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.
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]).
