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.
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.
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:
‘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, 6½, 5½, 4½ and 3½ 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 11½ 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.