880Feb.
2636M.Carcinoma.
Entirelarynxand
tworingsoftra-
chea.
Well18months
AFTEROPERATION.
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-
derer.
Tracheotomy,Sept.27,
1879.Laryngotomyforaccessto
growths,Feb.
3,1880.
33
Thiersch(Leipsic).1880April
1552M.Carcinoma.
Entirelarynx.Well17months
AFTEROPERATION.
Asabove.
Tracheotomv,Mar.2,1880.
34
Czerny(Heidel-berg).
1880Oct.11
47M.
Epitheliomaof
larynxand
su-
perjacentsoft
parts.
Larynxandsoft
tissuesinfrontof
it.
Deathfromexhaus-
tionandhemor-
rhage5
months(March25,
1881)
after.
Letterfromoperator
toDr.
Foulis.
COHEN,
tableI— continued.
No.
Operator.Date.Age.Sex.
Disease.Parts
removed.Result.
Reference.Remarks.
35
Hahn (Berlin).1880Oct.
2367M.Carcinoma.
Larynx,allexcept
a
portionofthe
thyroidcartilage.
Freefrom
recur-rence2
TEARSAFTEROPERATION,
Letterfrom
operatorto
Prof.Burow.
Archivesof
Laryn-gology,April,
1883.
36
Thiersch(Leipsic).1880Nov.
1045F.Carcinomaof
pharynxand
larynx.
Larynxandpartof
pharynx.Deathfromrecur-
rencein4months
(March16,1881).
Deutsch.,Ztsch.f.
Chir.,1881,xvi.p.
149.
Tracheotomy,Oct.17,1880.Recurrence noted
within6
weeksafter operation.
37
Bircher,H. (Aarau).
1880Dec.3
49F.
Seirrhusofthe
thyroidgland,
involvingthe
larynx.
Thyroidglandex-
cised;
6
monthslaterthe
cancerrecurred,
andthe
larynxwasex-
cisedwithpartof
thegullet.
Deathin16days
frompneumonia
andgangreneof
thelung.
Letterfromoperator
toDr.
Foulis.Trans.
Int.Med.Congress,
1881.
38
Pick (London).1881 Jan.
1639M.
Epitheliomaof
larynx(preced-
edby
papillo-mata).
Larynxandepiglot-
tis.
Deathin5
daysfrom
pleurisyandperi-
carditis.
Lancet,April3,1881,
p,541,
Brit.Med.
Journ,,April9,
1881,p.
563.
39 40
Thiersch (Leipsic). Toro (Cadiz).1881 Jan.
17 1881March9
57F.Carcinomaof
pharynxand
larynx.Epitheliomaof
larynx.
Entirelarynxand
partof
pharynx.Hyoidhone,
base
of
tongue,and
larynx.
Deathon
seventhday
fromsecondaryin-
fectiouspneumonia
Deathon
fourthday
frompulmonary emphysema.
Deutsch.Ztsch.f.
Chin,1881,
Bd.
xvi.p.149.
Med.Record,N.Y.,
August6,
1881,p.
167.
Tracheotomy,Dee.9,
1880.
41Winiwarter (Liege).
1881 April55F.Carcinoma.Entirelarynx.No
RECURRENCE11
MONTHSAFTER
OPE-
RATION.
CliniqueChir.Univ.
Liege;
Monatschr.f.
Ohrenheilk,1882,
No.9.
Burow’slist.
43
Foulis (Glasgow).1881 April
3050M.
Epitheliomaof
larynx(preced-
edby
papillo-mata).
Larynx.
WellandstrongAu-
gust,1881.
Brit.Med.
Jour.,May
7,June11,1881;
Trans.Int.Med.
Congress,London,
1881.
DOES LARYNGECTOMY PROLONG LIFE?
tableI— continued.
No-
Operator.Date.Age.Sex.
Disease.Partsremoved.
Result.
Reference.Remarks.
43
Czerny(Heidel-) berg).1881May
1347M.
Epithelioma.Larynx
andupper
tworingsoftra-
chea.
WellandstrongAu-
gust,1881.
Letterfromoperator
toDr.
Foulis.Ver-
balreportto
Int.
Med.Cong.,
Lon-
don,1881."
44
Reyher,Carl
(St.Peters- burgh).
1881May14
57M.Carcinoma.
Larynx.
Deathon
fifthday
fromseptic
bron- cho-pneumonia.Letter
fromoperator
toDr.
Foulis.Trans.
Int.Med.Congress,
1881.
45
Kocher (Berne).1881May
1659M.
Carcinoma.Entire
larynx,ex-
cepta
pieceof
thecricoid
car-tilage.
NoRECURRENCE
16
MONTHSAFTEROPE-
RATION.
Letterfromoperator
toProf.Burow.
Arch.Laryn.,N.Y.
April,1883.
Patientwearsa
selfmadearti-
ficialepiglottis
toovercome choking
inde-
glutition,re-
sultofexcision
ofepiglottis.
46
Tilanus(Am- sterdam).1881May
51M.
Epithelioma.Entire
larynx.Deathin86hours
fromcollapse.
Centbl.f.
Chir.,1882,
No.34.
47Gussenbauer(Prague).1881May
1948M.
Carcinoma.Entirelarynx.Well19months
AFTEROPERATION
doingdutyasa
riding-master.Letter
fromoperator
toProf.
Burow.Arch.
Laryn.,N.Y.
April,1883.
48
Volker (Bruns- wick).1881Maj7
2844F.Carcinomaepi-
tbelioides.Entire
larynx.Deathfromsuffoca-
tion5
monthsafter
operation.AcademischProef-
schrift,Amsterdam,
1883,pp.
84and
113.Suffocatedwhile
patienthad withdrawn
ca-
nulatocleanse
it. On13th,
hemor-rhagefromin-
ternalcarotid,
arrestedbyli-
gatureabove
andbelow
pointof
ero-sion.
Collapsesame
evening;death
nextday.
49
Albert (Vienna).1881 July
6
45M.Carcinoma,al-
mostfillingright
halfoflarynx.
Entirelarynx,ex-
ceptepiglottis;
alsosmallsection
ofadherent
oeso-phagus.
Deathon
eighthday
fromdiffusebron-
chitisandlobular
pneumonia.Wienmed.
Presse,1881,
xxii.p.1373.
COHEN,
tableI— continued.
No
Operator.Date.Age.Sex.
Disease.Parts
removed.Result.
Reference.Remarks.
50
Hahn1881
46M.Carcinoma.
Entirelarynx.
Deathin25daysfrom
Letterfromoperator
(Berlin).Aug.13
putridbronchitis.to
Prof.Burow.
Recurrenceat
51
Margary1881
36F.
Epitheliomaof
Larynx,firstringof
Arch.Ital.di
Lar.
(Turin).Sept.29
oesophagusandtrachea,
thyroid
Jan.15,1882.
endof3mos.
larynx.
body,partof
pharynx,and
oesophagus.
Letterfromoperator
52Gussenhauer1881
62M.Carcinoma.
Entirelarynx.Strongandwell
(Prague).Oct.
14MONTHSAFTERto
Prof.Burow.
OPERATION.
53
Reyher,Carl
(St.Peters-
1881 Oct.10
73M.
Carcinoma.Larynxand
upperthree
ringsof
Deathfrom
recur-rence,9
monthsSt.
Petersburg!!med.
Ztschr.,1882,
No.
burgh).
trachea.
afteroperation.28,
Letterfrom
operatorto
Prof.
Burow.
54
Reyher,Carl
(St.Peters- burgh).
1881 Oct.10
65M,Carcinoma.
Larynx.
Deathonseventh
day
fromsepticpneu-
monia.
Asabove.
55
Novarot.1881
63M.Carcinoma.
Entirelarynx.
RecurrenceinfourGiorn.diR.Acad,di
months.Excision
ofrightlobeof
thyroidglandand
partof
pharynx.Deathfromhem-
orrhageon11th
day.
med.diTorino,vol.
xxxix.1881,p.
39;
Arch.Ital.di
Lar.,
July15,1882.
56
Schede.1881
54M.
Cancroid.Larynx,hyoid
bone,andthy-
Twomonthslater
thepatient
wasDeutsche
med.Woch.,
1882,No.
roidgland.
fittedwithan
arti-33,p.45.
ficiallarynx.
67
Reyher,Carl
188255M.
Carcinomaepi-
Entirelarynx,pha-
Death14days
afterLetter
fromoperator
(St.Peters-April7
thelioides.rynx,andpartsoperationfromex-to
Prof.Burow.
burgh).
of
oesophagus.haustion.
Letterfromoperator
Recurrenceseven
58
Kocher188254
M.Carcinoma.
Entirelarynxand
(Berne).May13
carcinomatous
toProf.Burow.
monthsafter
glands.
operation.
DOES LARYNGECTOMY PROLONG LIFE?
tableI— concluded.
No.
Operator.Date.Age.Sex.
DiseaseParts
removed.Result.
Reference.Remarks.
59
Whitehead,Wm.(Man- chester)
.
1883 May27
46M.
Epitheliomaof
rightvocal
bandandpartssub-
jacent(asfar
downasupper
portionoftra-
chea).
Thyroidandcricoid
cartilagesandtwo
ringsoftrachea,
leavingepiglottis
intact.
WellJanuary
31,
1883.Probably
stillalive.
Lancet,Nov.
4,1883,p.
741.Letter
from
operatortocom-
piler,datedJan.
31,
1883.
60
Bergmann, von(Wurz-burg)
.
1883 June12
54M.
Carcinoma. (Adeno-sarco- ma?).
Entirelarynx.
Speakswellwith
artificial(Bruns)
LARYNXSOME
MOS.
AFTEROPERATION.
Sitzungsb.Wurzburg
Phys.Gesell.,1882,
47-56.Deutsche
med.Woch.,
1883,
No.35.;Centbl.f.
Chir.,Aug.19,
1882.
61 62
Burow (Kbnigs-berg).Kocher (Berne).1883 July7
1883Sept.38
44 43M. M.Carcinoma. Carcinoma.
Entirelarynx
with-outepiglottis.
Entirelarynxand
a
portionofoeso-
phagus.
Deathfrom
suddensuffocation4%mos.
afteroperation.
Archivesof
Laryn-
gology,April,
1883.
Samtnlungklin.Vor-
tragev.
Volkmann,No.234,p.
1944.
63
Maydl(Vienna).1883
50M.Carcinoma.
Larynx,exceptcri-
coidcartilage.
Excisionofa
gland,sizeofa
dove’segg.
Norecurrences mos.
afteroperation.
Wienmed.
Presse,1883,xxiii,1673;
Wienmed.Woch.,
1883,No.44.
Let-
terfromoperator
toProf.Burow.
64
Kuggi.188310M.
Polypiofthela-
rynx.
Entirelarynx.
Centbl.f.Chir.,1883,
No.45;
Raccogli-tore
med.,1883,
xviii.p.
36.
“Recoveryin38
days.”Burow’s
list.
65
McLeod(Calcutta).1883
35M.
Papillomaofla-
rynx.
Entirelarynx
and
thyroidgland.
Ingood
conditiononemonth
later.Ind.Med.Gaz.,1883,
xviii.,34-26.
COHEN,
Of the above sixty-five complete operations, fourwere performed in non-raalignant 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] ; onefor 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 copioushemorrhage 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-Ernilia, on Sept. 20, 1879,removed the larynx, pharynx, base of the tongue,soft palate and tonsils, from a female subject nineteenyears of age, for a sarcoma of the larynx, pharynx,palate, and base of 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-half months, respectively.
DOES LARYNGECTOMY PROLONG LIFE? 365
TABLE lI.—CASES OF SARCOMA.
1 (Lange) lived nearly 7 months.1 (Czerny) “ “ 15 “
1 (Foulis) “ “ “1 (Caselli) was alive Aug. 1881, nearly 2 years after operation.1 (Bottini) was alive and well Aug. 1881, 64 years after operation.
Taking for granted, as we are bound to do, thatdeath was imminent in these five cases of sarcomawhen 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.As far 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 headBchede’s case (sb) of “ cancroid.”
Let me read the list of deaths as far as reported ;
TABLE 111.—RECORDED DEATHS AFTER LARYNGECTOMY FOR
CARCINOMA.-
1. Tilanus, Case 46. Death in 36 hours from collapse.2. Macewen, “ 26. “ 3 days “ pneumonia.3. Bottini, “ 20. “ 3 “ “ “
4. Langenbuch, “ 30. “ 3 “ “ collapse.5. Schmidt, “ 4. “ 4 “ “ “
6. Gerdes, “ 14. “ 4 “ “ “
7. Billroth, “12. “ 4 “ “ pneumonia.8. Toro, “ 40. “ 4 “ “ pulmonary emphysema.9. Schonborn, “ 7. ,
“ 4 “ “ ?
10. Multanowski, “29. “ 5 “ “ pneumonia.11. Reyher, “ 44. “ 5 “ “ septic broncho-pneumonia.12. Pick, “38. “ 5 “ “ pleurisy and pericarditis.13. Reyher, “ 31. “ 7 “ “ septic broncho-pneumonia.14. Reyher, “ 54. “ 7 “ “ septic pneumonia.15. Watson, “ 16. “ 7 “ “ pulmonary embolism.16. Thiersch, “ 39. “ 7 “ “ “secondary infectious”
pneumonia.17. Albert, “ 49. “ 8 “ “ “diffuse bronchitis and
lobular” pneumonia.
COHEN,
table in.—continued.18. Reyher, Case 15. Death in 11 days from “hypostatic” pneumonia.19. Reyher, “ 57. “ 14 “ “ exhaustion.20. Maas, “ 5. “ 2 weeks “ pneumonia.21. Watson, “ 6. “ 2 “ “ “
22. Bircher, “ 37. “ 16 days “ pneumonia and “pulmo-nary gangrene.”
23. Hahn, “ 50. “ 25 “ “ putrid bronchitis24. Billroth, “24. “ 6 weeks “ passage of bougie into
mediastinum.25. Multanowski, “ 11. “ 2 mos. “ recurrence.26. Gussenbauer, “ 25. “ 2 “ “ tuberculosis pulmonum.27. Multanowski, “ 10. “ 3 “ “ “croupous” pneumonia.28. Langenbeck, “ 9. “ 4 “ “ recurrence.29. Thiersch, “ 36. “ 4 “ “ “
30. Novaro, “ 55. “ 4 “ “ recurrence and hemorrhageconsequent upon addi-tional operative proced-
31. von Burow, “61. “ “ “ sudden suffocation.32. Czerny, “ 34. “ 5 “ “ recurrence.33. Vblker, “ 48. “ 5 “ “ suffocation.34. Heine, “ 3. “ 6 “ “ recurrence.35. Maas, “ 18. “ 6 “ “ “
36. Billroth, “ 2. “ 7 “ “ “
37. Bruns, “ 21. “ 9 “ “ “
38. Kosinski, “ 17. “ 9 “ “ “
39. Reyher, “ 53. “ 9 “ “ “
40. Czerny, “ 23. “ 15 “ “ “
To this list may be added the cases of—Margary, Case 51, in which recurrence was reported at 3 months.Kocher, “58, “ “ “ 7 “
In the following cases neither death nor recurrence has been reported :1. Foulis, case 42, alive 5 weeks after operation.2. Czerny, “ 43, “ 6 “ “
3. Schede, “ 56, artificial larynx adjusted 2 months after operation.4. Mayal, “ 63, no recurrence 3 months after operation.5. von Bergmann, “ 60, alive “some” “ “
6. Wegner, “ 19, “ 7 months after operation.7. Whitehead, “ 59, “no recurrence;” alive 8 months after operation.8. Winniwarter, “ 41, “ “ “ 11 “ “
9. Gussenbauer, “ 52, well 14 months after operation.10. Kocher, “ 46, no recurrence 16 months after operation.11. Thiersch, “ 33, well 17 months after operation.12. Thiersch, “ 32, “ 18 “ “
13. Gussenbauer, “47, “19 “ “
14. Hahn, “ 35, “ 2 years “ “
Of the forty reported deaths, seventeen, or forty-two-and-a-half per cent., occurred within eight days,
DOES LARYNGECTOMY PROLONG LIFE? 367
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,there 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-tirpation 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
368 COHEN,
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. ISTine casesare reported living at seven, eight, eleven, fourteen,sixteen, seventeen, eighteen, nineteen, and twenty-four months, respectively. Thus forty-two-and-one-half per cent, of the forty cases, recorded as termi-nating fatally, or more than thirty per cent, ofthe 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
DOES LARYNGECTOMY PROLONG LIFE? 369
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 but 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 yeats 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 ofexistence of many others. The greatest goodto the greatest number appears better secured by de-pendence on the ]3alliative operation of tracheotomy.