transactions physicians of philadelphia ... of the college of physicians of philadelphia. third...

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.


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.


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.



No.


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.



No.


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

broncho-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,


No.


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.



No-


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

broncho-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,


No


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.


tableI— concluded.

No.


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-sarcoma?).

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,


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


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.

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