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MALIGNANT DISEASE OF THE 
 LARYNX 
 
MALIGNANT DISPASE 
 
 OF 
 
 THE LARYNX 
 
 {CARCINOMA AND SARCOMA) 
 
 BY 
 
 PHILIP R. W. DE SANTI, F.R.C.S. 
 
 SURGEON TO THE THROAT. NOSE AND EAR DEPARTMENTS, WESTMINSTER 
 
 HOSPITAL (late SENIOR ASSISTANT SURGEON, WESTMINSTER 
 
 hospital) ; LECTURER ON DISEASE OF THE THROAT, NOSE, 
 
 AND EAR, WESTMINSTER HOSPITAL IMEDICAL SCHOOL 
 
 NEW YORK 
 
 ^^' I L L I A M W O O D 6c COMPANY 
 
 MDCCCCV 
 


 PREFACE 
 
 It was originally intended that I should collaborate 
 with my old teacher and friend Mr. Butlin in re- 
 editing his monograph on ' Malignant Disease of the 
 Larynx.' Unfortunately, owing to the great demands 
 on Mr. Butlin's time, this arrangement has been 
 ri,^ found to be impracticable, and it has fallen to my 
 lot to publish this treatise on my own responsi- 
 '' bility. 
 
 C It is with gratitude that I acknowledge the kindly 
 t> help I have received in my task from Mr. Buthn and 
 Sir Felix Semon, the two foremost authorities in this 
 ^ country on malignant disease of the larynx, 
 ^v One of the main objects of this book is to place 
 S before the profession the views we hold in England 
 ^ as to the correct operative treatment of laryngeal 
 , cancer — views which have not so far been sufficiently 
 / understood or appreciated abroad. 
 "^ If this treatise should contribute towards popu- 
 N larizing the operative treatment as practised so 
 successfully in this country, I feel I shall not 
 altogether have written in vain. 
 
 15, Stratford Place, 
 
 Oxford Street, W. 
 
 September^ 1904. 
 
MALIGNANT DISEASE OF 
 THE LARYNX 
 
 HISTORY. 
 
 Malignant disease appears to have been known in 
 the earher times ; for instance, a case is recorded by 
 Professor Boerhave, of Leyden (1668-1738), and 
 Morgagni, of Padua, described the post-mortem 
 appearances of a case of cancer of the pharynx and 
 larynx in a man of fifty. Later, mention was made 
 of cancerous affections of the larynx, but it was not 
 until the discovery of the laryngoscope by Garcia in 
 1854* that any great advance in our knowledge of 
 laryngeal carcinoma and sarcoma, and of its accurate 
 diagnosis, became possible. 
 
 On December 31, 1873, the first complete extirpa- 
 tion of the larynx for cancer was performed by Bill- 
 roth. Subsequently Schrotter, Morell Mackenzie, 
 of London, and Fauvel, of Paris, paid particular 
 attention to the subject, and especially good work 
 was done by Krishaber, Eppinger, Cornil, and 
 
 ■^ It is interesting to note that Seiior Garcia is still alive and 
 well, and celebrates his one-hundredth b'rthday next year. 
 
 I 
 
2 Malignant Disease of the Larynx 
 
 Ranvier, the two latter in pathological anatomy. In 
 1883 a monograph on ' Malignant Disease of the 
 Larynx,' was published by Butlin, and since the illness 
 and death of the German Emperor, Frederick IIL 
 (1887-1888), a very considerable amount of clinical, 
 pathological, and operative work has been done in 
 connection with these serious and far from un- 
 common affections of the larynx. 
 
 Malignant disease of the larynx presents itself in 
 two forms — (i) carcinoma, (2) sarcoma. Each will be 
 dealt with separately, commencing with that form 
 which is infinitely the more common, namely, 
 carcinoma. 
 
Carcinoma of the Larynx 
 
 CARCINOMA OF THE LARYNX. 
 ETIOLOGY. 
 
 Of the nature of cancer of the larynx and of the 
 general causes on which it depends nothing more is 
 known than of the nature and etiolog}^ of cancer else- 
 where, and this is, when said, but little and involved 
 in obscurity. 
 
 Heredity does not seem to play any very marked 
 role ; indeed, of born or inherited predisposition to 
 cancer of the larynx the evidence is distinctly 
 negative, and curiously different to the inherited 
 predisposition noticeable in cancer of other parts of 
 the body, as of the breast or uterus. Nevertheless, 
 there are cases on record with a distinct history of 
 cancer in the family. Semon, out of 56 cases 
 under his own personal observation, records 3 in 
 which heredity played a part. In i case the father 
 of the patient suffering from laryngeal carcinoma 
 died from malignant tumour of the throat ; in 
 another two sisters of the patient died, one from 
 cancer of the uterus, the other from cancer of the 
 breast ; in his third case the heredity was of a more 
 distant nature. 
 
 Bailly and Isambert have recorded a case in which 
 the father of the affected patient died of cancer of 
 the pylorus and the sister of cancer of the uterus. 
 
 Other similar records exist, and have been noted 
 by Krishaber, Baratoux, Schmidt, etc., but whilst 
 
 I — 2 
 
4 Malignant Disease of the Larynx 
 
 admitting that a family history of cancer in persons 
 suffering from laryngeal cancer occasionally exists, it 
 has been of rare occurrence. 
 
 Chronic Irritation. — There seem to be fair grounds 
 for stating that chronic irritation is a predisposing 
 cause, and this is only in accordance with the know- 
 ledge we have of chronic irritation producing carci- 
 noma elsewhere — for instance, the lip from smoking, 
 the scrotum from soot (chimney-sweeps). 
 
 Excesses in alcohol and tobacco and overuse of 
 the voice have been considered predisposing causes, 
 but certainly, as regards overuse of the voice, clergy- 
 men, singers, and lawyers do not seem more liable to 
 the affection than other people. Nevertheless, on 
 investigation of the histories of some of the patients 
 suffering from this disease, it is noticeable that they 
 have attributed their laryngeal trouble to excessive 
 use of the voice, one man in particular ascribing his 
 malady to loud shouting in a sawmill, of which he 
 was manager. 
 
 I have certainly seen myself one case of epithelioma 
 of the larynx follow chronic laryngitis produced by 
 alcohol and abuse of tobacco. In this case there 
 was present the condition described by Virchow as 
 * pachydermia laryngis,' epithelioma supervening. 
 
 Many of the patients under Butlin's care believed 
 that a severe cold was the cause of the formation of 
 tumour, for in several cases the first symptoms of 
 disease were hoarseness and slight cough. But it is 
 almost certain that these symptoms of laryngeal 
 irritation were the early symptoms of the tumour. 
 They did not pass off or generally become less 
 
Carcinoma of the Larynx 5 
 
 marked even for a time, but in most instances 
 persisted, and gradually became more urgent. A 
 few of the patients, however, appear really to have 
 suffered from a severe cold, for they were able to 
 assign the precise date of its occurrence, and the 
 symptoms of the tumour commenced during the 
 period of chronic catarrh. 
 
 Syphilitic and tubercular lesions of the larynx are 
 important in so far as that they may lead to carci- 
 noma by virtue of the local irritation they set up. 
 
 Lepine and Krishaber have recorded cases in 
 which both tubercle and cancer of the larynx were 
 present in the same patient. 
 
 Semon also has seen cancer of the larynx associated 
 with tuberculosis of the lungs. 
 
 The assertion that there is a special liability to 
 transformation of simple benign tumours of the 
 larynx into malignant tumours after repeated endo- 
 laryngeal operations has been conclusively shown by 
 Semon's exhaustive collective investigation to be 
 unfounded. 
 
 In 8,216 cases of intralaryngeal operation there 
 were only 5 cases in which such a transformation 
 undoubtedly took place, a proportion of i in 1,645. 
 
 In 7 further cases the transformation, although 
 not certain, was probable, and in another 10 doubtful. 
 If these cases be included in addition to the certain 
 ones, the proportion of cases in which a benign 
 laryngeal growth underwent malignant degeneration 
 after endolaryngeal operation would be as i in 373, 
 whilst if the certain and probable cases only were 
 admitted, as i in 685. 
 
6 Malignant Disease of the Larynx 
 
 As playing a very small part in the etiology of 
 carcinoma laryngis, reference may be made to 
 contagion and autoinfection. There are a few cases 
 published bearing on these two cases, but the cases 
 are so few that no more need be said on the subject. 
 
 Age. — All authors agree that carcinoma of the 
 larynx is most frequently met with between the ages 
 of 40 and 70, and that of these 30 years, the decade 
 50 to 60 is the one in which cancer predominates. 
 
 In Butlin's monograph the following table is given 
 of the ages of 50 patients : 
 
 Years. Cases. 
 
 3 - - - - - - I 
 
 28 to 30 - - - - - 4 
 
 31 to 40 - - - - - 6 
 
 41 to 50 - - - - - 8 
 
 51 to 60 - - - - - 15 
 
 61 to 70 - - - - - 10 
 
 71 to 76 - - - - - 2 
 
 Uncertain - - - • - 4 
 
 Total - - 50 
 
 It will be seen that there is only one patient under 
 28 years of age, and that patient, strange to say, was 
 a boy of 3 years, whose case is recorded by Dr. Rehn.* 
 The disease began with symptoms of hoarseness, 
 which passed on to loss of voice, and later produced 
 attacks of suffocation. It was thought to have 
 existed for at least two years. During one of the 
 attacks of suffocation the patient died, although 
 tracheotomy was performed for his relief. Both 
 cords, the ventricles and ventricular bands, and the 
 epiglottis, were the seat of a whitish-red, warty, 
 
 * Virchow's Archiv^ Bd. xliii., S. 129, 1868. 
 
Carcinoma of the Larynx 7 
 
 cauliflower mass, which appeared to have originated 
 in the ventricles. Thus far the disease might be 
 regarded rather as a papilloma than an epithelioma, 
 but the diagnosis rested on the three following 
 circumstances : the tumour grew almost down to the 
 perichondrium of the thyroid cartilage ; the micro- 
 scopical examination made by Virchow discovered 
 the ordinary structure of epithelioma, with solid 
 plugs of epithelium dipping down into the muscles 
 and other deeply-seated tissues ; and there was one 
 enlarged lymphatic gland at the inner border of the 
 sterno-mastoid muscle. In the face of these condi- 
 tions the disease can scarcely be considered other 
 than epithelioma occurring at a marvellously early 
 age. With this exception the table of ages corre- 
 sponds with that of epithelioma of the tongue, the 
 lip, and other parts, save that the number of cases 
 between 28 and 30 is unusually large. 
 
 Dufour has recorded a case in a still younger 
 patient, a child of i year of age. 
 
 Sendziak's table of 486 cases of cancer of the 
 larynx collected from various sources gives the 
 following results : 
 
 
 
 Years. 
 
 
 
 
 
 Cases. 
 
 Between 
 
 I and 20 
 
 
 - 
 
 
 - 
 
 5 
 
 
 
 20 and 30 
 
 
 - 
 
 
 - 
 
 22 
 
 
 
 30 and 40 
 
 
 - 
 
 
 - 
 
 41 
 
 
 
 40 and 50 
 
 
 - 
 
 
 - 
 
 121 
 
 
 
 50 and 60 
 
 
 - 
 
 
 - 
 
 188 
 
 
 
 60 and 70 
 
 
 - 
 
 
 - 
 
 80 
 
 
 
 70 and 80 
 
 
 - 
 
 
 - 
 
 17 
 
 
 
 80 and 90 
 
 
 - 
 
 
 - 
 
 5 
 
 Cases 
 
 in 
 
 which the ; 
 
 age 
 
 was 
 
 not 
 
 stated - 
 
 7 
 
 Total - - 486 
 
8 Malignant Disease of the Larynx 
 
 Between the ages of 40 to 70 there were, therefore, 
 389 cases, more than 84 per cent, of the whole 
 number. These results agree with those of Semon. 
 He gives 103 cases, 87 of which occurred between 
 the ages of 40 to 70, again more than 84 per cent. 
 
 The tables of Baratoux and others support these 
 results. 
 
 The age of the oldest patient in which cancer of 
 the larynx has been recorded is 83 (Semon), and 
 next to this patient a man of 82 (Preisendorffer). 
 
 Sex. — The much greater liability of males than 
 females to cancer of the larynx has been noticed by 
 most writers. Of the 50 patients already referred to, 
 40 were males and 10 were females. Out of Send- 
 ziak's 486 cases, 400 were males, 68 females, and in 
 18 there is no mention of the sex. 
 
 Schwartz noted 153 males and 26 females. Bara- 
 toux's statistics give 265 males and only 36 females. 
 Semon notes 79 males and 24 females. Jurasz in 
 21 cases of cancer of the larjmx mentions only i as 
 being of the female sex. 
 
 There seem to be no satisfactor}^ reasons to explain 
 the differences in the liability of the sexes to carci- 
 noma of the larynx. In dealing with the occupations 
 and habits of the patients as etiological factors, it has 
 been pointed out that there is nothing which leads 
 one to suppose that either occupation or habit pre- 
 disposed to the disease in any appreciable number of 
 cases. 
 
 Fauvel has suggested that the larynx is much 
 more liable to innocent and malignant tumours in 
 men than women because these diseases find in 
 
Carcinoma of the Larynx 9 
 
 women a soil, as it were, prepared for them in the 
 breasts and uterus (' Physiological Activity and 
 Decline 'j. 
 
 Schiffers* has gone further than Fauvel by suppos- 
 ing that cancer plays in the larynx in the male the 
 role which it plays in the uterus in the female. He 
 speaks of the sympathy which exists between the 
 larynx and the uterus at puberty, and of their 
 reciprocal influence. 
 
 Dr. Schiffers seems to be unaware of the fact that 
 the lower lip, the tongue, and the oesophagus are all 
 more frequently attacked by cancer in men than 
 women, and that the disproportion is greatest in 
 cancer of the lower lip. 
 
 It is also a curious fact that in women the 
 extrinsic form, in men the intrinsic, is much more 
 common. 
 
 PATHOLOGICAL ANATOMY. 
 
 In considering both sarcoma and carcinoma of the 
 larynx, the division suggested by Krishaber into 
 tumours of intrinsic and extrinsic origin has been 
 hitherto that most universally adopted, for it appears 
 to be not merely convenient for purposes of classifi- 
 cation, but is considered valuable in relation to the 
 subject of secondary infection of the lymphatic glands. 
 
 The term intrinsic is applied to tumours which 
 arise in connection with the vocal cords, the ven- 
 tricles, the false vocal cords, and the parts immediately 
 below the true vocal cords ; the term extrinsic to 
 
 * Rev. Meiis. de Laryng.., vol. iv., p. i6, 1883. 
 
lo Malignant Disease of the Larynx 
 
 those tumours which grow from the epiglottis, the 
 aryepiglottic folds, the interarytenoid folds, etc. 
 
 The question of the affection of the lymphatic 
 glands is one whose importance it is difficult to 
 overestimate. In 1879* Krishaber laid down the 
 general rule that the extrinsic cancers affect the 
 glands at an early period, and that the intrinsic 
 cancers, so long as they are limited to the cavity of 
 the larynx, do not affect the glands. 
 
 Schwartz uses the terms ' cavitaires et marginaux ' 
 (of the interior, and of the borders of the larynx). 
 Recently Cuneot suggested the abandonment of 
 Krishaber's division into intrinsic and extrinsic 
 carcinomas, and the substitution of a division into 
 supraglottic, infraglottic, and glottic carcinomas, 
 basing this division on his anatomical researches 
 of the laryngeal lymphatic system. 
 
 In my opinion, no sufficient grounds have been 
 adduced for abandoning Krishaber's classification, 
 which in the main, as regards infection of the glands, 
 remains true to the present time. 
 
 The following account of the lymphatic system is 
 important in relation to the almost universal adoption 
 of Krishaber's classification and the deductions made 
 by him as to secondary lymphatic infection. 
 
 Lymphatics of the Larynx. 
 
 Apparently the first accurate description of the 
 laryngeal lymphatics was published by Teichmann, 
 
 * Krishaber, ' Annales de Laryngol.,' 1879. 
 t Gazette dcs Hopihiiix^ No. 141, 1902. 
 
Carcinoma of the Larynx i i 
 
 who laid particular stress on the distribution of the 
 terminal vessels in the mucous membrane of the 
 larynx. In 1871 Luschka published his excellent 
 work on the lymphatic system, and in 1874 Sappey* 
 completed the description of these vessels, and gave 
 an account of the general arrangement of the lym- 
 phatic radicles and their final distribution to the 
 lymphatic glands. In i887t Poirier injected the 
 lymphatics of the inferior true vocal cords, the 
 existence of which had up till then been contested, 
 and drew attention again to the pre-laryngeal glands 
 referred to by Engel in 1859, but which had not 
 been recognised by writers since. 
 
 In 1899+ Most investigated the laryngeal lym- 
 phatics, and for his investigation employed the 
 method of Gerota, and recently§ Cuneo published 
 an article giving his results obtained by injecting 
 several larynges in the same m^anner as Most, and 
 corroborating Most's results. I have also employed 
 Gerota's method, and find the results agree in the 
 main with Cuneo's. 
 
 The following account of the lymphatic laryngeal 
 system is as given by Cuneo, and confirmed by my 
 own injections, except where specifically found to 
 differ. 
 
 * ' Anatomie, Physiologic, Pathologic dcs Vaisseaux Lym- 
 phatiqucs.' Paris, 1874. 
 
 t ' Vaisseaux Lymphatiqucs du Larynx : GangHon Pre- 
 laryngd,' Progres Med., 1887, No. 19, p. 373. 
 
 ± Anat. Ans.^ 1899, p. 387, and Zeitschr. f. Chir., Bd. Ivii., 
 1900, 
 
 § Gazette des Hopitaitr, No. 141, 1902. 
 
12 Malignant Disease of the Larynx 
 
 The Lymphatic Radicles. — The lymphatics of the 
 larynx take their origin in a network that covers the 
 whole of the internal surface of the larynx, and is 
 densest where the mucous membrane is thickest, 
 but divisible into two areas, an upper and a lower 
 area. 
 
 The upper area in which the terminal network is 
 in greater part very dense, and quite easy to inject, 
 includes all the portion of the laryngeal mucous 
 membrane above the glottis, namely the epiglottis, 
 aryteno-epiglottidean folds, superior vocal cords, 
 and the ventricles. 
 
 The inferior area includes the mucous membrane 
 of the larynx below the glottis. At this level the 
 network is decidedly less dense, and in all cases less 
 easy to inject than that of the upper area. 
 
 These two areas are relatively independent of one 
 another. They are, as a matter of fact, separated by 
 an intermediary zone, formed by the inferior vocal 
 cords, at which level the lymphatic radicles are 
 even more rare and attenuated, though not entirely 
 absent. 
 
 At the level of the posterior aspect of the larynx 
 the two areas extend without any very clear line of 
 demarcation. If an injection at the level of the 
 inferior vocal cord be pushed, the material injected 
 usually enters, according to Most, the vessels of the 
 upper area. 
 
 It is of importance to note that the lymphatics of 
 one half of the larynx do not communicate with 
 those of the opposite side anteriorly, but that at the 
 level of the posterior median line the intercommuni- 
 
Carcinoma of the Larynx 13 
 
 cations are very numerous. The network of the 
 lower area is directly continuous with the tracheal 
 network, there being no line of demarcation at all. 
 Similarly the network of the upper area is directly 
 continuous with the network covering the mucous 
 membrane of the pharynx and base of the tongue. 
 
 All these facts are of great importance from the 
 point of view of the local spread of laryngeal cancer. 
 
 Distribution of the Lymphatic Channels arising 
 from the Lymphatic Radicles. 
 
 Each of the two areas have a distinct set of efferent 
 vessels. 
 
 The trunks arising from the upper meshwork 
 run towards the lateral parts of the epiglottis and 
 aryepiglottic folds, and then pierce the thyro-hyoid 
 membrane at the point of entry of the superior 
 laryngeal artery. 
 
 After piercing the thyro-hyoid membrane, these 
 collecting trunks divide into three sets, an ascending 
 group of one or two in number, which cross the 
 hypoglossal nerve and end in a gland situated just 
 below the posterior belly of the digastric muscle, a 
 horizontal group emptying into the glands placed on 
 the internal jugular vein at the level of the bifurca- 
 tion of the common carotid, and a descending group 
 ending in glands of the same chain at a level of the 
 middle part of the lateral lobes of the thyroid gland. 
 
 Occasionally one or two small glands are found on 
 the thyro-hyoid membrane itself, but they do not, 
 when present, receive lymphatics from the larynx ; 
 
14 Malignant Disease of the Larynx 
 
 their lymphatics come from the lateral regions of the 
 pharynx. 
 The trunks arising from the lower meshwork 
 
 are divisable into two groups, one anterior, the other 
 posterior. 
 
 The anterior group (supracricoid) consists of 
 three or four trunks, which perforate the crico-thyroid 
 membrane near the middle line. Some of these 
 trunks end in the pre-laryngeal glands (Poirier), 
 others in a pre-tracheal gland (Most), and others in 
 one of the glands of the middle or inferior sterno- 
 mastoid chain of glands. 
 
 The pre-laryngeal and pre-tracheal glands form 
 (Poirier-Charpy, t. xi., p. 1280) part of a chain 
 described as the deep cervical chain. 
 
 This chain consists, according to Poirier, of three 
 distinct groups or masses of glands. 
 
 (i) A pre-laryngeal mass, first noted by Engel. 
 Its existence has been confirmed by Poirier, he 
 finding the pre-laryngeal group present 49 times out 
 of 100. Usually only one gland is present, which in 
 the adult is about the size of a pea, and tends to 
 atrophy in old age. It is generally found in the 
 middle of the V-shaped space formed by the two 
 crico-thyroid muscles, although occasionally it is 
 overlapped by the inner border of one of these 
 muscles. 
 
 In I out of 6 cases a second gland about the size 
 of a pin's head has been found at the level of the top 
 of the V-shaped space. 
 
 Sometimes a gland has been found on the upper 
 edge of the isthmus of the thyroid (Mascagni, Rou- 
 
Carcinoma of the Larynx 15 
 
 baud, Most), and occasionally a gland in front of the 
 thyroid cartilage close to its anterior border. 
 
 (2) A pre4hyroidean mass, placed in front of the 
 isthmus of the thyroid. This group is only rarely 
 present. 
 
 (3) A pre-tracheal mass, usually consisting of 
 one gland of the size of a small pea, and situated 
 about i| centimetres above the sternal notch. 
 
 There may, however, be more than one pre-tracheal 
 gland. The afferent vessels of the pre-laryngeal 
 glands are some of the lymphatics of the middle 
 lymphatic pedicle of the larynx and those of the pre- 
 tracheal come partly from the thyroid body, parti}- 
 from the pre-laryngeal glands. 
 
 The efferent vessels from the pre-laryngeal, pre- 
 thyroidean, and pre-tracheal glands empty themselves 
 into the lowermost glands of the sterno-mastoid 
 chain. 
 
 The posterior or infracricoid group consists of 
 three to five trunks, which pass over the crico-tracheal 
 membrane at the junction of the lateral and posterior 
 aspects of the trachea. 
 
 These trunks end in two to five glands running 
 parallel with the recurrent laryngeal nerve. These 
 glands collect vessels from the thyroid body, the 
 lymphatics of the inferior pedicle of the larynx, and 
 the vessels from the cervical portion of the trachea 
 and oesophagus. 
 
 Their efferent vessels end in the lowermost glands 
 of the sterno-mastoid chain and the supraclavicular 
 glands. To sum up, the lymphatic channels emanat- 
 ing from the larynx empty themselves into the glands 
 
i6 Malignant Disease of the Larynx 
 
 situated beneath the sterno-mastoid muscles into the 
 pre-larj-ngo-tracheal glands and into the glands 
 accompanying the recurrent laryngeal nerves, and 
 additionally into the supra clavicularglands. 
 
 The group of glands underneath the sterno- 
 mastoid muscles must be looked upon as the 
 principal group of glands to finally receive the 
 lymphatics of the larynx. The pre-laryngeal, pre- 
 tracheal, and recurrent groups are only simple 
 glandular points placed as interrupters on the line of 
 the lymphatic vessels going from the subglottic 
 area to the deeper group of sterno-mastoid glands 
 (Cuneo). 
 
 Application of these Anatomical Facts to the 
 Extension of Epithelioma of the Larynx by 
 the Lymphatics. 
 
 Extrinsic carcinoma includes several varieties — 
 cancer of the epiglottis (very frequent), of the ary- 
 epiglottic folds (less frequent), and of the arytenoid 
 region (rare). 
 
 These differently - placed carcinomas all present 
 common characteristics. They tend to push them- 
 selves towards the upper opening of the larynx, and 
 to invade the lateral regions of the larynx and 
 pharynx. 
 
 Whilst extrinsic carcinoma reaches the final stage 
 of its evolution by invading the extra-laryngeal parts, 
 it is at the level of the posterior aspect of the thyro- 
 hyoid membrane that these extensions are liable to 
 become visible, namely, to ulcerate through. 
 
Carcinoma of the Larynx 17 
 
 Extrinsic carcinoma in its downward growth tends 
 to become arrested at the level of the inferior vocal 
 cords. This has been noted by several observers, 
 yet, at the same time, it must not be understood 
 that the inferior vocal cords form an absolutely im- 
 passable barrier, only that they seem, at all events, to 
 arrest its extension for some length of time. 
 
 Intrinsic carcinoma includes cancer affecting the 
 superior false vocal cords, the ventricles, the true 
 vocal cords, and the parts immediately below the 
 true vocal cords (subglottic region). The true vocal 
 cords are most frequently the initial seat of laryngeal 
 carcinoma, although some observers are of opinion 
 that the false vocal cords are most frequently affected. 
 The statistics of Sendziak show the true vocal cords 
 to have been the seat of disease in 107 cases, whereas 
 the false vocal cords were affected in only 27. Semon, 
 again, out of 55 cases, notes the true vocal cords as 
 affected in 15 cases and the false in 3 only. On the 
 other hand, Baratoux, out of 117 cases, noted 62 that 
 were primary in the false vocal cords against 29 in 
 the true vocal cords, and Fauvel, out of '^^ cases, 
 records only i in which the true vocal cords were 
 the primary seat of disease. 
 
 Carcinoma of the true or false vocal cords is con- 
 spicuous by virtue of the slowness of its evolution, 
 particularly so when the true vocal cord is the initial 
 seat of disease. 
 
 According to some authorities, carcinoma of the 
 true vocal cord has a tendency to extend at first 
 towards the opposite cord, then towards the supra- 
 glottic region. It is, however, in the majority of 
 
 2 
 
1 8 Malignant Disease of the Larynx 
 
 cases impossible to tell in what direction the growth 
 will spread, cases being very dissimilar in this respect. 
 At the same time, in my experience there is a 
 tendency for carcinoma attacking the true or false 
 vocal cords to spread towards the supraglottic 
 region. 
 
 Subglottic carcinoma is rare. Out of 486 cases of 
 laryngeal cancer, Sendziak only collected 5. Out of 
 50 cases collected by Butlin in his monograph on 
 * Malignant Disease of the Larynx,' 5 were infra- 
 glottic, in every case situated immediately below the 
 vocal cord. A case of this kind was published in the 
 NeiiJ York Medical Record by Dr. Delavan,* who 
 regarded the situation of the tumour as unique. But 
 a similar case is recorded by Emile Blanc, t a third 
 case by Krishaber,t and a fourth by Norton. § The 
 close resemblance of this case to that recorded by 
 Dr. Delavan is very striking. In neither was there a 
 visible tumour ; in both the vocal cord was paralyzed 
 and a little thrust up by the tumour. In neither was 
 there any affection of the glands or of any of the 
 other organs or tissues. In Blanc's case the tumour 
 was visible between the vocal cords, and the tumour 
 could also be seen in Krishaber's case. 
 
 The fifth of the series occurred in St. Bartholo- 
 mew's Hospital in a man fifty-six years old, who had 
 suffered from laryngeal trouble, slight hoarseness 
 and cough, with severe attacks of dyspnoea, for 
 
 * New York Medical Record, vol. xx., p. 625, 1881. 
 
 t Loc. cit., p. 46, obs. 2. 
 
 X Gaz. Hebdo7n.^ p. 540, 1879. 
 
 § Path. Trails.^ vol. xxiii., p. 43, 1872. 
 
Carcinoma of the Larynx 19 
 
 several months. One of the vocal cords was observed 
 to be paralyzed, but no tumour could be discovered. 
 His symptoms were ascribed to various causes, among 
 others to aneurism of the aorta, and to affection of 
 the recurrent laryngeal nerve ; and it was not until 
 after his death, which took place from apnoea, that 
 the real nature of the malady was made apparent. 
 
 A tumour the size of a hazel-nut lay immediately 
 below the right vocal cord, partly embedded in the 
 wall of the larynx. It had perforated the alae of the 
 thyroid cartilage, and produced a very small col- 
 lection of matter on the outer surface of the larynx. 
 The swelling had not been perceptible through the 
 tissues over the thyroid cartilage, nor was there any 
 enlargement of the lymphatic glands from which a 
 clue to the nature of the disease might have been 
 derived. The tumour was an admirable specimen of 
 squamous-celled carcinoma. 
 
 Subglottic carcinomas tend to invade the trachea, 
 and have been noticed to become arrested in their 
 growth for a time when reaching the level of the 
 inferior true vocal cords. In a case observed by 
 Cuneo, the true vocal cords were invaded, but the 
 supraglottic area was quite free. 
 
 Whatever may be the original site of origin of a 
 laryngeal carcinoma, it tends to remain limited at its 
 commencement to one -half of the larynx; only 
 carcinoma of the epiglottis and of the arytenoid 
 region are exceptions to this rule. This limitation 
 is of considerable importance in connection with 
 operative interference. It often permits of a partial 
 instead of a total laryngectomy, with a smaller death- 
 
 2 — 2 
 
20 Malignant Disease of the Larynx 
 
 rate and a better chance of restitution of the functions 
 of the organ. 
 
 This Hmitation to one-half is, however, merely 
 temporary ; sooner or later the neoplasm tends to 
 attack the opposite side. In a few cases the opposite 
 side has become affected by contact, but usually it 
 is by direct continuous invasion. This most often 
 occurs at the level of the posterior aspect of the 
 larynx, although it has been observed to invade the 
 opposite cord through the anterior commissure 
 (B. Fraenkel, Semon). 
 
 To sum up, extrinsic carcinomas tend to grow 
 towards the superior orifice of the larynx, and often 
 cease to extend when they reach the level of the 
 glottis. Intrinsic carcinomas, if above the glottis, 
 also tend to spread towards the superior orifice of 
 the larynx, but remain localized much longer than 
 extrinsic carcinomas, especially so when the true 
 vocal cords are primarily attacked ; if below the 
 glottis, they tend to spread towards the trachea. 
 
 Finally, with the exception of cancers of the 
 epiglottis and arytenoid region, laryngeal cancers 
 remain localized for a period more or less long. 
 These rules are by no means absolute ; there are 
 many exceptions; still, they are applicable to the 
 majority of cases. 
 
 It is easy to see that the distribution of the 
 lymphatics can to a great extent explain these 
 different particulars in the local extension of malig- 
 nant disease of the larynx. 
 
 The arrest for a long time of growths reaching to 
 the inferior vocal cords is the result of the attenua- 
 
Carcinoma of the Larynx 21 
 
 tion and diminution in number of the lymphatics at 
 this point. 
 
 In extending towards the superior laryngeal orifice, 
 extrinsic epitheliomas only obey the general law 
 observable in the extension of all epitheliomas — 
 namely, a preference to follow the course of the 
 lymphatic current. 
 
 Extension of epithelioma of the epiglottis to the 
 base of the tongue finds an easy explanation in the 
 connection of the lingual lymphatic vessels with 
 those originating from the anterior surface of the 
 epiglottis. 
 
 Moreover, the continuity of the subglottic mesh- 
 work with that of the trachea gives the clue to the 
 relative facility with which subglottic epithelioma 
 descends towards the trachea. The paucity in 
 number of the lymphatics, although slight as regards 
 the superior vocal cords, but very marked at the 
 level of the inferior vocal cords, is certainly one 
 of the factors determining the slow evolution of 
 epithelioma developing in these regions. Another 
 factor worthy of note, in my opinion, is the tendency 
 to atrophy of these lymphatic radicles as old age 
 approaches. It is certainly increasingly difficult to 
 make a thorough injection of the laryngeal lymphatics 
 the older the patient on whom the injection is 
 practised; in very young children an injection is 
 much more easy to make and extensive in nature. 
 
 Finally, the abstention of involvement of the 
 opposite side of the larynx for a more or less lengthy 
 period is due to the relative independence of the 
 lymphatics of each half of the larynx. 
 
2 2 Malignant Disease of the Larynx 
 
 Like all epitheliomas, cancer of the larynx tends 
 eventually to invade the lymphatic glands. This 
 implication is the rule in late cases ; it is generally 
 particularly well marked in those cases in which a 
 palliative tracheotomy has been performed, and in 
 which the disease is too extensive for operative inter- 
 ference. 
 
 It is decidedly rare to find cases in which the 
 whole of the interior of the larynx has been destroyed 
 by epithelioma without there being the slightest 
 glandular infection. A good example of such a case, 
 however, is given by Most. 
 
 Glandular infection is, however, undoubtedly rare 
 if the growth be of intrinsic origin and limited in 
 size, especially so if attacking the anterior two-thirds 
 of the true vocal cords. 
 
 Schleier* has noted it 20 times only out of 125 
 cases ; Sendziak, 54 out of 486 cases. Other authors, 
 however, give a much higher percentage. Jurasz,t 
 9 out of 21 cases; Schwartz, 13 out of 28. All these 
 statistics have only a relative value ; they are, as 
 Cuneo points out, based on clinical observations, 
 which are often fallacious. Absence of enlarged 
 glands to palpation does not prove their being free 
 from infection. Madelung, Salzer,t etc., have found 
 cancerous cells in glands which had retained their 
 normal size and appearance. 
 
 Again, glandular enlargement in a case of laryngeal 
 carcinoma does not necessarily mean malignant 
 
 * Deuts. Med. Wochens.., \\ 
 
 t Heymann's ' Handbuch,' vol. i., p. 885. 
 
 \ Salzer, Arch.f. Kli?i. Chir., 1885, Bd. xxxi. 
 
Carcinoma of the Larynx 23 
 
 infection. Such enlargement may be due to septic 
 infection from a septic cancerous ulcer, or be inde- 
 pendent of the cancer and due to some simple septic 
 lesion of the tonsils or pharynx. 
 
 Satisfactory statistics as to glandular infection can 
 only really be arrived at by thorough microscopic 
 examination of the glands in each and every case 
 removed at the same time as the laryngeal cancer, 
 both ante- and post-mortem. Nevertheless, the 
 broad clinical fact remains that in certain cases of 
 laryngeal carcinoma involvement of the glands is 
 certain and early, in others uncertain and late. 
 
 Several causes, according to Cuneo, have been 
 brought forward to explain the early immunity of 
 the glands. 
 
 First of all, the major number of laryngeal cancers 
 are squamous-celled epitheliomata (248 out of 486 
 cases, Sendziak), and it is stated by Cuneo that this 
 variety of growth generally attacks the glands some- 
 what late. This, however, cannot be held to be 
 correct, for in epithelioma attacking the tongue or 
 tonsil very early and extensive implication of the 
 glands is the rule. 
 
 Secondly, the same authority holds the opinion 
 that cancer of the larynx tends frequently to become 
 pedunculated, and to grow into the cavity of the 
 larynx without extending much beyond the border 
 of its base of origin, and that these pedunculated 
 cancers growing into a cavity do not as a rule invade 
 the glands until a very late stage, a good example 
 being papillary carcinoma of the bladder. 
 
 Whilst admitting that a laryngeal carcinoma may 
 
24 Malignant Disease of the Larynx 
 
 become pedunculated, such an occurrence is decidedly 
 uncommon ; the general rule is to find a sessile 
 growth with early infiltration of the parts at its base 
 of origin. 
 
 Finally, if certain parts of the larynx, such as the 
 aryteno-epiglottidean folds and epiglottis, are very 
 rich in lymphatics, it is seen that in other parts, such 
 as the subglottic area, the lymphatic meshwork is 
 much less developed, and that on the true vocal 
 cords, one of the sites of election for epithelioma, 
 the lymphatics are so few in number that their 
 injection is a matter of considerable difficulty. 
 
 Is it not probable that the more or less tardy 
 appearance of glandular infection is intimately 
 connected with the site of origin of a laryngeal 
 cancer ? 
 
 ' As long as the cancer remains intrinsic,' says 
 Krishaber, * there is no cervical glandular enlarge- 
 ment ; when it is extrinsic the glands are infected.' 
 
 This statement, although too absolute, is borne 
 out by general experience. 
 
 Cuneo considers Krishaber's classification incon- 
 venient, in that it includes under the same heading 
 varieties behaving, as regards glandular infection, in 
 very different ways. Cuneo states : ' One would 
 have to admit that epitheliomas attacking the 
 superior vocal cords, which are rich in lymphatics, 
 involve the glands equally late as in epithelioma 
 attacking the inferior vocal cords, the lymphatics of 
 which are extremely few and ill -developed.' He 
 goes on to state that he has seen and collected other 
 cases showing that glandular infection occurs early 
 
Carcinoma of the Larynx 25 
 
 when the superior vocal cords are the site of origin 
 of laryngeal cancer. 
 
 In describing the anatomy of the laryngeal lym- 
 phatics, I have stated that, in the main, the results 
 of my injections were identical with those of Cuneo ; 
 yet, as regards the richness of the lymphatic network 
 in the region of the superior vocal cords, I did not 
 find myself in agreement with him. I found there 
 was a distinct tendency in a supraglottic injection 
 for the lymphatic system, as it invaded the superior 
 vocal cords, to become altered ; though the lym- 
 phatic radicles traversed the superior cords, still, they 
 were found to become more and more attenuated as 
 they reached their free border. In fact, the region 
 of the superior vocal cords was distinctly less rich in 
 lymphatics than the parts above, although richer 
 than in the region of the inferior vocal cords. 
 Again, those English laryngologists who have had 
 most experience of malignant disease of the larynx 
 do not agree with Cuneo's statement that glandular 
 infection occurs early in cancer attacking the superior 
 vocal cords; on the contrary, glandular infection is 
 met with in such cases as a rule at a late stage, 
 usually when the disease has spread to the extrinsic 
 parts of the larynx. 
 
 In my opinion, the immunity of the glands to 
 secondary infection depends mainly on the original 
 site of origin of the malignant growth. If intrinsic, 
 glandular infection is rare and only occurs late ; if 
 extrinsic, it is the rule, and occurs early. This 
 difference in the tendency to implication of the 
 neighbouring glands according to whether the disease 
 
26 Malignant Disease of the Larynx 
 
 is of intrinsic or extrinsic origin is due, in my opinion, 
 to the distribution of the lymphatics already de- 
 scribed in these two areas. 
 
 It has been amply demonstrated that the lym- 
 phatic meshwork is much less dense in the area 
 described as intrinsic than in the extrinsic area, and 
 it is to this diminution and attenuation of the lym- 
 phatic radicles in the intrinsic parts that the marked 
 immunity to early glandular infection must be 
 ascribed. 
 
 A secondary factor, as has already been pointed 
 out, probably exists in the tendency to progressive 
 atrophy, normally found, of the lymphatic system in 
 the larynges of old people, and this attenuation and 
 atrophy not only applies to the laryngeal mucous 
 membrane, but also to the lymphatic ducts that go 
 to the neighbouring glands. 
 
 Topography of the Glands attacked by Laryngeal 
 
 Carcinoma. 
 
 Bearing in mind the anatomical description already 
 given, one finds that theoretically the chain of glands 
 underneath the sterno- mastoid, the pre -laryngo- 
 tracheal, and the recurrent laryngeal group of glands 
 should show signs of infection. Special stress has 
 already been laid on the infection of the substerno- 
 mastoid chain ; all the glands included between the 
 posterior belly of the digastric muscle and the 
 clavicle may become infected in cases of malignant 
 disease of the larynx. There is nothing especially 
 characteristic in their mode of invasion. Infected 
 
Carcinoma of the Larynx 27 
 
 and broken-down glands are frequently found ad- 
 herent to the vasculo- nervous sheaths; they are 
 usually independent of the larynx itself, although 
 in some cases they have been found to be incor- 
 porated with that organ. 
 
 Cuneo has seen a case in w^hich there was a direct 
 extension of the growth formed by a much-thickened 
 superior lymphatic duct which pierced the thyro- 
 hyoid membrane, and eventually became lost in a 
 general glandular mass in the neck. 
 
 Infection of the pre-laryngeal glands is fairly rare. 
 Most, however, has seen a few such cases. 
 
 Instead of occupying the border of the crico-thyroid 
 membrane, the infected gland may be found placed 
 over the middle of the thyroid cartilage (Maas*) or 
 even its superior depression (Zeisslt). There seems 
 to be no record of infection of the pre-tracheal glands. 
 Jurasz and Fraenkel have seen the glands of the 
 recurrent chain involved by cancer. Bergeat,;!; 
 Maurer,§ and Most have also recorded similar cases ; 
 but in all the verification has been post-mortem, as 
 enlargement of these glands, owing to their small 
 size and depth, cannot be recognised clinically. 
 
 It was also at a post-mortem examination that 
 Zeissl found a case of involvement of the retro- 
 oesophageal glands. The order in which these 
 different groups of glands become infected varies 
 according to the initial seat of origin of the laryngeal 
 
 * Maas, Arch.f. Klin. Chir.^ Bd. xix. 
 
 t Zeissl, Wiener Med. Presse, 1881, No. 44. 
 
 % Bergeat, Monatschr. f. Ohrenheilk.., 1895, P- 368- 
 
 § Maurer, Berli)i Klin. Wochens., 1882, Nos. 26, 27. 
 
2 8 Malignant Disease of the Larynx 
 
 growth. When the disease is of extrinsic origin, 
 glandular infection is most likely to occur in the 
 upper glands of the sterno-mastoid chain. When 
 intrinsic and above the glottis, the gland, which is 
 first found to be enlarged (according to Schwartz), 
 is placed at the level of the anterior border of the 
 sterno-mastoid muscle, about the height of the space 
 which separates the hyoid bone from the thjToid 
 cartilage ; if subglottic in origin, the lowermost 
 glands of the same chain are generally the first to be 
 attacked. 
 
 Bearing in mind, however, the many ways in 
 which the lymphatic vessels draining the area in 
 question may terminate, these rules obviously have 
 many exceptions. 
 
 Infection of the pre-laryngo- tracheal and recurrent 
 chains implies disease attacking the subglottic region. 
 Inversely, in cases of growths strictly limited to the 
 extrinsic area and regions of the true and false vocal 
 cords, these glands remain free. 
 
 In one case of extrinsic carcinoma Cuneo was 
 able to prove microscopically the absolute immunity 
 of the pre-laryngeal glands, although the glands 
 appertaining to the extrinsic area were so infected 
 by carcinoma as to form a mass as large as one's fist. 
 So long as one-half of the larynx only is affected, the 
 glands only on that side are infected. 
 
 Most and Roubaud were unable to find a record 
 of any case in which a unilateral laryngeal carcinoma 
 had caused involvement of the glands on both sides. 
 This agrees with the results of experimental research 
 and of the pathological anatomy of the parts ; for it 
 
Carcinoma of the Larynx 29 
 
 has already been pointed out that an injection of the 
 lymphatics of one-half of the larynx, although oc- 
 casionally able to cross the median line, never 
 penetrates the lymphatic radicles of the opposite 
 side. 
 
 Dissemination. 
 
 There is no matter of doubt that dissemination in 
 malignant disease of the larynx is extremely rare. 
 Out of eighteen or nineteen post-mortems for carci- 
 noma of the larynx mentioned in Butlin's mono- 
 graph, dissemination of the disease was recorded 
 only in three instances. One of these was reported 
 by Sands,* another by Desnos, t the third by 
 Schiffers.t 
 
 In the first case, that of a woman aged thirty, the 
 tumour was confined to the left vocal cord. The 
 symptoms commenced in September, 1862. Laryn- 
 gotomy was performed in January, 1865 — more than 
 two years and a quarter, therefore, after the com- 
 mencement of the disease There was no affection 
 of the glands of the neck, but the lumbar glands were 
 enlarged, and the left suprarenal capsule, the left 
 kidney, and ureter were extensively diseased. 
 
 In the second case, that of a man whose age is not 
 recorded, the tumour arose in the left aryepiglottic 
 fold, and extended down to the ventricular band. 
 There was a large glandular tumour at the base of 
 the neck occupying the sheath of the sterno-mastoid 
 
 * New York Medical J ourjtal^ 1865, p. no. 
 
 f Bull. Soc. Anat., 4th series, vol. iii., p. 398, 1878. 
 
 X Rev. Mens, de Laryngologie^ 1883, p. i. 
 
30 Malignant Disease of the Larynx 
 
 muscle, and one small mass of carcinoma was em- 
 bedded in the middle of the right lobe of the liver. 
 It is difficult to calculate the exact duration of the 
 disease from the report, but it had probably existed 
 for more than one and for less than two years. 
 
 The third patient was a man fifty-three years old, 
 who was first attacked with hoarseness during March, 
 1 88 1, and who died a few^ days before Christmas. 
 The entire left half of the larynx was diseased, but 
 the tumour w^as thought to have taken its origin in 
 the false vocal cord. The glands along the course 
 of the jugular vein were extensively affected, and the 
 lungs contained man}' secondary nodules, varying in 
 size from a pin's head to a nut. No operation had 
 been performed. 
 
 It is well worthy of note that the tumour in all 
 these cases was a well-marked specimen of squamous- 
 celled carcinoma (epithelioma). 
 
 Other cases have been recorded — for instance, 
 Isambert has recorded a case of epithelioma of the 
 larynx, with carcinoma of the prepuce. Cadier, a case 
 of epithelioma of the interarytenoid space in a patient 
 who had been operated on three years previously for 
 carcinoma of the breast. Thiersch has recorded a 
 case similar to Schiffers. Schmidt has seen a case 
 of cancer of the larynx after carcinoma of the breast. 
 Poucet, a case of carcinoma of the frontal bone in a 
 patient with carcinoma of the right aryepiglottic fold. 
 Mericamp, a case of carcinoma of the left aryepi- 
 glottic fold and cricoid, contemporaneous with carci- 
 noma of the liver. Latil, a case of cancer of the 
 liver together with cancer of the false vocal cord. 
 
Carcinoma of the Larynx 31 
 
 Bronner also has recorded a case of cancer of the 
 epiglottis with metastasis in the liver and lungs, and 
 Grayson a case of cancer of the larynx with epithe- 
 lioma of the lip. Kocher, a man, fifty-nine years 
 of age, who died two years after partial resection of 
 the larynx. There was no local recurrence, but 
 carcinoma of the abdominal cavity was found post- 
 mortem. 
 
 Pinner-Schmidt mentions a case of a woman, 
 forty-seven years of age, in whom partial laryngec- 
 tomy was performed for cancer of the larynx. The 
 patient died seven years later of cancer of the 
 stomach. It is a question whether in this patient 
 the cancer of the stomach was a fresh outbreak of 
 the disease or a secondary growth of slow progress. 
 
 Schmiegelow, again, removed half the larynx in 
 a female aged forty -six, who was suffering from 
 carcinoma. She died ten months later of carcinoma 
 of the stomach. There was no local recurrence. 
 
 Morian performed a similar operation on a male 
 aged forty - seven, who died seven weeks later. 
 Secondary growths were found in the lungs. There 
 w^as no local recurrence. 
 
 Wolff performed total laryngectomy in a male 
 aged forty-one. The patient died two and a half 
 years later with secondary growths in the bones and 
 lungs. 
 
 Both Schrotter and Fauvel, men of wide experience 
 in laryngology, have not seen a single case of metas- 
 tasis, and Morell Mackenzie only once came across 
 such a condition in his practice. 
 
 It is surely a remarkable circumstance that dis- 
 
32 Malignant Disease of the Larynx 
 
 semination should occur so rarely of a disease which 
 in many instances produces death slowly, and has, 
 therefore, ample time to become generalized. And it 
 is still more remarkable that in the few cases in 
 which dissemination is actuall}^ known to have 
 occurred the abdominal viscera rather than the lungs 
 were affected (abdominal viscera, 8 cases ; lungs, 
 4 cases; both regions, i case). 
 
 It has elsewhere been pointed out* that carcinoma 
 of the oesophagus apparently only affects the lungs 
 under what may be termed very favourable condi- 
 tions — when, for example, fragments of a tumour 
 which has penetrated into the air-passages are carried 
 into the terminal or almost terminal bronchial tubes. 
 Here, however, is a disease situated generally im- 
 mediately over or within the entrance to the air- 
 passages, therefore, as one might suppose, constantly 
 furnishing fragments which are carried into the lungs 
 with the inspired air, yet scarcely under any condi- 
 tions obtaining a hold upon them. The rule is the 
 same not only for the squamous-celled carcinomas, 
 which we are, most of us, inclined to regard as little 
 liable to dissemination, but also for the spheroidal- 
 celled carcinomas, which in the larynx, as in other 
 parts, are sometimes very soft and cellular, and 
 therefore of the kind most given to dissemination. 
 
 There are, of course, some conditions which may 
 possibly be regarded as modifying the conclusions 
 which have been drawn from post-mortem examina- 
 tions. In the first place, death has resulted directly 
 from operation in many cases, and although the 
 * Butlin, ' Sarcoma and Carcinoma.' 
 
Carcinoma of the Larynx ;^;^ 
 
 disease in many of these lasted for a long time, it 
 may fairly be said that its natural course was cut 
 short. 
 
 In the second place, although the disease was 
 situated over the entrance to the air-passages, and 
 fragments were liable to be sucked in during inspira- 
 tion, tracheotomy was performed in several instances, 
 and this danger, therefore, to a certain extent was 
 averted. In many cases, however, in which an 
 autopsy was made no operation had been performed ; 
 and even in those cases in which the trachea had 
 been opened there was nothing to prevent dissemina- 
 tion through the circulation, by far the most frequent 
 medium for the dissemination of malignant disease 
 generally. It is certainly most difficult to under- 
 stand why a malignant disease situated in so 
 important an organ should be so little given to dis- 
 semination. It is the more difficult to understand 
 because experience shows that carcinoma of the 
 larynx is in other respects a very malignant disease, 
 and has been until quite recent times very little 
 amenable to radical treatment. 
 
 Histological Structure. 
 
 All authorities agree that epithelioma is the variety 
 of cancer that attacks the larynx the most frequently. 
 Encephaloid (carcinoma medullare), scirrhus, and 
 cylindrical - celled carcinomas have all been met 
 with in the larynx, but are, especially the last two 
 varieties, exceedingly rare. 
 
 Schwartz, out of 103 cases of laryngeal cancer, 
 
 3 
 
34 Malignant Disease of the Larynx 
 
 found 54 to be epithelioma ; Schrotter, out of 20 
 cases, 17 ; Ziemssen, out of 68 cases, 57. Sendziak 
 notes 248 cases in his statistics, and Semon, out of 
 103 cases, 40 epithehomas. 
 
 Cyhndrical or columnar-celled carcinoma appears 
 to be exceedingly rare. Only a few cases are to be 
 found in the literature of the subject. It is some- 
 what surprising that columnar-celled carcinoma is 
 not more common in the larynx, for the origin of the 
 disease is by no means limited to those tracts of the 
 mucous membrane which are covered with squamous 
 epithelium. 
 
 Apparently the influence which suffices during 
 health to maintain the normal relation between the 
 two varieties of epithelium, confining each variety to 
 its particular areas, and suffering neither to intrude 
 upon the other, disappears under pressure of disease, 
 and the squamous epithelium, being, as it were, the 
 stronger and more enduring variety, impresses its 
 form upon the elements of the cancer, which thus 
 becomes a squamous-celled carcinoma. 
 
 SYMPTOMS. 
 
 The symptoms of carcinoma of the larynx, especi- 
 ally in the early stages, depend to a certain extent, as 
 might be expected, on the situation of the growth. 
 There is no one symptom that is absolutely diagnostic 
 of the disease. 
 
 The intrinsic growths usually commence with 
 hoarseness and occasionally slight cough, symptoms 
 
Carcinoma of the Larvnx 35 
 
 which indicate a laryngeal catarrh rather than a 
 more serious affection. 
 
 Considerable importance, however, attaches to this 
 hoarseness. It is frequently the only symptom of 
 early malignant disease involving the true vocal cords 
 or anterior commissure, and may last as long as a 
 year without any other evidence of malignant disease 
 presenting itself. 
 
 A most careful laryngoscopic examination should 
 always be made in any middle-aged patient who 
 complains of obstinate hoarseness of any appreciable 
 duration, even if there be no other symptom of any 
 kind. 
 
 As the disease advances and ulceration supervenes, 
 the hoarseness increases, and the voice may eventually 
 be entirely lost. The extrinsic growths, especially 
 those of the epiglottis and arytenoids, more often 
 produce dysphagia than hoarseness, and it is not 
 until the disease is far advanced and the intrinsic 
 muscles or cartilages are involved that vocal and 
 respiratory troubles are observed. 
 
 Involvement of the neighbouring glands and 
 pressure on the recurrent laryngeal nerves, or dis- 
 placement of the arytenoid cartilages, will, when 
 present, affect the voice in extrinsic carcinoma. 
 When the cricoid plate is primarily affected, early 
 and extensive involvement of the neighbouring glands 
 is the rule. 
 
 Difficulty and pain in swallowing, the secretion 
 of frothy and blood-stained mucus, are also early 
 symptoms of carcinoma of the cricoid plate. Involve- 
 ment of the glands under the angle of the jaw, and 
 
 3—2 
 
J 
 
 6 Malignant Disease of the Larynx 
 
 subsequently along the whole length of the sterno- 
 mastoid, soon follows, and as the growth increases in 
 size, not only does the dysphagia increase, but 
 dyspnoea becomes marked and urgent. The dyspncea 
 is due to involvement of the muscular substance of 
 the posterior crico-arytenoid muscles and their sub- 
 sequent myopathic paralysis, with gradual narrowing 
 of the glottis (Semon). 
 
 Again, pain is a symptom which belongs especially 
 to extrinsic tumours, although it is by no means 
 unknown in cases of intrinsic tumour. The pain is 
 sometimes peculiarly severe, and is not limited to the 
 larjmx or even to the parts around, but radiates over 
 the whole of the neck on the affected side and is 
 frequently complained of in the ear, resembling in 
 these respects the referred pain in cases of toothache 
 and of hip disease. 
 
 In some of the cases of intrinsic carcinoma no pain 
 is experienced during the whole course of the disease ; 
 in other cases, although the pain is not spontaneous, 
 it is produced by swallowing or speaking. 
 
 The radiating pains to the ear are, however, very 
 characteristic of malignant disease, and are not so 
 frequently noted in other affections of the larynx. 
 They are probably due to irritation of the fibres of 
 the superior lar}''ngeal nerve by the growth ; this 
 irritation is referred to the auricular branch of the 
 pneumogastric nerve, and thus pain is felt in the ear. 
 In a few cases local tenderness on pressure has been 
 present. 
 
 Expectoration is in some cases very abundant, 
 but it is rarely so unless the growth is deeply ulcerated 
 
Carcinoma of the Larynx '^^'j 
 
 or extensive. The sputa are at first usually frothy, 
 but later become purulent, and may be stained or 
 streaked with blood ; there may be considerable 
 fcetor of a sickly, musty odour and cough, especially 
 in the later stages, from breaking down of the 
 malignant masses. Sometimes a fragment of the 
 growth or even of the cartilages of the larynx is 
 coughed up. 
 
 Haemorrhage is an unusual symptom, and scarcely 
 ever occurs unless the disease has extended to the 
 tongue or neighbouring vessels, but few fatal cases 
 are recorded as actually resulting from haemorrhage. 
 In one the base of the tongue was extensively 
 affected, and in four or five others repeated bleedings 
 hastened, although they did not actually produce, 
 the fatal result (Tiirck, Dreyfuss, Desnos, Maydl). 
 
 Dyspncea. — Occasional attacks of dyspnoea show 
 that the gravity of the disease has been underrated. 
 It usually at first shows itself on exertion, and is 
 generally due to direct obstruction by the tumour, 
 although infiltration and consequent weakness of the 
 intrinsic laryngeal muscles plays an important part. 
 Later on in the progress of the disease there may be 
 very severe paroxysms of dyspnoea due to glandular 
 pressure on, or involvement of, the laryngeal nerve 
 or trachea, in other cases to oedema or stenosis of 
 the glottic aperture. 
 
 Dysphagia has already been referred to as an 
 early symptom when the site of the disease is the 
 epiglottis or arytenoid region. It is uncommon in 
 cases of carcinoma of the true or false vocal cords. 
 Scheier in 102 cases noted its presence in only 15 
 
38 Malignant Disease of T£iE Larynx 
 
 cases, and in each of these there was ulceration 
 present. 
 
 In a few rare cases the symptoms are from the 
 very first those of perichondritis (pain, fever, dys- 
 phagia, and alteration of the voice), and in such cases 
 errors of diagnosis are likely, the disease tending to 
 be mistaken for tubercle or syphilis of the larynx. 
 
 Cachexia is far less common than in carcinoma 
 attacking other parts of the body ; it is especially 
 infrequent in intrinsic carcinoma. When the growth 
 is of extrinsic origin and the neighbouring glands 
 have become involved cachexia may supervene, but 
 even in these cases it does not become marked until 
 the disease has reached a very advanced stage. 
 
 This comparative immunity to cachexia is in 
 accordance with the rarity of dissemination of the 
 disease, and is probably attributable to the lymphatic 
 isolation of the larynx already referred to under 
 Pathology. 
 
 SIGNS. 
 
 The appearance of the disease as seen by the 
 laryngoscope varies somewhat according to its situa- 
 tion. 
 
 Carcinoma of the epiglottis sometimes appears 
 as a destructive ulceration, but more frequently it 
 presents itself as a distinct and nodular tumour of a 
 grayish or pinkish white colour, which may be 
 limited to the epiglottis, or may extend to the base 
 of the tongue, the lateral walls of the pharynx, 
 oesophagus, or to the aryepiglottic folds. The 
 
Carcinoma of the Larynx 39 
 
 affected part is from an early stage seen to be fixed, 
 and if the finger be inserted into the mouth the epi- 
 glottis will be felt to be hard to the touch. The 
 primary tumours of the arytenoids and the ary- 
 epiglottic folds are generally masses of considerable 
 size, and present the same outward characters, 
 whether they are squamous-celled or sphenoidal-celled 
 carcinomas. 
 
 If ulceration is present, the ulcer is characterized 
 by its irregular crateriform shape, its heaped-up 
 everted edges, its foul sanious discharge, and by the 
 very early immobility of the part affected. Fungating 
 granulations of a reddish colour sprout up, and may 
 be seen one day and be found to have almost dis- 
 appeared the next. When the perichondrium be- 
 comes involved considerable oedema may be present 
 surrounding, and possibly obscuring, the original 
 growth. 
 
 If the disease presents as a distinct mass or 
 masses, it may at first resemble simple papillomata. 
 The tumour, however, in malignant disease has a 
 broader base, is of firmer consistency, and tends 
 early to deep infiltration of the neighbouring parts. 
 
 Malignant disease of the ventricular bands may 
 appear as a unilateral tumefaction, as a general 
 infiltration pinkish or reddish in colour, with a 
 coarsely mammillated uneven surface, or may present 
 itself as a definite tumour, sessile, solitary, dusky-red 
 in colour, sometimes smooth, but more often ir- 
 regular in shape, and frequently closely resembling 
 a wart in appearance. 
 
 On the vocal cords carcinoma in the early stages 
 
40 Malignant Disease of the Larynx 
 
 may present itself as (a) a unilateral congestion or 
 swelling, the unilateral character of the swelling 
 being always suggestive of commencing malignancy; 
 (b) as an infiltrating growth of a reddish and uneven 
 surface, and no tendency to limitation ; (c) as a 
 single reddish or pinkish sessile growth, sometimes 
 ulcerated, and very like a papilloma, more rarely a 
 fibroma, in character. 
 
 If the growth be pedunculated, the similarity to a 
 papilloma or fibroma becomes more marked. In a 
 case observed by Semon the papillomatous appear- 
 ance of a small epithelioma was masked by a large 
 blood-clot which had formed round the papillomatous 
 excrescences, the new growth being taken by several 
 observers for an angioma. 
 
 A zone of circumscribed hypersemia surrounding a 
 malignant new growth is not by any means infre- 
 quent, and is particularly noticeable when the growth 
 occupies the mid region of the vocal cord, the 
 anterior and posterior parts of the cord standing out 
 a brilliant white, in marked contrast to the hyper- 
 yemic area. 
 
 Here, again, in growths or infiltrations attacking 
 the true vocal cords, and of a malignant nature, 
 impairment of mobility of the vocal cord becomes a 
 sign of the greatest importance, and is again referred 
 to more fully under Differential Diagnosis. Malignant 
 disease of the larynx is usually insidious in its onset, 
 extending somewhat slowly, yet surely, at first. 
 Later on it advances rapidly, growing in size and 
 invading the neighbouring parts of the larynx. Car- 
 cinoma commencing on one of the true or false vocal 
 
Carcinoma of the Larynx 41 
 
 cords is somewhat liable to spread to the fellow cord 
 on the opposite side. 
 
 Whether the disease be squamous or spheroidal- 
 celled, it generally presents the same outward 
 characters, so that it is rarely possible to tell from 
 the macroscopic characters to which variety it 
 belongs. 
 
 Ulceration is very common, almost as much so of 
 the spheroidal-celled as of the squamous-celled carci- 
 nomas. The time within which ulceration becomes 
 apparent is liable to considerable variation in indi- 
 vidual cases. Sometimes it is seen within three or 
 four months from the onset of the disease, in other 
 cases ulceration may be delayed for a much longer 
 period, even for so long as a year and a half from the 
 commencement of the disease. In many cases the 
 destruction and resulting deformity and displacement 
 is very great, and constitutes a most striking character 
 of the disease. 
 
 In the later stages, whether the disease be of 
 intrinsic or extrinsic origin, the entire larynx is liable 
 to become involved. The tumours which arise 
 within the larynx occupy the whole of the cavity, 
 and when involving the cartilaginous framework 
 marked broadening and tenderness of the larynx may 
 be seen and felt. Sometimes the growth perforates 
 the cartilages or passes between them, invading 
 rapidly the surrounding muscles, and finally present- 
 ing as a fungating mass through the skin. 
 
 The tumours which arise in the outer portions of 
 the larynx pass down the sides and into the cavity, 
 and destroy large pieces of the cartilage and mucous 
 
42 Malignant Disease of the Larynx 
 
 membrane. When once the disease has reached the 
 stage in which the whole larynx is more or less 
 involved, and transformed into a mass of broken- 
 down ulcerating tissue, with prominent exuberant 
 masses of granulations, and in most cases glandular 
 involvement, there can usually be no difficulty in 
 diagnosis. Unfortunately, in this stage but little, if 
 anything, can be done for the patient. 
 
 It is of importance to remember that it is some- 
 times impossible to limit from the laryngoscopic 
 picture the extent of the disease present. Even when 
 the growth forms a mass as large as a nut or larger, 
 it may be so situated that only its upper surface is 
 visible on laryngoscopic examination. 
 
 If left to pursue its course, malignant disease of 
 the larynx usually ends fatally within three years of 
 its appearance. With progressive emaciation the 
 patient becomes feebler and feebler and dies. In 
 some cases an intercurrent affection such as bron- 
 chitis or * foreign body ' pneumonia, due to the 
 inhalation of secretion or particles of the growth or 
 food, ends the scene. In others a fatal termination 
 results from sudden or repeated hsemorrhages, dysp- 
 noea, or severe dysphagia. 
 
 DIAGNOSIS. 
 
 The diagnosis of an advanced carcinoma is in 
 most instances very easy. The extensive ulceration, 
 the implication of several structures, the destruction 
 wrought by the disease, the steady progress of the 
 symptoms, the radiating pain and pain in the ear. 
 
Carcinoma of the Larynx 43 
 
 and (in cases of extrinsic cancer) the enlargement of 
 the lymphatic glands, exclude all doubt of the malig- 
 nant nature of the malady. But in the earlier 
 stages the diagnosis is often beset with difficulties, 
 and may be impossible. 
 
 The principal points to lay especial stress on in 
 early malignant disease of the larynx are the age and 
 sex of the patient, the symptoms, especially that of 
 hoarseness without obvious cause, and the presence 
 or absence of any constitutional diathesis, the laryn- 
 goscopic appearances, and whenever possible the 
 removal and examination microscopically of a frag- 
 ment or fragments of the growth by a skilled 
 pathologist. 
 
 If too small or too superficially extirpated frag- 
 ments be examined, mistakes may be made. When a 
 fragment has been removed for microscopic examina- 
 tion, several sections should be cut and carefully 
 examined. If no evidence of malignancy be found, 
 it is advisable, if the clinical symptoms justify it, to 
 remove a further and deeper part of the growth and 
 subject it to a similar careful examination. 
 
 Cases are on record of tumours partaking of a 
 mixed character — i.e., papilloma and carcinoma 
 (Semon) being present in the larynx. 
 
 It is important to bear in mind that a negative 
 verdict by the pathologist is not sufficient to set 
 aside clinical appearances when they are markedly 
 suggestive of a malignant type. It devolves on the 
 surgeon in such cases to have the courage of his 
 own opinion, and to be prepared to form a definite 
 diagnosis from clinical signs alone. 
 
44 Malignant Disease of the Larynx 
 
 A differential diagnosis has to be made from 
 inflammatory diseases, benign laryngeal tumours, 
 pachydermia laryngis, syphilis, tubercle, lupus, laryn- 
 geal paralyses and perichronditis. From chronic 
 laryngitis malignant disease, if associated with marked 
 hyperaemia, can usually be diagnosed by its unilateral 
 character, the contrast if a vocal cord be affected 
 with the normally white one being very marked. 
 
 At the same time it is well to remember that cases 
 have occurred, although rarely, in which apparently 
 simple bilateral congestion of the vocal cords has 
 preceded malignant disease ; the possibility, therefore, 
 of malignancy should be borne in mind if an appar- 
 ently simple chronic laryngitis, even though bilateral, 
 does not yield to its usual remedies (Semon). 
 
 As time goes on a most important sign becomes 
 noticeable — namely, sluggishness of movement of 
 the affected vocal cord, ' impaired mobihty.' This 
 impaired mobility is often present at a very early 
 stage of the disease, but naturally varies according 
 to the situation of the disease. For instance, in 
 cases where the origin of the growth is the ventricle 
 of Morgagni, the cord on the affected side may be 
 entirely covered by the mass, but yet be quite free in 
 its movements. 
 
 This sign, to which Semon was the first to draw 
 attention, is of great diagnostic importance, and has 
 been but little understood and valued on the Con- 
 tinent. In England its value has been fully appre- 
 ciated, and has certainly helped enormously in correct 
 diagnosis of early malignant disease of the vocal 
 cords. Of this sign Semon ('Encyclopaedia Medica') 
 
Carcinoma of the Larynx 45 
 
 says : ' The value of this sign, to which I was the first 
 to draw attention, has been repeatedly decried, and 
 my utterances on this subject have been curiously 
 misunderstood by some Continental authors. I wish, 
 therefore, to declare as plainly as possible that I 
 neither believe such impairment of mobility to be 
 present in every case of early malignant disease of the 
 vocal cords, nor that its absence in any way militates 
 against the disease being malignant. All I contend 
 is that if in the case of a doubtful growth springing 
 from a vocal cord — and not only when the growth is 
 situated near the crico-arytenoid articulation, but 
 even in the anterior part of the vocal cord — an 
 impairment of mobility — i.e., some sluggishness of 
 the movements of the affected cord — is observed, this 
 is a most valuable sign, pointing to the malignant 
 nature of the affection.' 
 
 From benign laryngeal tumours (papilloma, fibroma, 
 cysts), the presence or absence of infiltration, the age 
 of the patient, and the plurality of the growths are 
 among the most important points to determine. It 
 is also of great importance to note the site of the 
 growth. A malignant neoplasm may grow from any 
 part of the vocal cord, but most frequently arises 
 from the middle or posterior third of the vocal cord ; 
 when a growth is seen to originate in these situations 
 in a patient over fifty years of age it is always to be 
 looked upon as suspicious, and is not the usual seat 
 of origin of benign papilloma. 
 
 It is especially the differential diagnosis between 
 papillomata and malignant disease that is often so 
 difficult. Besides the points already referred to, the 
 
46 Malignant Disease of the Larynx 
 
 mobility and more circumscribed appearance of the 
 papilloma, together with its consistency, the younger 
 age of the patient, the length of time the disease has 
 existed, and the free mobility of the vocal cord or 
 cords are the main signs to be guided by. 
 
 Usually, too, the papillae in the benign growth are 
 much longer and coarser than in a warty carcinoma, 
 their tips are rounded instead of pointed, and if the 
 colour of the tumour be snowy white instead of a 
 pinkish colour, as is usual in laryngeal papilloma, 
 there is still further corroborative evidence of the 
 malignant nature of the growth. 
 
 In fibroma the tumour is generally of globular 
 shape, does not tend to ulcerate, and when growing 
 from a vocal cord, however large it may tend to 
 become, never causes any impairment of mobility of 
 the cord ; whereas in malignant disease, even if the 
 growth be semiglobular in form to begin with, it 
 tends to become mammillated, to ulcerate, and to 
 cause impairment of mobility of the affected vocal 
 cord. If after removal of an apparently innocent 
 growth rapid recurrence takes place or a dirty, 
 sloughy ulcer is left, malignant disease is to be sus- 
 pected, especially if the patient be beyond middle 
 age. 
 
 From Pachydermia laryngis {Pachydermia verucosa 
 of Virchow) the diagnosis is made by the typical 
 appearance presented by the latter disease — namely, 
 in the early stages symmetrically-placed wart-like 
 growths occupying the posterior third of the vocal 
 cords or interarytenoid space, and in the later stages 
 the crateriform depression at the top of one tume- 
 
Carcinoma of the Larynx 47 
 
 faction with a corresponding elevation on the other. 
 Moreover, the cords remain freely movable, there is 
 very much less hoarseness than in malignant disease, 
 and there is usually a well-marked history of chronic 
 alcoholism. From syphilis of the larynx, especially 
 when the latter presents itself in an ulcerative form, 
 the diagnosis is often replete with difticulties, and 
 particularly so, as cases of the two diseases being 
 present together have been recorded (Hunter, Mac- 
 kenzie). 
 
 There is generally a marked absence of pain in 
 syphilitic ulcerations of the larynx, and the ulcers 
 that form as a result of the breaking down of 
 gummata are usually sharply cut out and depressed, 
 and extend rapidly, at first, from the centre to the 
 periphery. Their base generally shows a more or 
 less typical wet chamois-leather-like slough. If the 
 syphilitic ulcer be solitary, it rarely becomes as large 
 in size as a carcinomatous one. Later on cicatriza- 
 tion with, possibly, extensive deformity and stenosis 
 results. 
 
 In other cases a diffuse infiltration attacks the 
 epiglottis, vocal cords, or interarytenoid fold. The 
 extent of the infiltration and the absence of any 
 distinct growth are usually sufficient to prevent a 
 diagnosis of malignant disease being made. 
 
 Other manifestations of syphilis may be present. 
 At any rate, in cases of doubt, even when syphilis is 
 not suspected, it is a good rule to administer iodide 
 of potassium 10 grains internally, and to gradually 
 increase the dose to 30 grains three times a day. 
 Careful note should be made of any changes in the 
 
48 Malignant Disease of the Larynx 
 
 size or extent of the ulcers or infiltration, for it 
 should be remembered that an apparent improve- 
 ment may follow on the administration of iodide of 
 potassium in malignant disease, due not to any 
 effect on the growth itself, but to resorption of the 
 surrounding inflammatory oedema. This improve- 
 ment is, of course, only temporary. 
 
 From tubercle, as a rule, the diagnosis is easy, yet 
 there are many cases in which it is extremely difficult 
 to give a definite opinion. Patients suffering from 
 tuberculosis of the larynx are usually of a younger 
 age than those attacked by malignant disease. The 
 affection is generally bilateral — in malignant disease, 
 at any rate — in its earlier stages unilateral. There is 
 more or less actual tumour formation in tuberculosis, 
 and the ulcers that form are generally multiple, 
 superficial, and of a ' mouse-nibbled ' appearance at 
 the edges. CEdema and pallor of the surrounding 
 parts, especially of the epiglottis and arytenoids, are 
 usually well marked, and the condition of the lungs 
 and sputa on examination will generally give corro- 
 borative evidence. Cases have, although rarely, been 
 published in which carcinoma of the throat has 
 co-existed with general phthisis (Wolfenden). 
 
 From lupus, the youth of the patient, the very slow 
 progress of the disease, the resulting cicatrization and 
 deformity, the absence of pain, and the presence of 
 the same disease in other parts, as the pharynx or 
 skin, render the differential diagnosis sufficiently 
 easy. From various forms of paralysis difficulties in 
 differential diagnosis are not likely to occur. 
 
 Semon, however, has seen two cases in which the 
 
Carcinoma of the Larynx 49 
 
 appearances were absolutely those of bilateral ab- 
 ductor paralysis, the vocal cords lying close to one 
 another in the mid-line of the larynx. The subse- 
 quent history proved that this appearance was due to 
 subglottic malignant disease, in one case to an epi- 
 thelioma, in another to sarcoma. 
 
 PROGNOSIS. 
 
 There can be no manner of doubt that the prog- 
 nosis of any given case of carcinoma of the larynx 
 varies very greatly according to (a) the original site 
 of the growth ; (6) the period at which the disease 
 comes under observation ; (c) the general health of 
 the patient. 
 
 There is nothing more remarkable in the recent 
 operative work on cancer generally than the results 
 obtained by radical operation in certain cases 01 
 cancer of the larynx. If the disease be of intrinsic 
 origin, limited in extent — that is to say, seen and 
 diagnosed in an early stage — the patient not too old, 
 and in fairly good general health, and willing to 
 undergo immediate operation, the very best results 
 may be anticipated with safety. At any rate, in 
 England such cases operated on almost entirely, be 
 it said, by thyrotomy, have resulted within recent 
 years in lasting cures exceeding 80 per cent. Such 
 results speak for themselves. 
 
 By contrast, however, the prognosis becomes 
 increasingly grave in cases where the disease, 
 although of intrinsic origin, has become very exten- 
 
 4 
 
50 Malignant Disease of the Larynx 
 
 sive ; when the lymphatic glands have become in- 
 volved, the patient is old and his general health bad. 
 The prognosis is always grave in cases of extrinsic 
 origin by virtue of the early lymphatic involvement, 
 and especially so in carcinoma affecting the cricoid 
 plate. Nevertheless, it must be remembered that 
 recent improved methods of operation have even in 
 these bad cases given some exceptionally good 
 results, notably at the hands of Gluck, of Berlin, 
 although the patients are of necessity subjected to 
 loss of the whole larynx, and a consequent very 
 pitiable after-condition. 
 
 TREATMENT. 
 
 The treatment of carcinoma of the larynx may 
 best be discussed under two headings : 
 
 1. Radical treatment by operation. 
 
 2. Palliative treatment. 
 
 Radical Treatment. 
 
 Methods of Operation — (i) Endolaryngeal Re- 
 moval. — Although removal of the disease, whether 
 sarcoma or carcinoma, per vias naturales has in a 
 few instances been attended with brilliant results, this 
 method should only exceptionally be resorted to. 
 It is undoubtedly founded on wrong surgical prin- 
 ciples. As in malignant disease elsewhere, malignant 
 disease is from the beginning of an infiltrating nature, 
 and for its extirpation it is essential that a sufficiently 
 
Carcinoma of the Larynx 51 
 
 wide area of the surrounding healthy tissues be 
 removed with the growth. This can but rarely and 
 with no degree whatever of certainty be accomplished 
 by endolaryngeal operations. Moreover, it is a well- 
 known fact that the infiltration in malignant disease 
 is nearly always of much greater extent than would 
 have been thought from the laryngoscopic examina- 
 tion. 
 
 The class of cases in which it may be employed 
 are those in which the disease is found to be very 
 limited and quite on the edge of the vocal cord, and 
 in which extreme old age or very serious impairment 
 of the health preclude an external operation, or in 
 which the patient refuses any external operation. 
 
 The uncertainty of the method, the probability 
 that the disease will not be sufficiently removed, and 
 the possibility of irritating a very mdolent disease 
 and exciting it to rapid and dangerous growth, must 
 all be taken into account in concluding to attempt 
 the removal of malignant disease of the larynx 
 through, the mouth. 
 
 (2) Suprathyroid Laryngotomy (subhyoid pharyn- 
 gotomy). — This operation has been performed occa- 
 sionally in cases where the malignant growth has 
 been situated at the upper opening of the larynx, par- 
 ticularly in connection with the epiglottis. Butlin, 
 however, is strongly of opinion that all growths 
 occupying the sides and back of the larynx can be 
 more thoroughly exposed and removed by division 
 of the thyroid cartilage (laryngo-fissure — thyrotomy) 
 than by suprath3Toid laryngotomy, and that the 
 epiglottis can be better dealt with by thyrotomy. 
 
 4—2 
 
52 Malignant Disease of the Larynx 
 
 The operation of suprathyroid laryngotomy is carried 
 out by making a transverse incision through the 
 thyro-hyoid membrane along the lower border of the 
 hyoid bone; the incision divides the skin, superficial 
 fascia, inner half of the sterno-hyoid and thyro-hyoid 
 muscles, the membrane itself, and the mucous mem- 
 brane between the base of the tongue and the 
 epiglottis. 
 
 The epiglottis is now seized and brought out 
 through the wound, and the growth removed in 
 such a manner as appears most suitable to the 
 individual case. The length of the incision and the 
 structures which are divided vary according to the 
 size and situation of the tumour. 
 
 There is little if any haemorrhage, the vessels 
 wounded being few in number and insignificant in 
 size. After the operation the wound is carefully 
 closed with fine silk sutures, and healing should take 
 place by first intention. 
 
 (3) Infrathyroid Laryngotomy. — This operation 
 has been advocated and practised for the removal of 
 growths on the under aspect of the cords, or actually 
 below the cords (subglottic growths). Thyrotomy, 
 however, with a downward extension of the incision 
 gives more room and a better chance of thorough 
 removal of the disease, and is therefore to be pre- 
 ferred. 
 
 By this means Butlin has removed tumours an 
 inch below the vocal cords, and for those which lie 
 immediately below the cords there is no necessity to 
 practise even a modification of the ordinary operation 
 of thyrotomy. 
 
Carcinoma of the Larynx 53 
 
 Irlfrathyroid laryngotomy is performed in just the 
 same way as laryngotomy, but the incision is made 
 transversely, and not vertically, as in laryngotomy. 
 The only vessel likely to give rise to any haemorrhage 
 is the crico-thyroid artery, and, if cut, its ends should 
 be secured before incising the crico-thyroid mem- 
 brane. 
 
 (4) Thyrotomy or Laryngo-fissure has, during 
 the last fifteen years, been performed much more 
 frequently than any other operation for the removal 
 of malignant disease of the larynx in this country, 
 and has steadily gained in repute during that period. 
 It is particularly applicable to sarcomas and carci- 
 nomas of intrinsic origin. As Butlin (in conjunction 
 with Semon) has been mainly responsible for the 
 introduction of it into this country in cases of 
 malignant disease, and for such modifications in the 
 after-treatment as have served to render it far less 
 fatal than it used to be, a description of Butlin's 
 method of performing the operation is herewith 
 given. 
 
 The patient, having been placed in a good light, 
 chloroform or A.C.E. mixture is administered ; 
 ether, if possible, should be avoided, as it excites 
 the secretion of much mucus and saliva, which 
 obscure the parts to be removed. The patient being 
 anaesthetized, the shoulders and neck are raised and 
 the head is thrown back. The skin is prepared as 
 for any other operation. An incision is made from 
 the hyoid bone accurately in the middle line down 
 almost to the sternum, and the structures are divided 
 right down to the thyroid cartilage and the trachea, 
 
54 Malignant Disease of the Larynx 
 
 including generally the isthmus of the thyroid gland. 
 The vessels, mostly veins, are clamped. The trachea 
 is then freely opened below the cricoid cartilage, and 
 a Hahn's compressed sponge cannula inserted." It 
 is of the greatest importance that the compressed 
 sponge be rendered thoroughly aseptic before it is 
 used. 
 
 Thus ends the first part of the operation, for an 
 interval of ten to twelve minutes must now be 
 allowed before the larynx is opened, in order to 
 permit of the expansion of the compressed sponge, 
 the object of which is to occlude the lower air- 
 passages and prevent the entry of any blood or other 
 liquids therein when the lar3nx is opened. There 
 should be no undue haste to open the larynx after 
 tracheotomy has been performed, the full ten minutes' 
 interval being carefully observed. During this interval 
 the clamped vessels should be ligatured, and the 
 
 * There is a tendency at the present time to dispense with 
 the tampon cannulae, Kocher lately having renounced them 
 altogether. If, however, as is still usual, a tampon cannula be 
 used, that of Hahn is to be preferred. Butlin gives the fol- 
 lowing reasons for his preference of this tube : (i) It consists of 
 an inner and outer tube, the former of which is the longer, and 
 projects about ^ inch in front of the shield, thus rendering the 
 entrance of blood less likely. (2) The outer tube is partly 
 covered with a layer of compressed sponge previously soaked 
 in iodoform and ether (i in 7). (3) About ten minutes after the 
 introduction of the tube the sponge swells up from absorption 
 of moisture and effectually tampons the trachea, thus prevent- 
 ing the entrance of liquids. This arrangement of sponge holds 
 the tube steadier than the indiarubber bag of Trendelenburg's 
 cannula, which latter, moreover, is liable to become slippery, to 
 leak, or even burst, during the progress of the operation. 
 
Carcinoma of the Larynx 55 
 
 upper part of the wound be kept covered with 
 gauze. 
 
 At the expiration of the ten or twelve minutes 
 the thyroid cartilage, which has been exposed by the 
 preliminary median incision, is split in the middle 
 line from below upwards. This is important ; for, 
 as the cartilage is generally calcified and requires the 
 use of bone forceps, the inner blade of the forceps 
 working from above downwards may slit or detach 
 one of the vocal cords at its anterior extremity. If 
 the growth proves after all to be innocent, and does 
 not call for removal of any part of the vocal cords, 
 such an accident results almost certainly in per- 
 manent injury to the voice. In patients of such an 
 age as those in whom these operations are performed 
 it is not unusual to find the thyroid cartilage ossified, 
 and this condition may necessitate the use of a saw 
 for its division.* The crico-thyroid membrane is 
 divided down to the cricoid cartilage, and the in- 
 cision is carried upwards beyond the level of the 
 upper border of the thyroid cartilage in order to gain 
 as much space as possible, but it is desirable not 
 to interfere with the attachment of the epiglottis, 
 
 ■^ Quite recently Mr. Waggett, of London, has invented a pair 
 of shears for division of the thyroid cartilage without damage to 
 the vocal cords. The shears have strong thick blades set at a 
 right angle to the handles. The inner blade is inserted below 
 through an incision in the crico-thyroid membrane. The outer 
 blade is provided with a projecting tooth at its distal end. This 
 tooth enables the surgeon to fix the blade exactly in the mid- 
 line of the larynx before cutting through the thyroid cartilage. 
 The instrument has been used in several cases of thyrotoniy, 
 and found to be very efficient. 
 
56 Malignant Disease of the Larynx 
 
 unless the situation of the growth makes this im- 
 perative. 
 
 The two alae of the thyroid cartilage are then held 
 widely apart by means of silk threads passed through 
 each. The interior of the larynx is sponged out dry, 
 and is then brushed with a 20 per cent, solution of 
 cocaine, the effect of which is to cause contraction 
 of the small vessels and lessening of any haemor- 
 rhage, and also a diminution of the sensibility of the 
 parts — a very important point if the patient is not 
 deeply under the influence of the anaesthetic used. 
 
 At this stage of the operation the use of a frontal 
 mirror and a good source of light in order to illu- 
 minate the interior of the larynx and define the 
 extent and exact situation of the disease will be found 
 of great advantage. 
 
 Two elliptical incisions carried down to the peri- 
 chondrium and surrounding the diseased tissues, and 
 including more than half an inch of the surrounding 
 apparently healthy tissues, without respect to the 
 after-use of the voice or any other consideration 
 except the complete removal of the disease, are made 
 with knife or scissors. The included area is cut out 
 right down to the cartilage, which is laid bare, and 
 finally scraped absolutely bare with a Volkmann's 
 sharp spoon. The cavity left is plugged with iodo- 
 form gauze, upon which pressure is made for two or 
 three minutes. By this means the bleeding, which 
 is never serious, is checked. The gauze is then 
 removed and the surface dusted with powdered iodo- 
 form. 
 
 Neither Butiin nor Semon has used the galvano- 
 
Carcinoma of the Larynx 57 
 
 cautery to the interior of the larynx for some years 
 past, and neither has ever seen bleeding which could 
 occasion the least anxiety. If a small vessel spouts 
 it should be ligatured with the finest catgut or silk. 
 
 The alae of the thyroid cartilage are now brought 
 together with a couple of silk or silver sutures, and 
 are brought into as close apposition as possible. The 
 Hahn's tube is removed, and the edges of the wound 
 in the soft parts brought together and sutured, except 
 at the lower part where the tube was inserted. It is 
 infinitely safer to leave this part open, so that there 
 may be a ready exit for the escape of blood and other 
 liquids from the larynx and trachea, and in order to 
 guard against cellular infiltration beneath the skin. 
 
 In order to hasten convalescence, some* operators 
 have lately closed the entire wound. It is, however, 
 a proceeding to be condemned, as it aims solely at 
 shortening what is really a very short after-treatment, 
 and does so with decided risk to the patient. 
 
 Butlin has devoted considerable attention to the 
 after-treatment of these operations, which is now 
 conducted on the following lines : Hahn's tube is 
 
 * Moure {Journal of Laryjtgology , December, 1903), after 
 thyrotomy, sutures completely the laryngo-tracheal opening 
 from top to bottom— that is to say, he omits all kinds of 
 cannula. For prudence' sake he leaves unsutured a spot cor- 
 responding to the tracheal opening, but brings the lips of the 
 tracheal aperture together. An assistant has to remain close at 
 hand for twenty-four to forty-eight hours in case the cannula 
 has to be suddenly inserted. Moure claims that this closure 
 hastens cure and lessens materially the tendency to broncho- 
 pneumonia. He has had no death from the operation as he 
 practises it. 
 
58 Malignant Disease of the Larynx 
 
 removed as soon as the operation is finished, and no 
 tube of any sort is employed in its place. A piece 
 of cyanide or iodoform gauze is placed over the 
 wound, and secured by means of a single turn of 
 bandage. The piece of gauze is changed by the 
 nurse as frequently as it becomes soiled. The patient 
 is placed on his side with only a single flat pillow 
 for the head, that side being lowermost which corre- 
 sponds to the half of the larynx operated upon. In 
 this position all liquids tend to pass out of the air- 
 passages, especially through the external wound. 
 
 Formerly the sponge cannula was left in the 
 trachea for the first twenty-four or forty-eight hours, 
 in case any secondary haemorrhage occurred, and the 
 interior of the larynx was packed with strips of iodo- 
 form gauze. After the Hahn's tube was removed, an 
 ordinary tracheotomy tube was inserted. There is 
 no doubt that the compressed sponge surrounding 
 Hahn's tube has in some cases of thyrotomy, where 
 it has been retained from twenty-four to forty-eight 
 hours, acted as a source of septic infection. Again, 
 the strips of iodoform gauze packed into the larynx 
 in the earlier operations acted as irritants to that 
 organ, becoming soaked in mucus and saliva, and 
 in some cases getting displaced, hanging down the 
 trachea and acting as foreign bodies. Hahn's tube 
 and the iodoform gauze plugging were therefore 
 entirely discarded by Butlin, and with most excellent 
 results. 
 
 Within four or five hours of the operation an 
 attempt may be made to swallow. The patient is 
 made to lean well over to the opposite side to that 
 
Carcinoma of the Larynx 59 
 
 operated on, and the dressing is taken off the wound,, 
 beneath which a basin is placed. Cold sterilized 
 water is drunk out of a feeder placed in the corner 
 of the mouth. If this experiment is successful, all 
 the water passes down into the stomach ; if it is only 
 partially successful, some escapes into the larynx. 
 The posture, however, of the patient insures that it 
 runs out through the wound and does not enter the 
 air-passages. If there is any fear of collapse, and 
 the patient be feeble or very old, brandy and beef- 
 tea may be administered by the rectum. As soon as 
 water can be swallowed with ease, milk, beef-tea, and 
 other liquids may be drunk, for the fear of ' degluti- 
 tion pneumonia ' {Schluckpneumonie) is practically at 
 an end. The wound is generally closed within ten 
 or twelve days of the operation, and the patient is 
 rarely confined to the house for more than ten days. 
 This description applies only to those cases in which 
 the disease is limited to the soft parts of the larynx 
 and is of small extent. 
 
 In other cases the operation may need to be 
 modified, even to the extent of removal of a large 
 part, or even the whole, of the framework of the 
 larynx. The operation may thus pass into that of a 
 more or less atypical partial laryngectomy, and as 
 almost invariably the amount of disease found to be 
 present after opening the larynx is greater than the 
 laryngoscopic picture has shown it to be, it should 
 be a rule before undertaking the operation of thyro- 
 tomy for malignant disease of the larynx to obtain 
 the patient's consent to the performance of a more 
 extensive and graver operation if it is found necessary. 
 
6o Malignant Disease of the Larynx 
 
 Although the operation in some cases ends in a 
 more or less atypical partial laryngectomy, yet the 
 removal of insignificant portions of cartilage from 
 the interior of the larynx, together with the diseased 
 soft parts, should not permit the operation being 
 classified as other than thyrotomy. Again, the 
 operator may find on examination that the patient is 
 not likely to be benefited by an attempt to remove the 
 disease, and may then decide to abandon the opera- 
 tion, contenting himself, perhaps, with introducing 
 an ordinary tracheotomy tube for permanent wear. 
 
 Iodoform powder may be insufflated into the 
 larynx during the first days after the operation 
 through the mouth by means of an insufflator with a 
 bent nozzle. Subsequently careful periodical exami- 
 nations of the larynx should be made. It is not 
 infrequent to find a mass of granulation tissue in the 
 anterior commissure after thyrotomy* for malignant 
 disease. To those not acquainted with this fact, this 
 tissue is very likely to be mistaken for a recurrence of 
 the growth. In such cases the tissue should be left 
 alone at first, and later a piece removed by endo- 
 laryngeal operation and submitted to microscopic 
 examination. Almost invariably this tissue is found 
 to be innocent in nature, and after the removal of a 
 piece it usually shrinks, and finally disappears. 
 
 * It has been recently suggested that this granulation tissue 
 is found in the line of the sutures uniting the two halves of the 
 thyroid cartilage, and some operators pass their sutures through 
 only part of the substance of the cartilage, so as to obviate any 
 irritative action of the sutures if passing through the cartilage 
 and thus into the interior of the larynx. 
 
Carcinoma of the Larynx 6i 
 
 (5) Excision or Extirpation of the Larynx, 
 Complete and Partial (Total and Hemi Laryngec- 
 tomy). — The first complete excision of the larynx 
 was performed by Dr. Patrick H. Watson in 1866. 
 The patient, a male, aged thirty-six, was suffering 
 from severe syphilitic stenosis of the larynx, and sur- 
 vived the operation three weeks. Billroth, in the year 
 1873, performed the first complete extirpation of the 
 larynx for carcinoma of that organ, death taking 
 place seven months later from recurrence. In 1878 
 the same operator excised half the larynx for the 
 same disease. 
 
 Since that date a large number of extirpations has 
 been performed, so that Sendziak was able years ago 
 to put together 188 cases of total removal of the 
 larynx for malignant disease, and might have used 
 a larger number had the reports been sufficiently 
 complete for his purpose. But while thyrotomy has 
 been steadily growing in favour during the last ten to 
 fifteen years, total extirpation has been decidedly less 
 frequently practised. 
 
 Again, thyrotomy is the operation of the English 
 school, while extirpation is largely practised by the 
 German School of Surgery. Between 1881 and 1888, 
 according to Sendziak, no total extirpations were 
 performed ; between 1888 and 1894 only 47. 
 
 Operation of Total Laryngectomy. 
 
 Tracheotomy. — The trachea may be opened (a) 
 either some time previously, {b) at the time of opera- 
 tion, (c) or be dispensed with altogether. • 
 
62 Malignant Disease of the Larynx 
 
 In patients suffering from long-continued dyspnoea 
 it is probably an advantage to perform tracheotomy 
 at least a week before laryngectomy. The patient 
 becomes accustomed to breathing through the arti- 
 ficial apparatus, and the lungs become less engorged, 
 consequently broncho-pneumonia is less likely to 
 ensue. Moreover, less time will be taken up by the 
 operation, and no blood will enter the trachea from 
 this source. A low tracheotomy is preferable to a 
 high one, as the latter may be too near the seat of 
 disease. 
 
 There is a decided tendency for operators at the 
 present time to dispense with tracheotomy altogether. 
 In Jacobson's ' Operations of Surgery,' vol. i., p. 513, 
 the following statement of Professor Keen is given : 
 
 * In the case which is the basis of this paper (a 
 patient aged thirty-nine. Thyrotomy, May, i8g8 ; 
 recurrence in September. Complete laryngectom}', 
 October. Recovery), I did tracheotomy at the 
 time of operation, but removed the tube at the 
 termination of the laryngectomy, immediately closed 
 the wound in the trachea, and obtained absolute 
 primary union. In any future case I am strongly of 
 opinion that it will be better to omit tracheotomy 
 altogether. As I shall show, it is not, in my opinion, 
 needful, and by omitting it we shall eliminate one 
 cause of septic pneumonia.' And, again, later : ' A 
 further improvement can be made in the technique — 
 viz., the omission of an}-, even a temporary, tracheo- 
 tomy. In my next case, after dissecting the soft 
 parts from the larynx and upper trachea back to the 
 oesophagus on both sides, I shall place the patient in 
 
Carcinoma of the Larynx 67, 
 
 the Trendelenburg position, and deepen the narcosis 
 to a sHght extent. I shall then divide the trachea 
 transversely, and by three sutures, one in the mid- 
 line and one on each side, I shall quickly attach the 
 tracheal stump to the skin. Then I shall introduce 
 the ordinary tracheotomy tube into the open end of 
 the trachea instead of through a tracheotomy wound, 
 and continue the anaesthetic through the tube. In 
 order not to embarrass the operator, the flange of the 
 tracheotomy tube should only project at the sides, as 
 the usual wide upper border of the flange would 
 interfere with access to the parts at the beginning of 
 removal of the larynx.' 
 
 The position of the patient is a debatable one. If 
 the surgeon decides to perform the operation by 
 cutting from above downwards, then the position of 
 the patient will be the same as for thyrotomy ; if 
 from below upwards, Trendelenburg's position must 
 be employed. 
 
 Removal by cutting from above downwards is the 
 more usual procedure, and has the advantage of 
 leaving the division of the trachea to the last, thus 
 avoiding the risk of the escape of blood and lotions 
 into the trachea. It also avoids the need of using a 
 tampon cannula. 
 
 If no tracheotomy is performed, either previously 
 or at the time of operation, the median incision being- 
 made, the trachea is first isolated and divided, and a 
 large tube inserted. 
 
 Professor Keen strongly advocates Trendelenburg's 
 position in this and all operations on the upper air- 
 passages. 
 
64 Malignant Disease of the Larynx 
 
 The patient should be prepared in the usual way 
 as regards the skin, and particular attention should 
 be paid to the teeth, nose, and mouth for three days 
 prior to operation. 
 
 A.C.E. mixture is the anaesthetic generally used, 
 and it should, when feasible, be given for as long as 
 possible by the mouth, and later on when the trachea 
 is severed through the tracheotomy tube by tubing 
 attached to the inner tube. 
 
 If the operation be begun from above downwards, 
 a vertical incision is made from the lower border of 
 the hyoid bone exactly in the middle line down to 
 the level of the second or third ring of the trachea. 
 This vertical incision is usually supplemented by a 
 transverse incision across the thyro-hyoid membrane 
 just below the great cornua of the hyoid bone, or 
 across the thyroid cartilage, and passing outwards to 
 the sterno-mastoid muscles. The vertical incision, 
 as in thyrotomy, should go down to the thyroid and 
 cricoid cartilages and trachea. 
 
 After securing the superior and inferior thyroid 
 arteries, the fascia in the mid-line must be well 
 divided, and the soft parts turned back from the 
 cartilages and trachea with a broad periosteal elevator 
 or rugine to a level with the middle of the junction 
 of the larynx and pharynx. 
 
 In some cases the flaps have to be turned back 
 even further, and the sterno-mastoid muscles partly 
 divided. This is not necessary, however, unless the 
 disease has extended into the surrounding struc- 
 tures, or the glands are to be removed at the same 
 time. 
 
Carcinoma of the Larynx 65 
 
 It is better to open the larynx by carefully dividing 
 the thyroid cartilage in the mid-line before deter- 
 mining the extent of the operation, although some 
 operators object to the practice on account of the 
 greater difficulty afterwards in removing the larynx. 
 But it is so important to be certain of the limits of 
 the disease before proceeding to perform extirpation 
 that this consideration outweighs any disadvantages 
 which arise from the splitting of the thyroid cartilage. 
 If the disease is quite limited to the soft parts, yet of 
 large extent, the operation maybe limited to the very 
 free removal of the affected tissues, with a wide area 
 of the surrounding healthy structures. And this may 
 do as much for the patient as would be accomplished 
 by the removal of any part of the laryngeal frame- 
 work. If the disease is limited to one-half of the 
 larynx, the operation of partial excision may be 
 carried out and the healthy side of the larynx be 
 left. Again, in cases in which it is found to be 
 necessary to remove the entire larynx, the operator 
 may judge from his inspection of the disease whether 
 the epiglottis and cricoid cartilage should also be 
 removed. 
 
 Before proceeding to the actual removal of the 
 larynx, the sterno-hyoid, sterno-thyroid, and thyro- 
 hyoid muscles having been separated and turned off 
 the thyroid cartilage, the lateral lobes of the thyroid 
 gland must be carefully separated with a raspatory, 
 and the soft parts at the sides which contain the 
 large vessels carefully retracted, and the larynx alter- 
 nately pulled over first to one side and then to the 
 other so that the attachments of the constrictor 
 
 5 
 
66 Malignant Disease of the Larynx 
 
 muscles to the thyroid and cricoid cartilages may be 
 divided. For this purpose it is important to employ 
 curved blunt-pointed scissors and keep very close to 
 the cartilages. 
 
 The actual removal of the larynx is now proceeded 
 with, and can be carried out either from below 
 upwards or from above downwards, according to the 
 views of the operator. It is on the whole preferable 
 to remove the larynx from above downwards. The 
 thyro-hyoid ligaments and membrane are divided, 
 and the extralaryngeal attachments of the epiglottis* 
 cut through. The entire larynx is now held well 
 forwards by means of a vulsellum forceps, and the 
 organ is separated from its remaining connections to 
 the pharynx and oesophagus at first laterally and then 
 from above downwards. 
 
 Especial care should be taken to keep close to the 
 larynx in order to avoid wounding the large vessels 
 and nerves which lie beside it; and if the cricoidt 
 'cartilage and upper rings of the trachea are removed, 
 the same care should be exercised to avoid opening 
 the oesophagus. 
 
 When or as the trachea is divided, two ligatures 
 should be passed through the divided upper end to 
 prevent the trachea slipping down, and the upper 
 end is firmly secured to the skin by several points of 
 interrupted sutures. 
 
 Finally, three to four deep silver sutures are passed 
 
 ■^ It is far safer to always remove the epiglottis ; it is of no 
 use if left, and may be the seat of a rapidly-recurring growth. 
 
 t The cricoid, if left, interferes, according to Hahn, seriously 
 with deglutition. 
 
Carcinoma of the Larynx 67 
 
 beneath the uppermost ring and attach the trachea 
 to the skin, and a further set of fine superficial 
 sutures unite the mucous membrane of the trachea 
 to the cut edge of the skin. 
 
 Some operators retain Hahn's tube for two or 
 more days after the operation ; others remove it 
 earher, and replace it with an ordinary full-sized 
 tracheotomy tube surrounded with iodoform gauze, 
 the gauze being changed daily and wrung out in 
 I in 20 carbolic acid. The transverse incision should 
 be brought together at the ends by one or two 
 sutures, but the vertical incision should be left open 
 for drainage, the wound being tamponaded with 
 iodoform gauze. 
 
 After-treatment. — The dressings should not be 
 changed too frequently, but at each dressing care- 
 ful cleansing of the large wound must be carried 
 out. 
 
 The patient is fed during some days through an 
 indiarubber tube, which may either be permanently 
 retained as long as it is requisite or may be passed 
 for each feeding. At the end of four or five days an 
 attempt is made to swallow. The same posture and 
 precautions should be adopted as have been described 
 in the operation for thyrotomy, but soft solids such 
 as jelly are generally more easily swallowed than 
 liquids. 
 
 The temperature of the room must be kept at from 
 65° to 70°, and the inspired air charged wdth anti- 
 septic vapours. 
 
 The sutures connecting the trachea with the skin 
 should be removed at as early a date as possible ; 
 
 5—2 
 
68 Malignant Disease of the Larynx 
 
 they very soon tend to become buried, and are corre- 
 spondingly difficult to find and remove. 
 
 The tracheotomy tube must be kept exceedingly 
 clean. 
 
 Partial Extirpation of the Larynx : Hemi- 
 laryngectomy. 
 
 This operation, which consists in the removal of 
 one-half of the larynx, is in details practically identical 
 with complete laryngectomy. The vertical incision 
 is the same, but the transverse incision is made only 
 on the diseased side. 
 
 The larynx having been exposed by separating the 
 soft parts on its outer surface with elevator or rugine, 
 the thyroid cartilage is carefully divided in the mid- 
 line either by cutting bone forceps or saw, and the 
 extent of the disease ascertained. If found to be 
 limited to one-half of the larynx, and yet too exten- 
 sive for removal by thyrotomy, excision of the affected 
 half is proceeded with. 
 
 The soft parts having been carefully raised from 
 the affected half, the attachments to the pharynx 
 are separated, the thyro-hyoid and crico-thyroid 
 membranes cut as close as possible to the margin of 
 the thyroid cartilage, and the superior cornu of the 
 latter divided at its base with bone forceps. 
 
 The aryepiglottic fold is now divided on the 
 affected side close to the cartilage of Wrisberg ; in 
 some cases one-half of the epiglottis is split and 
 removed. 
 
 The cricoid cartilage is now divided in the mid- 
 
Carcinoma of the Larynx 69 
 
 line both in front and behind, and the divided half 
 of the larynx detached from the first ring of the 
 trachea and thus removed. 
 
 In partial excision of the larynx for intrinsic 
 disease there is usually no need to remove one-half 
 of the cricoid cartilage. 
 
 The after-treatment is the same as in total removal 
 of the larynx, but it will be found that the patient is 
 able to dispense with the cannula earlier, and to take 
 food by the mouth a few days after operation. 
 
 Results of Operation. 
 
 Mortality due to the Operation. — The mortality 
 varies enormously according to the operation which is 
 performed, and particularly so according to whether it 
 is performed for extrinsic or intrinsic disease of the 
 larynx. Among the many publications which have 
 appeared in recent times, that which probably contains 
 the largest number of collected cases is Sendziak's 
 {loc. cit.). 
 
 The material has been obtained from both private 
 and public sources, and Sendziak has given an 
 immense amount of labour to the analysis of it. He 
 has not, however, quite grasped the importance of 
 a separation of the intrinsic from the extrinsic carci- 
 nomas, and apparently has not realized that the 
 practice of this country is founded upon the great 
 difference in the pathology of laryngeal carcinoma 
 according as it originates from the intrinsic or ex- 
 trinsic parts of the larynx. Moreover, he has not 
 attached sufficient weight io the marked improve- 
 
/O Malignant Disease of the Larynx 
 
 ments that have taken place during the last ten to 
 fifteen years. 
 
 The conclusions at which Butlin arrived from a 
 study of the disease, and the operations which had 
 been performed for its removal in 1883 (' Malignant 
 Disease of the Larynx ') and in 1887, when the first 
 edition of his book, ' The Operative Surgery of 
 Malignant Disease,' was published, were so gloomy 
 that there seemed to him at that time to be scarcely 
 justification for the performance of a radical operation 
 for carcinoma. Scarcely a single case had been 
 cured by partial extirpation, and the operation was 
 highly dangerous to life ; while the mortality conse- 
 quent on complete extirpation of the larynx was 
 extremely large, and the successes surprisingly small. 
 Moreover, the condition of the patient after complete 
 extirpation of the larynx was far from enviable. 
 
 Several circumstances, however, seemed to justify 
 further experiment. In the first place, the mortality 
 from partial resection of the larynx had not been 
 extremely large, and it left the patient in a suffi- 
 ciently comfortable condition. In the second place, 
 an exhaustive study of the pathology of the disease 
 led Butlin to the conclusion that Krishaber's division 
 of carcinoma of the larynx into those of intrinsic and 
 those of extrinsic origin was of the greatest im- 
 portance and value from a pathological point of 
 view. On the strength of this view, he suggested 
 that ' in the immediate future extirpation of the 
 larynx for carcinoma should be practised only for 
 intrinsic carcinoma which is still limited to the 
 larynx.' 
 
Carcinoma of the Larynx 71 
 
 Sir Felix Semon accepted this suggestion, and he 
 and Buthn have been intimately associated ever since 
 that time in working out to a successful issue the 
 treatment of intrinsic carcinoma of the larynx by 
 operation. The first case which seemed to Semon 
 suitable for operation was treated by Hahn, of 
 Berlin ; the second case by Butlin ; and many cases 
 since then by Semon, Butlin, and other English 
 laryngologists. 
 
 The nature of the operation in the two first cases 
 was partial resection of the larynx. But almost all 
 the later operations have consisted, as far as Semon 
 and Butlin are concerned, in opening the larynx and 
 freely excising the disease together with a wide area 
 of the surrounding and apparently healthy tissues, 
 so much so that the operation of thyrotomy is now 
 looked upon as the English operation for carcinoma 
 of the larynx : and Sendziak said in 1897 that 
 Butlin personally had performed one-fifth of all the 
 thyrotomies for cancer which were up to that date 
 on record in medical literature. 
 
 The reasons in favour of the limitation of the 
 operation to thyrotomy are : the very small liability 
 of the disease to infiltrate the cartilage of the 
 larynx, whether it is in a state of calcification or 
 not ; the similarity of the course of the disease 
 to cancer of the lip ; and the great improvement 
 which has been made in the early diagnosis of the 
 disease, which is very greatly due to the work of 
 Semon. 
 
 It is sincerely to be hoped that the results to be 
 described will tend to further popularize an operation 
 
72 Malignant Disease of the Larynx 
 
 which, when appHed to suitable cases, is without 
 doubt marvellously successful. 
 
 Sendziak reported g deaths in 92 thyrotomies 
 performed for cancer, 4 of which occurred from 
 pulmonary troubles, 3 from various forms of septic 
 infection, i from failure of the heart, and i from 
 syncope. The greater number of these operations 
 were naturally performed for carcinoma of intrinsic 
 origin, but the list includes operations for extrinsic 
 carcinoma ; and as these operations are decidedly 
 more dangerous to life than those which are per- 
 formed for intrinsic carcinoma, the mortality is b}' 
 no means high. 
 
 Up to the end of July, i8g6, Butlin and Semon 
 had perfomed 17 thyrotomies (on 16 patients) for 
 intrinsic carcinoma with 2 deaths, i due to sepsis, 
 the other to bronchitis ; so that at first sight their 
 mortality seems larger than that of Sendziak's series 
 of cases. But since August, 1896, neither of them 
 has lost a patient from the operation ; Butlin 's last 
 fatal case being in 1889, and Semon's in 1894, from 
 bronchitis, which was present before the operation. 
 The number of thyrotomies Semon has performed 
 since July, 1896, up to the present time for un- 
 doubted intrinsic carcinoma of the larynx amounts 
 to 16 ; in none of these has death followed the 
 operation. 
 
 Butlin's results are similar, so that Butlin and 
 Semon can now lay claim to a long series of cases 
 of thyrotomy for intrinsic carcinoma unbroken by a 
 single fatal result. These results are not due to mere 
 accident or good fortune, but are dependent on the 
 
Carcinoma of the Larynx 'j;^ 
 
 improvements which have been made, both in the 
 manner of performing the operation and even more 
 in the after-treatment. The immediate removal of 
 Hahn's tube, the frequent changing of the loose 
 dressing v^hich covers the wound, and the care given 
 to the proper feeding of the patient have effected a 
 most salutary change in the prospect of recovery 
 from the operation. 
 
 Sendziak looks upon a mortality of lo per cent, 
 as marvellously small, but it is quite certain that 
 100 thyrotomies ought to be performed at the 
 present time for intrinsic carcinoma, with a mortality 
 of 2 to 3, perhaps less even than this. 
 
 Of partial extirpations of the larynx for carcinoma, 
 Sendziak has collected no cases, with a mortality 
 from the operation of 29, equal, therefore, to a per- 
 centage of 26*3. This percentage is, therefore, nearly 
 three times greater than that of the thyrotomies 
 collected by him. 
 
 By far the greater number — i.e., 22 — of the patients 
 died of some form of pulmonary complication, mostly 
 septic, 6 of collapse or cardiac failure, and 3 of 
 haemorrhage. Sendziak is of opinion that this per- 
 centage proves decidedly that partial resection of 
 the larynx is by no means a dangerous operation ! 
 Surely a mortality amounting to more than one- 
 fourth is extremely high for such an operation. 
 
 Moreover, a careful examination of his tables, 
 from which these deductions are drawn, points to a 
 mortality even larger than he has stated ; for there 
 appear to be more than 32 deaths, and his own list 
 of the causes of death makes the total 36, unless 
 
74 Malignant Disease of the Larynx 
 
 several of the cases are placed under more than one 
 heading. 
 
 This is certainly a larger mortality than ought to 
 follow removal of not more than one-half of the 
 larynx. Indeed, the far smaller mortality in the last 
 60 cases (performed during or since 1888) than in the 
 first 50 strongly bears out this more favourable view. 
 The mortality percentage is almost twice as large 
 for the first 50 cases. This is only what might be 
 expected from the improved methods which have 
 been employed, not only in carrying out the opera- 
 tion itself, but in the after-treatment of the patient. 
 
 Total extirpation of the larynx is an extremely dan- 
 gerous operation. Sendziak notes 84 deaths in 188 
 cases, and places the mortality at 44*7 per cent. 
 Naturally, many of the operations were far more 
 extensive than the mere removal of the larynx, 
 necessitating far-reaching dissections into the neigh- 
 bouring parts and removal of such parts as the 
 muscles, lymphatic glands, and pharynx. But as 
 laryngectomies in the future are not likely to be less 
 extensive, it is matter of doubt whether any allow- 
 ance should be made on this account. 
 
 But here, again, the later mortality is much less 
 than that which followed the earlier operations. For 
 instance, 56 of the 184 operations were performed 
 during, or subsequent to, 1888, with only 18 deaths. 
 Had the mortality been equal for the whole series 
 there should have been 25 deaths, so that the relative 
 mortality is very much lessened. 
 
 Schmiegelow {Ann. des M. de V Oreille, du Larynx, 
 April, 1897), mentions 50 cases of total laryngectomy 
 
Carcinoma of the Larynx 75 
 
 for carcinoma performed between 1890 and 1897; 
 the mortality was 22 per cent., half, therefore, that 
 given in Sendziak's tables. 
 
 Still later Gluck, at the meeting of the British 
 Medical Association held at Swansea, 1903, has given 
 an account of his operations and their remarkable 
 and brilliant results. He performed 22 total extir- 
 pations with only i death, and 27 transverse extir- 
 pations of the larynx, pharynx, and glands, with also 
 only I death. 
 
 Despite, however, every care and skill on the part 
 of the operator, it is probable that the operation of 
 complete laryngectomy will always be attended by a 
 somewhat high rate of mortality. There must always 
 be grave danger from pulmonary complications, nearly 
 40 of the patients in Sendziak's tables succumbing to 
 pneumonia, usually of septic origin. Moreover, no 
 fewer than 17 of the deaths were due to collapse 
 and paralysis of the heart, a complication possibly 
 dependent on division of the inhibitory nerves of 
 the heart or to persistent irritation of the superior 
 laryngeal nerve. 
 
 Cures due to Operation. — In this matter par- 
 ticular attention must be drawn to the different con- 
 clusions which are to be derived from a study of 
 Sendziak's tables, and from a study of the thyro- 
 tomies which have been performed during the last 
 fifteen years in this country. Sendziak states that 8 
 out of the total number of 85 were alive and well for 
 more than three years subsequent to the operation of 
 thyrotomy. Eight, however, of the 85 were lost 
 sight of soon after operation, and must be left out of 
 
76 Malignant Disease of the Larynx 
 
 account, leaving the total at "]"] cases with 8 cures, 
 just over lo per cent. 
 
 But here, again, no division is made between the 
 operations for intrinsic and extrinsic disease, a dis- 
 tinction which in this country is looked upon as of 
 vital importance, and the great difference in the 
 earlier and later cases is not emphasized. 
 
 Thus, 6 of the 8 successful operations were per- 
 formed during or after i888, and the 6 contained 
 three of Butlin's and one of Semon's, so that these 
 two are responsible for one-half of the total 8 suc- 
 cessful cases. Reference has already been made in 
 treating of the mortality of thyrotomy for malignant 
 disease to the number of cases performed by Butlin 
 and Semon up to July, 1896. Their results since 
 then have been even better. For instance, Semon 
 states {British Medical Journal, November 28, 1903): 
 * I can now summarize my results to the effect that 
 out of 18 cases of undoubted malignant disease of the 
 larynx which I have operated upon by thyrotomy 
 between June 2, 1891, and July 29, 1902, 15 — that is, 
 85 per cent. — were permanently cured. Three of 
 these patients died several years after the operation 
 from affections altogether unconnected with the 
 original disease, one six years after from an acute 
 abdominal affection ; the second, three years and a 
 quarter after the operation from embolism of the 
 heart or the lungs ; the third, four years after opera- 
 tion from pneumonia. The remaining 12 are now 
 alive and well, whilst the vocal results, with the 
 exception of a few cases in which it was necessary to 
 remove both vocal cords, are surprisingly good.' 
 
Carcinoma of the Larynx "j^ 
 
 It is difficult to lay down any strict rule as to the 
 period that should elapse subsequent to operation for 
 the term ' cured ' to be used. In Sendziak's work 
 all cases under three years from operation are spoken 
 of as ' relative cures,' and all cases free from disease 
 three years or more subsequent to operation as ' per- 
 manent or definite cures.' Semon considers a case 
 to be cured that is free from any recurrence one year 
 after operation, and states that it has been his 
 experience that recurrence takes place within a year 
 of operation or not at all. His published cases, with 
 their results, seem to bear out his views. 
 
 The results obtained by Butlin and Semon are 
 due to early diagnosis and limitation of the opera- 
 tion most rigidly to suitable cases, selected by 
 virtue of their being of intrinsic origin and limited 
 in extent. 
 
 It is of the greatest importance to operate early in 
 these cases, and thus it has fallen to their lot to have 
 to open the larynx in more than one case in which 
 there was a doubt as to the nature of the disease, 
 and the diagnosis could not be cleared up by the 
 removal of a fragment through the mouth for micro- 
 scopical examination. When the disease has been 
 found to be of an innocent nature the larynx has 
 been closed at once, and no evil has resulted. On 
 the other hand, they have perhaps erred somewhat in 
 declining to operate in advanced cases of carcinoma 
 of the larynx, and have very infrequently operated 
 for carcinoma of extrinsic origin. 
 
 Of the table of no partial laryngectomies put 
 together by Sendziak, he finds lo cases which he 
 
78 Malignant Disease of the Larynx 
 
 claims as successes, but the total may be reduced by 
 deducting some 14 or 15 cases in which the observa- 
 tion of the case lasted less than a year, or the patient 
 died within three years of some other cause than 
 carcinoma of the larynx and glands. The proportion 
 of successes is, therefore, even after this deduction, 
 very small, about the same as was obtained by the 
 operation of thyrotomy. It is here of great impor- 
 tance to examine the class of cases in which success 
 was obtained. Seven of the cases were certainly of 
 intrinsic origin and only one of them certainly ex- 
 trmsic, w^hile in the two remaining cases the disease 
 was probably, but not certainly, intrinsic. 
 
 By the exclusion of the same kind of cases as have 
 been excluded in considering the table of partial 
 laryngectomies, the 188 total laryngectomies of Send- 
 ziak may be reduced to about 170, and there are 
 eleven successes to be claimed. Among the excluded 
 cases it is wonderful how many are to be excluded on 
 account of death from pneumonia or bronchitis 
 within three or four months of the operation. The 
 proportion of cured cases is lamentably small, while 
 the mortality of the operation is extremely large. It 
 is very difficult in most of the successful cases to 
 come to any conclusion as to the extent or origin of 
 the disease, but it appears generally to have been 
 very extensive, and is more than once spoken of as 
 filling the cavity of the larynx. 
 
 On the other hand, the description of the disease 
 in many of the 188 cases inclines one to the belief 
 that total laryngectomy was a much larger operation 
 than was necessary, and that the conditions of the 
 
Carcinoma of the Larynx 
 
 79 
 
 case might well have been met by partial laryngec- 
 tomy or even by an extensive th3Totomy. 
 
 As might be expected, the ultimate results of the 
 cases during and since 1888 are somewhat better 
 than those of the cases before that date. It has 
 already been shown that the death-rate due to the 
 operation is less, and of the 56 patients alive and 
 free from disease, 4 were alive and free from 
 recurrence more than three years after the opera- 
 tion. 
 
 That the results, both as regards recurrence, cure, 
 and mortality following total laryngectomy, have 
 been steadily improving of late may be proved by the 
 following tables of comparison : 
 
 
 Sendziak's Tables 
 
 Schmiegelow's Tables, 
 
 
 (188 Cases). 
 
 T890-1897 (50 Cases). 
 
 
 Per Cent. 
 
 Per Cent. 
 
 Mortality 
 
 447 
 
 22 
 
 Recurrence - - - 
 
 3-"45 
 
 20 
 
 Relative cure (less than 
 
 
 
 three years) 
 
 6-9 
 
 48 
 
 Definite cure (three or 
 
 
 
 more years) 
 
 5-85 
 
 10 
 
 The results, however, obtained by Professor Gluck, 
 of Berlin, and described by him at the British 
 Medical Association's meeting at Swansea, July, 
 1903, are most surprisingly brilliant, and hold out 
 the greatest hope for the future. He stated he had 
 performed 35 hemilaryngectomies with only 3 deaths, 
 one twenty- four hours after operation from sudden 
 heart failure, one from phlegmon of the right gluteal 
 muscle, and one from pneumonia on the fifth day. 
 
8o Malignant Disease of the Larynx 
 
 He also had performed 22 total extirpations of the 
 larynx with one death, this being in an old man of 
 seventy, who succumbed to iodoform poisoning the 
 eleventh day after operation. 
 
 He also performed 27 transverse extirpations of 
 the larynx, pharynx, and glands, with again only i 
 death. He furthermore pointed out that in a former 
 series of 9 cases he had had 4 deaths ; and going 
 back to 1888 and the first cases, there had been only 
 2 recoveries out of 10 operations. 
 
 Professor Gluck said he could have brought 
 forward 38 of his patients, some of whom had 
 survived operation 11, 8, 6J^, 5^, 4^, and3i years, and 
 were in full health. 
 
 Are Patients who are not cured relieved by the 
 Operation ? — Patients on whom the operation of 
 thyrotomy or partial extirpation of the larynx has 
 been performed are generally quite comfortable in all 
 respects. They are not obliged to wear a tube, can 
 swallow well, and can speak sometimes exceedingly 
 w^ell, and at all times in a gruff whisper. So long, 
 then, as there is no recurrence of the disease, they 
 are absolutely relieved by the operation, but the 
 voice, of course, is not as a rule improved by the 
 operation, although it maybe quite as good after it as 
 it was for some time previously. 
 
 On the other hand, patients who have undergone 
 total extirpation of the larynx, especially when the 
 operation has been extended into the neighbouring 
 soft parts, are often in quite a miserable condition. 
 In some there is great difficulty in swallowing. All 
 of them need to wear a tracheotomy tube unless the 
 
Carcinoma of the Larynx 8i 
 
 trachea is fastened to the opening in the skin ; and 
 the artificial larynx is much more troublesome to 
 wear and manage than is usually thought. Further- 
 more, there is no doubt that these patients are much 
 more liable than other persons to pneumonia and 
 other affections of the lungs. 
 
 Conclusions. 
 
 Endolaryngeal operations are only indicated in 
 very exceptional circumstances. The disease must 
 be very limited in extent, and quite superficial, and 
 even then endolaryngeal removal should only be 
 adopted in those cases in which there are very 
 urgent reasons against opening the larynx, or in 
 which the patient refuses a major operation. 
 
 Thyrotomy is the operation for all cases of intrinsic 
 carcinomas in which the disease is limited to the 
 interior of the larynx. It is but seldom necessary in 
 such cases to remove any of the framework of the 
 larynx except when the disease is situated at the 
 posterior part of the larynx. 
 
 It is quite sufficient to scrape or cut away the 
 superficial part of the cartilage beneath the base of 
 the disease. 
 
 Thyrotomy, according to the experience of English 
 laryngologists, is a safer and more satisfactory opera- 
 tion than the various modifications of pharyngotom}' 
 for the removal of cancer of the epiglottis and ary- 
 epiglottic folds, etc. 
 
 It permits of a more thorough exposure of the 
 disease and of greater certainty in dealing with it, 
 
 6 
 
82 Malignant Disease of the Larynx 
 
 and it, moreover, seems to be less dangerous to 
 life. 
 
 Partial excision of the larynx, either of one-half or 
 an atypical operation adapted to the extent and 
 character of the disease, is suitable to cases in which 
 the disease, although of intrinsic origin, is of greater 
 extent than could be dealt with satisfactorily by 
 thyrotomy and removal of the soft parts. 
 
 It is also indicated in those cases in which rapid 
 recurrence has followed a carefully executed thyro- 
 tomy, and in cases of extrinsic origin limited to one- 
 half of the larynx. 
 
 Total extirpation of the larynx has been but 
 seldom performed in this country, and has been 
 losing favour in other countries. If the extent of 
 the disease be so great that partial laryngectomy will 
 not suffice, the prospect of success from an operation 
 has been hitherto deemed bad. The patient is much 
 more liable after it to pulmonary affections, particu- 
 larly to fatal pneumonia, and the mutilation caused 
 by the operation is often so considerable that the 
 patient's lot is a very sad one. At the same time, the 
 results obtained by Gluck, and already referred to, 
 point to the fact that total laryngectomy can be per- 
 formed with excellent immediate and remote results, 
 and should go a long way towards popularizing an 
 operation hitherto exceedingly unpopular, at all 
 events in this country. 
 
 The operations that are suitable for the removal 
 of carcinoma are equally suitable for the removal of 
 sarcoma. 
 
 Glandular infection occurs late in cancers of 
 
Carcinoma of the Larynx S; 
 
 o 
 
 intrinsic origin, especially when attacking the an- 
 terior two-thirds of the true vocal cords or the false 
 vocal cords ; it occurs equally early in cancers of 
 extrinsic origin. It is probably sound surgery to 
 remove the glands liable to infection, whether en- 
 larged or not, in all cases of laryngeal cancer 
 excepting those attacking the anterior two-thirds of 
 the true vocal cords or the false vocal cords, in 
 which situations experience has proved that glandular 
 infection but rarely occurs, and then only at a late 
 stage of the disease. 
 
 The most promising cases of carcinoma for opera- 
 tion are those in which the disease is situated on the 
 anterior two-thirds of the true vocal cords or on the 
 false vocal cords, is small in extent and not deeply 
 fixed. And the best patients are those who other- 
 wise are in good health, and particularly those who 
 are not liable to bronchitis. Sarcomas of small size 
 and of intrinsic origin are probably equally promising 
 for operation. 
 
 Carcinomas of extrinsic origin are always much 
 less favourable for operation. The actual removal 
 of the disease is more dangerous to life, while the 
 greater local malignancy of the disease and the earh' 
 tendency to infection of the lymphatic glands render 
 the prospect of cure poor. 
 
 Palliative Measures. 
 
 It appears, from a consideration of the cases which 
 have been treated by palliative measures only, that 
 the life of a patient suffering from carcinoma of the 
 
 6—2 
 
84 Malignant Disease of the Larynx 
 
 larynx may last as long as two, three, and even, 
 though rarely, more years ; and life may often be 
 prolonged and rendered far more comfortable and 
 the end more easy by the timely performance of 
 tracheotomy. Tracheotomy is therefore indicated 
 in those cases of laryngeal cancer which are con- 
 sidered inoperable and in which there is increasing 
 dyspnoea. 
 
 Fauvel gives some statistics from his own practice 
 showing the utility of this operation as a palliative 
 measure. His statistics show that in 7 patients on 
 whom tracheotomy was performed for carcinoma of 
 the larynx the average duration of life was four years, 
 whereas in 6 patients suffering from a similar con- 
 dition, and in whom no operation was performed, 
 the average duration of life was twenty-one months. 
 
 Dr. Solis Cohen, in a paper* on excision of the 
 larynx, speaks thus of tracheotomy in carcinoma : 
 ' Of a num.ber of cases of carcinoma of the larynx 
 under my own care who agreed to submit to resection 
 of the larynx should I so determine, and in whom 
 I performed tracheotomy in preference, i lived 
 six months, 2 lived seven months, i lived thirteen 
 months, and i eighteen months respectively after the 
 tracheotomy. Had laryngectomy been practised in 
 these five cases with equal tenure of existence, the 
 result would have been accredited to the radical 
 procedure.' If tracheotomy be performed the low 
 operation should be chosen. 
 
 Constitutional treatment holds out no hope of 
 
 * ' Does Excision of the Larynx tend to Prolongation of 
 Life?' p. 18. Philadelphia, 1883. 
 
Carcinoma of the Larynx 85 
 
 cure. Serum-therapy has been given an extensive 
 trial, but unfortunately there is nothing so far to be 
 said in favour of it as a curative agent. The same 
 applies to the employment of the X rays, radium, 
 etc. In inoperable cases pain, if present, must be 
 relieved by the insufflation of morphine, J to h grain, 
 or the local application of a solution of cocaine (10 to 
 20 per cent.). Insufflations of orthoform are also 
 much in vogue at present. 
 
 When there is much ulceration and foetor, inhala- 
 tions of creosote or benzoin are useful and soothing, 
 or a powder of iodoform gr. i., ac. borici gr. i., 
 morph. hydrochlor. gr. -J, cocaine gr. J, may be used 
 for insufflation. It is necessary to warn the patient 
 against the use of tobacco and strong spirits. 
 
 Should there be pain in swallowing, it may become 
 necessary to adopt rectal feeding. The passage of 
 oesophageal tubes is contra-indicated in these cases, 
 but, if employed, Symonds' tube is the most useful. 
 
86 Malignant Disease of the Larynx 
 
 SARCOMA OF THE LARYNX. 
 
 Sarcoma as affecting the larynx is of infinitely less 
 frequency than carcinoma. In olden days its differ- 
 entiation from cancer of the larynx did not exist, and 
 it has been only during the last thirty years that 
 sufficient attention has been given to the differential 
 diagnosis and the two diseases clearly recognised. 
 According to Sendziak, the first case of primary 
 sarcoma of the larynx to be met with in medical 
 literature was published by Broadbent in 1861. 
 
 Since then many observers have worked at and 
 written on the subject. Bergeat, of Munich, has 
 collected from various sources 114 cases of sarcoma 
 affecting the larynx and trachea, and various authors 
 have referred to the subject in their works on 
 diseases of the larynx (Mackenzie, Von Ziemssen, 
 Schrotter, Massei, Gottstein, etc.). 
 
 In Butlin's monograph on ' Malignant Disease of 
 the Larynx ' (1883), the number of cases of sarcoma 
 affecting the larynx collected from various sources 
 amounted to 23, and in Sendziak's recent work on 
 ' Malignant Disease of the Larynx ' statistics are 
 given of 50 cases of sarcoma. 
 
Sarcoma of the Larynx Sy 
 
 ETIOLOGY. 
 
 The etiology of sarcoma of the larynx is practically 
 unknown. Occupation does not seem to have exer- 
 cised any marked influence in the production of the 
 tumours, but the great preponderance of males among 
 the patients — in Sendziak's tables of 50 cases, 31 
 males, 13 females ; in Bergeat's, 48 males, 18 females 
 — may suggest that strong and over use of the voice, 
 with perhaps tobacco-smoke and other irritants, play 
 a part in the etiology of sarcoma. Bergeat refers to 
 the fact that in many of the cases collected by him 
 the patients were more or less connected in their 
 work with horses, and both he and Von Esmarch 
 believe syphilis to be a strong predisposing agent. 
 
 In some instances sarcomatous tumours of the 
 larynx have been attributed to severe colds. 
 
 Frequency. — As already stated, sarcoma is infinitely 
 more uncommon than carcinoma of the larynx, the 
 proportion of cases being variously put at i to 11 or 12, 
 I to 17-25 (Schmidt). 
 
 Mackenzie, in his practice, out of 53 cases of 
 malignant tumours, only met with it in 5, and Semon 
 3 times out of 103 cases of malignant disease of the 
 larynx ; Massei, out of 200 similar cases, 6 times. 
 
 Again, in relation to sarcoma occurring in other 
 parts of the body, it is found that the larynx is a 
 rare organ to be attacked. Gurlt, out of 848 cases of 
 sarcoma, noted the presence of one solitary case in 
 the lar^^nx. 
 
 Age. — Age does not play so important a part as in 
 

 Years. 
 
 
 7 
 
 
 13 
 
 
 i8 
 
 
 19 
 
 Between 
 
 I 21 and 30 
 
 5? 
 
 31 and 40 
 
 5) 
 
 41 and 50 
 
 55 
 
 5 r and 60 
 
 5) 
 
 61 and 70 
 
 
 74 
 
 Not noted - 
 
 SS Malignant Disease of the Larynx 
 
 carcinoma. Sarcoma is frequently met with at an 
 earlier age than carcinoma, as the following analysis 
 of Sendziak's 50 cases shows : 
 
 Cases. 
 
 - I 
 
 I 
 I 
 I 
 
 - 6 
 
 - 6 
 
 - 10 
 
 - 13 
 
 43 
 - 7 
 
 50 
 
 The youngest of the patients was, accordingly, 
 7 years of age, the oldest 74 (Semon has met with a 
 case in a man of 81), but in the first case the disease 
 was believed to be congenital. 
 
 Bergeat's statistics give : 
 
 Years. Cases. 
 
 Between 20 and 30 - - - 6 
 
 „ 30 and 40 - - - 1 1 
 
 „ 40 and 50 - - - 13 
 
 From 40 to 60 may be said to be the commonest 
 age for sarcoma of the larynx. In women it has 
 been noted most frequently from 30 to 50 years of 
 age, and in men from 50 to 60. 
 
 In those over 60 years of age the male sex pre- 
 ponderates (Lange 74, Semon 81). 
 
Sarcoma of the Larynx 89 
 
 Situation. — As in carcinoma, sarcoma of the larynx 
 can best be classified as (i) intrinsic, (2) extrinsic in 
 origin. 
 
 In 23 cases collected by Butlin in 1883, 17 were 
 intrinsic, 3 extrinsic, and 3 of uncertain origin. 
 
 In Sendziak's 50 cases, 26 were of intrinsic and 15 
 of extrinsic origin, and 9 not noted. 
 
 In some of the cases the whole of the interior of 
 the larynx was occupied by the disease, but where 
 the seat of origin could be distinguished, it was for 
 the large majority of the intrinsic sarcomas the true 
 vocal cords or the ventricular bands, of the extrinsic 
 sarcomas the epiglottis. 
 
 Taking the two classes together, the order of 
 frequency may be said to be, first, the true vocal 
 cord, next the epiglottis, then the false vocal cord, 
 and more rarely the posterior part of the larynx and 
 ventricle of Morgagni. 
 
 As in carcinoma, it is very rare to find the sinus 
 pyriformis the original seat of growth. It is or 
 importance to remember that the disease may be 
 infraglottic ; Sendziak reports 6 such cases out of 
 his series of 50 sarcomas of the larynx. 
 
 Apparently, the left half of the larynx is more 
 frequently attacked than the right, and there is no 
 reason known why this should be so. Sarcoma of 
 the larynx may be primary or secondary in origin. 
 In 97 cases noted by Bergeat 85 were primary and 
 12 secondary, the latter mostly arising from con- 
 tinuity of tissue, and but very rarely from metas- 
 tasis. 
 
 In connection with the subject of metastasis, it is 
 
90 Malignant Disease of the Larynx 
 
 to be noted that out of the 50 cases already referred 
 to (Sendziak's) of laryngeal sarcoma there was but 
 I case (Table VII., Case 6) in which post-mortem ex- 
 amination revealed a secondary growth (in the lung). 
 
 Rollier, however, has reported a case of sarcoma 
 of the larynx with secondary growths in the lungs, 
 liver, and brain, and Koschier one in which lympho- 
 sarcoma of the breast, sternum, mediastinum, pleurae, 
 glands, pharynx, and larynx was found. 
 
 Out of the 23 cases collected by Butlin the number 
 of complete autopsies was only 2 ; in neither of them 
 were secondary tumours found, nor were there any 
 signs which denoted the formation of secondary 
 tumours in any of the patients before death. He 
 therefore stated : ' A more extended series of obser- 
 vations may show that secondary growths are not 
 uncommon, but the evidence at present before us 
 seems to prove that sarcoma of the larynx neither 
 affects the lymphatic glands nor produces secondary 
 growths, and that its malignant properties are limited 
 to infiltration of adjoining parts.' These views were 
 expressed in 1883, and not only does further ex- 
 perience prove the rarity of secondary growths, but 
 also that involvement of the glands in the neighbour- 
 hood is the exception and not the rule. 
 
 Out of Sendziak's 50 cases only 3 are mentioned 
 in which the glands were affected — namely, Table V., 
 Case 4. A man aged fifty-one with a round-celled 
 sarcoma under the left vocal process. Laryngo-fissure 
 and excision of the affected glands was performed 
 with good results (Bessel and Hagen). 
 
 Table VI., Case 8. — A male aged fifty-seven with 
 
Sarcoma of the Larynx 91 
 
 a round-celled sarcoma affecting the right processus 
 vocalis. The right half of the larynx and the affected 
 glands were removed. Death ensued three days later 
 from coma (Gluck). 
 
 Table VII., Case 2. — A male aged forty-six with 
 ulcerating lympho-sarcoma of the base of the epi- 
 glottis. Total laryngectomy and excision of the 
 affected glands was performed. Death ensued fifteen 
 months later from recurrence (Czerny). 
 
 The absence of glandular affection in sarcoma of 
 the larynx has been clearly recognised by most of 
 those who have written on the subject, and is a 
 matter of great importance, both from a pathological 
 and clinical point of view. 
 
 Reference has already been made to the distribu- 
 tion of the lymphatic vessels of the larynx in treating 
 of carcinoma of that organ, and it can scarcely be 
 maintained that the absence of lymphatic vessels is 
 the reason why sarcomas do not affect the lymphatic 
 glands. The extrinsic parts of the larynx at all 
 events are very amply provided with lymphatics, 
 and it has been already pointed out that carcinoma 
 of these parts affect the lymphatic glands at an early 
 period ; yet sarcoma affecting these same parts does 
 not lead to glandular involvement or secondary 
 growths. They, however, give evidence of their 
 malignant properties in the manner in which they 
 infiltrate the tissues, and in the obstinacy with which 
 some of them recur after what appears to be complete 
 removal. 
 
 Taking now the microscopical characters of the 
 various sarcomata of the larynx met with, it is found 
 
92 Malignant Disease of the Larynx 
 
 that in nearly half the cases the tumour was spindle- 
 celled, or composed of cells closely resembling the 
 typical spindle cell. Included in this variety are the 
 cases described as fibro-sarcomata. Next in frequency 
 come the round-celled tumours, and finally alveolar 
 sarcoma. 
 
 The foUow^ing varieties have also been noted by 
 various authors, but are all of exceptional rarity ; 
 sarcoma carcinomatodes, myeloid, chondro-, angio-, 
 adeno-, lympho-sarcoma, melanotic and papillary 
 sarcoma. In many cases recorded the tumours are 
 merely said to be * sarcomas.' 
 
 Szmurlo has described a very interesting case of 
 mixed cancer and sarcoma of the larynx. 
 
 CLINICAL VARIETIES AND SYMPTOMS. 
 
 Sarcoma of the larynx presents itself clinically in 
 very varied forms, according to the time the disease 
 has been in existence. It always forms a definite 
 tumour, generally diffuse in character, and with a 
 broad base arising from the true or false vocal cord, 
 epiglottis, or aryepiglottic fold. It is uncommon to 
 find it presenting itself as a circumscribed tumour of 
 a polypoidal type, and in those cases partaking of 
 this character the origin has been almost invariably 
 the true vocal cord. 
 
 The tumour seldom grows to a large size, the 
 largest examples only attaining the size of a walnut 
 or a little larger. 
 
 The mucous membrane covering the tumour is 
 
Sarcoma of the Larynx 93 
 
 generally discoloured, the character of the discolora- 
 tion varying considerably, some of the tumours being 
 much paler than the normal mucous membrane, 
 others much darker, either deep red or livid, and 
 traversed by large full vessels. 
 
 In shape the neoplasm is generally round, with a 
 variable surface. The latter may be smooth, uneven, 
 or wart-like. Mackenzie noted a wart-like appear- 
 ance in 4 out of his 5 cases. 
 
 Sooner or later infiltration invariably takes place. 
 In the worst cases the tumour, being of extrinsic 
 origin, has grown into the base of the tongue or 
 wall of the pharynx ; or, being of intrinsic origin, 
 has extended through the membranes or the thyroid 
 cartilage into the hyoid muscles. 
 
 One of the most characteristic features of laryngeal 
 sarcoma is the absence of ulceration. When ulcers 
 are seen they are generally small and superficial. As 
 in carcinoma, perichondritis, with all its after-effects, 
 may occur. 
 
 Most of the tumours feel firm or hard when 
 examined with the laryngeal probe, although Schmidt 
 is of a different opinion. Bergeat noted 15 cases 
 as hard and 13 as soft. In a few cases the tumour 
 has been of mixed consistency — hard at the base 
 and soft at the apex. As a rule, the growth is 
 solitary, although in a few rare cases two or more 
 growths have been present either close together or 
 separated by a narrow interval, while in one instance 
 two growths were attached to the two vocal cords, 
 and were separated by a narrow chink of glottis 
 (Schnitzler- Krajewski) . 
 
94 Malignant Disease of the Larynx 
 
 The course of the disease is certainly more rapid 
 than in carcinoma, especially in cases of so-called 
 alveolar sarcoma. Burow has recorded an example 
 in which the tumour, which grew from the posterior 
 aspect of the epiglottis, was as large as a small 
 walnut when an attempt was made to remove it six 
 weeks after the symptoms were first noticed. It was 
 a spindle-celled sarcoma. 
 
 Symptoms. 
 
 The symptoms of sarcoma affecting the larynx are 
 very similar to those of simple laryngeal tumours. 
 One of the earliest symptoms is hoarseness or some 
 slight affection of the voice, although this is much 
 less frequent and marked than in carcinoma. 
 
 Pain, especially in the early stages, is absent, or 
 only slight, though it may become more marked 
 later on. At all events, it is invariably much less 
 intense than in carcinoma. There may be a feeling 
 as of a foreign body in the throat, and the patient 
 may suffer from impeded respiration, and, as the 
 glottis becomes narrowed, stenosis may become well 
 marked. 
 
 Dysphagia, especially in sarcoma attacking the 
 epiglottis, is often present, and may sometimes be 
 very severe. 
 
 Secretion is usually insignificant ; if ulceration be 
 present it may be blood-stained. 
 
 As already stated, the neighbouring glands are in 
 most instances not affected, although they are liable 
 to become involved in the later periods of the disease. 
 
Sarcoma of the Larynx 95 
 
 Even in the later stages, however, the glands usually 
 escape infection. 
 
 Limited movement of the cords may be present 
 or absent, although, according to some laryngolo- 
 gists, this symptom has not the same significance as 
 in carcinoma. 
 
 Diagnosis. 
 
 Before a course of treatment which may be deemed 
 suitable to any given case can be pursued, a correct 
 diagnosis of the nature of the tumour must be made. 
 
 In some instances it may be easy to decide that a 
 certain tumour is sarcomatous, but this is not at all 
 the rule. It is usually very difficult to distinguish 
 from the objective symptoms or from the external 
 characters of the tumour between sarcoma and 
 carcinoma on the one hand, between sarcoma and 
 innocent tumours on the other hand. It is also 
 difficult to diagnose in certain cases between sarcoma 
 and gummatous deposits or syphilitic perichondritis. 
 
 The external characters of the tumour, although 
 they may lead to the suspicion that the disease is 
 malignant and yet not carcinoma, can seldom be 
 implicitly relied on. The absence of ulceration has 
 already been alluded to, but ulceration may be 
 absent in carcinoma, and is generally absent in non- 
 malignant tumours. 
 
 Fortunately, however, the diagnosis, which might 
 seem from what has just been said to be so difficult, 
 may easily be made in almost every case by compara- 
 tively simple means. A portion of the tumour may 
 be removed with the cutting laryngeal forceps, and 
 
96 Malignant Disease of the Larynx 
 
 be subjected to microscopical examination. Tumours 
 of the epiglottis and extrinsic portions of the larynx 
 may be treated in this way with scarcely any difficulty ; 
 tumours of the ventricular bands and vocal cords 
 wdth greater difficulty, of course, but with a difficulty 
 which depends largely on the size and exact situa- 
 tion of the tumour. It must be understood that the 
 fragment thus removed be subjected to a searching 
 microscopical examination, and that several sections 
 of the fragment removed be made. It is important 
 to examine all parts of the excised fragment, especi- 
 ally its base. The removal endolaryngeally of even 
 a large fragment is productive of scarcely any pain, 
 and so far from being dangerous, has often afforded 
 marked temporary relief. 
 
 Prognosis. 
 
 Sarcoma of the larynx, compared with carcinoma, 
 offers a much more favourable prognosis, both with 
 regard to life and tendency to recurrence. In com- 
 parison with innocent tumours the prognosis is a 
 great deal worse. 
 
 The tendency of the disease is to cause death from 
 suffocation or exhaustion, and this may take place 
 within a year or eighteen months of the first appear- 
 ance of the disease. Usually, however, the course of 
 the disease is much slower, and the patient may live 
 for two, three, or more years. 
 
Sarcoma of the Larynx 97 
 
 Treatment. 
 
 It is hardly necessary to mention that the only 
 rational treatment for laryngeal sarcoma is operative. 
 Palliative treatment may demand tracheotomy, and 
 in some cases Coley's fluid (toxin of Streptococcus 
 ery sip el at OS us and Bacillus prodigiosus) has been in- 
 jected, but with no good results. 
 
 Such measures as the employment of the galvano- 
 cautery, the use of caustics, etc., should be strongly 
 condemned, for they merely stimulate the activity of 
 the growth. 
 
 The operative measures that have been employed 
 for the removal of sarcoma of the larynx are as 
 follows : 
 
 1. Endolaryngeal Removal. 
 
 2. Suprathyroid Laryngotomy. 
 
 3. Infrathyroid Laryngotomy. 
 
 4. Thyrotomy. 
 
 5. Partial Extirpation of the Larynx. 
 
 6. Total Extirpation of the Larynx. 
 
 (i) Endolaryng-eal Removal. — If mere removal 
 with endolaryngeal forceps ^er vias naturales be con- 
 sidered, few, if any, complete recoveries can be 
 claimed. In the section of his work which is devoted 
 to sarcoma Mackenzie spoke hopefully of the endo- 
 laryngeal method, and stated : ' In one case I suc- 
 ceeded in permanently removing the growth per vias 
 naturales, and Navratil, Gottstein, Tiirck, and others 
 have effected cures in this way.' This was in the 
 year 1881. 
 
 7 
 
98 Malignant Disease of the Larynx 
 
 Now, on examining these references of Mackenzie's, 
 we find that in only one case, that of Gottstein's, 
 was a permanent cure effected. The patient was a 
 boy aged seven, suffering from a fibro-sarcoma of the 
 vocal cord ; the tumour was removed with a snare, 
 and thirteen years later the boy was still well and his 
 voice good. 
 
 In Navratil's case the diagnosis was not confirmed 
 microscopically, and the later history of the case is 
 unknown. 
 
 In Tiirck's case, a round-celled sarcoma of the left 
 vocal cord, the subsequent history is also unknown. 
 
 Taking Sendziak's series of cases, we find he has 
 collected 13 in which endolaryngeal removal was 
 performed. 
 
 Of actual cures — that is to say, longer than three 
 years without recurrence — there is only i case, 
 namely, that of Gottstein's, already referred to. 
 
 Of relative cures — that is to say, no return up to 
 one year after — 2 cases. 
 
 Of recurrences 5 cases (i.e., from two to eight 
 months). Results uncertain, 5 cases. 
 
 What has already been said as to the limitation of 
 this method of operation with regard to carcinoma 
 of the larynx holds equally good in connection with 
 sarcoma. Only in those suffering from extreme old 
 age or grave impairment of the health should this 
 method be attempted. 
 
 (2) Suprathyroid Laryngotomy. — The number 
 of cases in which suprathyroid laryngotomy has 
 been performed is too few to be able to judge the 
 value of the operation. 
 
Sarcoma of the Larynx 99 
 
 It has been performed for the removal of growths 
 situated at the upper opening of the larynx, particu- 
 larly in connection with the epiglottis. 
 
 Burow, for instance, has described the case of a 
 man thirty years of age who suffered from a spindle- 
 celled sarcoma of the epiglottis. It was removed 
 with forceps and cautery, a little later with the steel 
 loop, and again a few days later with a sharp spoon 
 and scissors, after a free incision had been made in 
 the sublingual region. Eighteen months after the 
 last operation the patient was quite well. This is 
 the more remarkable because the original tumour had 
 grown very rapidly, and recurrence had taken place 
 almost immediately. 
 
 (3) Infrathyroid Laryngotomy. — What has already 
 been said as to the indications and value of this 
 operation as applied to carcinoma of the larynx 
 equally applies to sarcoma of the larynx. 
 
 (4) Thyrotomy or Laryngo-fissure. — The first 
 case, apparently, in which thyrotomy was performed 
 for sarcoma of the larynx is mentioned by Laroyenne. 
 The patient was a woman suffering from a spindle- 
 celled sarcoma of the right vocal cord, which had 
 been growing for about twelve months. It was 
 removed after division of the thyroid cartilage. 
 Eight months after the operation she was free from 
 disease. 
 
 Sendziak has collected 12 cases of sarcoma in which 
 thyrotomy was performed. Two of the 12 patients 
 were well and free from disease, i four years 
 after the operation, and the other nearly five 
 years after it was performed. This, therefore, 
 
 7—2 
 
loo Malignant Disease of the Larynx 
 
 insures 2 thoroughly successful cases out of the total 
 of 12. 
 
 None of the other patients can be claimed to have 
 been cured, but 4 of them were well two years, or 
 nearly two years, after the operation, and 2 other 
 patients were well a year after the operation. There 
 were 2 cases, also, in whom too short a period had 
 elapsed since the operation to judge of the results, 
 while recurrence of the disease was only noted in 
 2 of the 12 cases. 
 
 In no case was there a fatal issue from the opera- 
 tion itself, and the phonatory results were as good as 
 the general results. 
 
 (5) Partial Laryngectomy. — In Sendziak's tables 
 there is a series of 10 cases recorded in which partial 
 laryngectomy was performed for sarcoma. 
 
 The results are very different from those following 
 thyrotomy. 
 
 One patient was free from recurrence four years 
 after the removal of a round-celled sarcoma of the 
 left true and false cords (Bull, of America). Three 
 died of lung mischief (apparently non-malignant) at 
 periods of three months, twelve months, and eighteen 
 months after the operation, and without any sign of 
 recurrence of the disease. One patient suffered from 
 immediate recurrence of the disease, and Kiister 
 successfully removed the whole of the larynx. 
 Another patient died of recurrence two and a half 
 years after operation. Three patients died as a 
 result of the operation, 2 on the third day from coma, 
 and I from pneumonia. The remaining patient was 
 still well about a year after the operation. 
 
Sarcoma of the Larynx ioi 
 
 (6) Total Extirpation of the Larynx. — An 
 
 analysis of Sendziak's ii cases furnishes really 
 better results. 
 
 There were 3 cases of definite cure, i patient 
 being quite well seven, another eight, and yet 
 another fifteen years after the operation. Of the 
 remaining 8 cases, however, it is found that 4 
 died of recurrence of the disease five months, seven 
 months, one year, and fifteen months respectively 
 after the operation, and 3 as a result of the 
 operation, w^hile in i case the time that had 
 elapsed since operation was too short to be able to 
 judge of the result. 
 
 The results, therefore, of the ^^ operations 
 included under thyrotomy, partial and complete 
 laryngectomy, can hardly, from any point of view, be 
 called good, yet they are not wholly bad, because, in 
 addition to the really successful cases, there are 
 several in which there is reason to hope that the 
 result proved quite successful. 
 
 The successful laryngectomies were performed for 
 three varieties of sarcoma, one round and spindle- 
 celled, the second lympho-sarcoma, and the third 
 ' sarcoma carcinomatodes.' 
 
 The results of these various operations for sarcoma 
 of the larynx, when compared together, work out as 
 follows : 
 
 Per Cent, of 
 Good Results. 
 
 1. Thyrotomy (best measure) - - 58'3 
 
 2. Total laryngectomy . . . ^6'^ 
 
 3. Partial laryngectomy - - -30 
 
 4. Suprathyroid laryngotomy - - ^S 
 
 5. Endolaryngeal removal - - - 23 
 
I02 Malignant Disease of the Larynx 
 
 By good results are understood the cases of definite 
 as well as relative cures. 
 
 If we take the definite cures by themselves the 
 results work out as follows : 
 
 Per Cent. 
 
 1. Total laryngectomy - - - 27'3 
 
 2. Partial laryngectomy - - - lo'o 
 
 3. Thyrotomy _ . . . g-^ 
 
 4. Endolaryngeal removal - - - 8'o 
 
 The relative cures give : 
 
 Per Cent. 
 
 1. Thyrotomy - - - " 50 
 
 2. Partial laryngectomy - - - 20 
 
 3. Endolaryngeal removal - - -15 
 
 4. Total laryngectomy - - - 9 
 
 Now, taking the had results as regards {a) recur- 
 rence, {b) fatal results, we find : 
 
 {a) Recurrence. 
 
 Per Cent. 
 
 Endolaryngeal ... - 38-5 
 
 Partial laryngectomy - - - 20 
 
 Total laryngectomy - - - - 18 
 
 Thyrotomy ----- i6'6 
 
 (b) Fatal Results {within Two Weeks of the Operation). 
 
 Per Cent. 
 
 Partial laryngectomy - ■ - 80 
 
 Total laryngectomy - - - - 27 '3 
 
 There have been no fatal results at all from 
 thyrotomy or endolaryngeal operation. 
 
 Where total laryngectomy is indicated, the results 
 apparently are better than in similar conditions for 
 carcinoma of the larynx. 
 
 The treatment of sarcoma of the larynx is thus in 
 most instances clear. 
 
Sarcoma of the Larynx 103 
 
 When the disease is of intrinsic origin, limited in 
 extent, especially to one cord or ventricular band, 
 thyrotomy should undoubtedly be performed. Simi- 
 larly, thyrotomy is indicated after recurrence follow- 
 ing the endolaryngeal method (this latter method 
 should, however, only exceptionally be advised), and 
 also as a preliminary diagnostic step to laryngectomy. 
 When, after thyrotomy, the disease recurs and ex- 
 hibits signs of more extensive infiltration, or when 
 from the first it presents a much more formidable 
 appearance — in those instances, for example, when 
 the entire larynx seems filled by a sarcomatous 
 tumour, the attachments of which are evidently 
 deep-seated and widely extended — the question of 
 removal of the larynx, either partial or complete, 
 will naturally be raised. 
 
 If the patient be not too old or weak for so severe 
 an operation, and if it be certain that the disease can 
 be entirely removed, especially if it be limited to the 
 interior of the larynx, and that at the same time 
 thyrotomy will not meet the case, then extirpation, 
 partial or complete, of the affected organ is indi- 
 cated. 
 
 The question very naturally arises how far the 
 removal of the larynx contributes to a fatal issue 
 from pulmonary disease. Out of Sendziak's 21 cases 
 a fatal issue from lung trouble occurred in 4 patients ; 
 I, three months after operation, from pneumonia; 
 2 from pleuritis, twelve and fifteen months respec- 
 tively after operation ; and i from tubercle, eighteen 
 months subsequent to removal of the larynx. Of 
 deaths from the operation itself there are 5 cases, 
 
I04 Malignant Disease of the Larynx 
 
 and of these 3 were from pneumonia and 2 from 
 coma. 
 
 There can therefore scarcely be a doubt that 
 removal of the larynx, either partial or complete, 
 must increase the liability to pulmonary affections, 
 immediate or remote. 
 
 This, however, should not contra-indicate the per- 
 formance of the operation whenever it is clearly indi- 
 cated in cases of sarcoma. Improved methods of 
 operation have of recent years tended to lessen these 
 liabilities, and it must be remembered that death 
 from an acute or even tolerably chronic pulmonary 
 disease is in most instances preferable to death from 
 obstruction of the larynx and its attendant evils 
 when the obstruction is due to a sarcomatous 
 tumour. 
 
 Contra-indications to the operation (partial or 
 complete laryngectomy) are general bad condition 
 of the patient, too extensive growth, affection of the 
 neighbouring parts — i.e., pharynx, etc. — and, lastly, 
 tubercle of the lungs. 
 
INDEX 
 
 CARCINOMA OF THE LARYNX 
 
 After-treatment of opera- 
 tions, 6i 
 Age, 6 
 
 Anatomy, pathological, g 
 Auto-infection, 6 
 
 Benign tumours, 45 
 
 Cachexia, 38 
 
 Cannula, 54 
 
 Chronic irritation, 4 
 
 Chronic laryngitis, 44 
 
 Complete excision of larynx, 61 
 
 Contagion, 6 
 
 Cures due to operation, 75 
 
 Diagnosis, 42 
 
 differential, 44 
 
 from benign tumours, 45 
 from chronic laryngitis, 
 from lupus, 48 [44 
 
 from pachydermia, 46 
 from paralyses, 48 
 from syphilis, 47 
 from tubercle, 48 
 
 Dysphagia, 37 
 
 Dyspnoea, 37 
 
 Endolaryngeal operations, 50 
 
 Etiology, 3 
 
 Excision of glands, 82 
 
 of larynx, 61 
 Expectoration, 37 
 Extrinsic carcinoma, 9, 16 
 
 symptoms of, 35 
 
 Glands, excision of, 82 
 immunity of, 25 
 implication of, 22, 27 
 prelaryngeal, 14, 26 
 pre-tracheal, 15, 26 
 pre-thyroidean, 15, 26 
 recurrent laryngeal, 15, 26 
 sterno-mastoid, 15, 26 
 
 Haemorrhage, 37 
 Heredity, 3 
 
 Histological structure, 33 
 History, i 
 Hoarseness, 34 
 
 Impaired mobility of vocal cords, 
 
 40, 44 
 Indications for operation, 81 
 Infrathyroid laryngotomy, 52 
 Intrinsic carcinoma, 9, 17 
 symptoms of, 34 
 
 Lupus, 48 
 
 Lymphatic channels, 13 
 Lymphatic radicles, 12 
 Lymphatics of larynx, 10 
 
 attenuation of, 12, 21 
 
 atrophy of, 21, 26 
 
 Mortality from partial excision 
 of larynx, 73 
 from total excision of larynx, 
 
 74 
 from thyrotomy, 71 
 
 105 
 
io6 Malignant Disease of the Larynx 
 
 CEdema, 39 
 
 Pachydermia, 46 
 
 Pain, 36 
 
 Palliative treatment, 83 
 
 Paralyses, 48 
 
 Partial excision of larynx, 68 
 
 cures from, 77 
 
 indications for, 81 
 
 mortality from, 73 
 
 recurrence after, 79 
 Pathological anatomy, 9 
 Perichondritis, 38 
 Prelaryngeal glands, 14, 26 
 Pre-thyroidean, 15, 26 
 Pre-tracheal glands, 15, 26 
 Prognosis, 49 
 
 Radical treatment, 50 
 Radium, 85 
 
 Recurrence after operation, 79 
 Recurrent laryngeal glands, 15, 
 26 
 
 Secretion, 35 
 Serum therapy, 85 
 
 Sex, 8 
 Signs, 38 
 
 Simple tumours, 5 
 Sterno-mastoid glands, 15, 26 
 Subglottic carcinoma, 18 
 Subhyoid pharyngotomy, 51 
 Suprathyroid laryngotomy, 51 
 Symptoms, 34 
 Syphilis, 5, 47 
 
 Tampon cannula, 54 
 
 Thyrotomy, operation of, 53 
 cures from, 76 
 indications for, 81 
 mortality from, 6g, 71 
 recurrence after, 79 
 shears for, 55 
 
 Tracheotomy, 84 
 
 Tubercle, 5, 48 
 
 Ulceration, 39 
 
 Vocal cords, impaired mobility 
 of, 40, 44 
 
 X rays, 85 
 
 SARCOMA OF THE LARYNX 
 
 Age, 87 
 
 Clinical varieties, 92 
 Coley's fluid, 97 
 Consistency, 93 
 
 Contra-indications to operation, 
 104 
 
 Diagnosis, 95 
 Dysphagia, 94 
 
 Endolaryngeal removal, 97 
 
 results of, 98 
 
 indications for, 98 
 Etiology, 87 
 Extrinsic, 89 
 
 Frequency, 87 
 
 Glands, lymphatic, 91 
 
 affection of, 90 
 Gummatous deposits, 95 
 
 Histology, 91 
 Hoarseness, 94 
 
 Impeded respiration, 94 
 Indications for operation, loi 
 Infiltration, 93 
 
 Infrathyroid laryngotomy, 99 
 Intrinsic, 89 
 
 Laryngectomy, partial, results 
 of, 100 
 
 total, results of, loi 
 Laryngotomy, infrathyroid, 99 
 
 suprathyroid, 98 
 Lymphatic vessels, 91 
 
Index 
 
 107 
 
 Metastasis, 89 
 
 Microscopical examination of 
 fragments, 95 
 
 Operations for, results of, loi 
 
 Pain, 94 
 
 Perichondritis, 95 
 Primary, 89 
 Prognosis, 96 
 Pulmonary disease, 103 
 
 Rapidity, 94 
 
 Results of operations, loi 
 
 Secondary, 89 
 
 Secretion, 94 
 
 Situation, 89 
 
 Stenosis, 94 
 
 Suprathyroid laryngotomy, 98 
 
 Symptoms, 94 
 
 Thyrotomy, 99 
 
 results of, 100 
 Tracheotomy, 97 
 Treatment, 97, 103 
 
 Ulceration, 93 
 
 Vocal cords, impaired mobility 
 of, 94 
 
 THE END 
 
 Bailliere, Tindall, &= Cox, 8, Henrietta Street, Covent Garden 
 
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