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 pa.s.ses 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 pa.s.ses into the mucous membrane of the other side, it is exceptional for it to pa.s.s 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 s.p.a.ce 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 ma.s.sive 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, anaesthetic, 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 sophagus; the lower end is carefully freed from the sophagus, and two strong catgut sutures are pa.s.sed 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 b.u.t.ton-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 anaesthetic is continued. By this means the lower air-pa.s.sages are completely cut off from the region of the tumour, and no blood or septic matter can pa.s.s into the lungs.

[Ill.u.s.tration: FIG. 262. TOTAL LARYNGECTOMY. A, Crico-thyreoid muscle; B, Attachment of inferior constrictor of pharynx to thyreoid cartilage; C, Cut edge of inferior constrictor; D, Thyreo-hyoid membrane; E, sophagus; F, Trachea.]

_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 sophagus 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 ma.s.s is removed, including, if necessary, the pharynx and upper part of the sophagus. It is important not to drag upon the sophagus; 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 sophagus remains to be decided. In order to restore the cavity of the pharynx, the upper end of the sophagus 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 st.i.tches, 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 pa.s.sed previously through the nose into the sophagus, 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-pa.s.sages. 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 anaesthetic 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 sophagus which is diseased, are separated from above downwards, the trachea being severed transversely as a final stage and sewn into a b.u.t.ton-hole immediately above the sternum. A soft rubber tube having been introduced through the nose into the sophagus, 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.

[Ill.u.s.tration: FIG. 263. TOTAL LARYNGECTOMY. GLUCK'S METHOD. Tracheotomy canula with rubber tube for Hahn's adjustment tied into the upper opening of the larynx. A, Epiglottis; B, Superior cornu of thyreoid cartilage; C, Posterior surface of cricoid with crico-arytenoid muscles; D, Trachea; E, sophagus.]

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 sophagus 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 pa.s.sing 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.

Foderl 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-pa.s.sages; 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 sophagus were closed by sutures. The patient recovered with a pharyngeal fistula through which the saliva pa.s.sed, 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 const.i.tutional disease. Moreover, the above figures are sufficient to show that the immediate mortality from this operation under favourable circ.u.mstances is not large.

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