Prognosis.
—The prognosis will depend upon the character of the tumor and the local conditions—i. e., size, fixation, location, etc. In the young it is serious because of the danger attending its removal. Rational adults can be usually put in excellent condition for endolaryngeal operation by the aid of local anesthesia, and expert specialists become dexterous in their manipulation of the specially shaped forceps, curettes, and the like which are required for removal of these growths. As elsewhere a truly innocent tumor in this location does not recur after complete extirpation.
MALIGNANT TUMORS OF THE LARYNX AND TRACHEA.
Of these tumors the most common is epithelioma within the larynx. Sarcoma occasionally originates from the vocal bands, true or false, and will usually form a nodular tumor, of rugose surface, until it begins to ulcerate. Once it begins to break down it is difficult to distinguish from the other varieties without the aid of the microscope; but epithelioma may be met with in any part of the larynx, generally arising from the ventricular bands. Here, as ordinarily upon mucous surfaces, it begins as a small nodule with a definite zone of infiltration about it; if seen early it may be mistaken for innocent papilloma. As infiltration progresses the hoarseness resulting from its presence will change to loss of voice, because of the fixation of the tissues whose mobility is essential to voice production. Pain may be an early feature, depending upon ulceration and exposure of sensory nerve endings. Later when the ulcerated surface has become deep, irregularly covered with fetid discharge, and more or less concealed by edematous surroundings, the picture is more complete in one respect, although the details may be obscure. From the mucous and softer tissues the disease will spread and invade the cartilages themselves, as well as the tissues outside, and so with the progress of the cancer the entire larynx becomes fixed in a bed of infiltrated tissue extending in all directions, involving the upper part of the trachea, the epiglottis, and the base of the tongue. Meantime the loss of voice, the distressing cough, and the other evidences of local invasion will have kept pace with the progress of the disease, and dyspnea will come on sooner or later as the passage-way becomes blocked, while from sudden, violent efforts at coughing acute attacks of edema, which may result fatally, are liable to occur.
Tumors of the trachea proper are far less common. They may be benign or malignant. In either event they will prove to be of about the same type as those already discussed above as occurring within the larynx. They cause less interference with speech, but as much or even more difficulty in respiration.
When tracheotomy was a frequent resort in croup and diphtheria a peculiar form of new formation in the trachea was occasionally encountered, resulting from the irritation of the trachea tube, whose presence sometimes provokes excessive formation of granulation tissue, whose subsequent contraction brings about not only the formation of a dense granuloma, but cicatricial contraction. Hence in the older literature references to granulation stenosis were common. Now that intubation has almost completely replaced tracheotomy for these purposes the latter is rarely performed, and tubes are seldom left more than a day or two in situ, so that this kind of local provocation, with its consequences, is rarely encountered.
It may be possible by expert use of the laryngoscope to see a tumor located within the trachea. If the patient cannot tolerate its use the parts may be made tolerant by the use of a weak cocaine spray. Such a growth, if accessible from above, may be removed through the glottis by forceps. Most operators, however, prefer to make an opening through the trachea and thus profit by the larger surgical opportunities thus afforded. Such an operation should be made with the patient’s head low in order that blood may gravitate to the pharynx rather than to the lungs.
OPERATIONS UPON THE LARYNX.
Cancer of the larynx was regarded, until the last quarter of the previous century, as an absolutely hopeless condition for which nothing could be done until it became necessary to do a tracheotomy, this simply affording relief from some of the distressing features, but aiding nowise to check the progress of the growth. The first demonstration of the possibility of successful removal of the larynx was made by Czerny, in 1870, upon dogs. Watson, of Edinburgh, had removed a syphilitic larynx in toto in 1866, but this summary operation only became known to the world through a publication of Foulis in 1881. Meantime, Czerny’s experiments were so successful that Billroth was induced to attempt the removal of the entire larynx in a case of cancer, with results which astonished the profession of that day. Thus introduced, nevertheless, the mortality rate was great, the principal cause of death being inspiration pneumonia—that is, rapid infection of the lung through the widely opened trachea and the entrance of saliva and fluids from the mouth. Hahn, of Berlin, undertook the improvement of the technique and was able to reduce the mortality from this cause. Meantime another radical method—namely, thyrotomy, i. e., opening the laryngeal box—had not fared much better than the measure just mentioned. Thus until about twenty-five years ago the radical treatment of laryngeal cancer stood in an unpleasant light, partly because diagnostic methods were unsatisfactory and our general knowledge of the disease incomplete, partly because operation was always delayed until late, and because operative measures had yet to be much improved. Tremendous impetus was given to the whole subject by the celebrated case of the Emperor Frederick, and the acrimonious criticisms concerning its conduct were not without benefit, since they led to a careful re-study of the whole situation, with its numerous subsidiary questions, among which was the possibility of transformation of a benign into a malignant tumor. At present, largely through the labors of Hahn and Billroth, in Germany, and Semon, in London, the question of operative procedures is fairly settled, everyone now believing that the disease should be radically attacked at the earliest possible moment, opinions differing only in regard to the route which the surgeon should adopt, i. e., whether he should make an intralaryngeal operation, as is now favored in Germany; a thyrotomy, as preferred in Great Britain, or a laryngectomy, as some of the general surgeons in all parts of the world prefer.
The different methods of attack upon the larynx for cancer may then be summarized as including intralaryngeal extirpation through the natural passages, thyrotomy, and partial or complete laryngectomy.