A System of Operative Surgery Part 75

Endothelioma has not often been discovered.

The importance of distinguishing innocent from malignant tumours is greater now than in former years, since it is agreed that endolaryngeal operations are preferable for the eradication of the former, while the latter are better treated by extra-laryngeal methods. Moreover, the differential diagnosis has steadily improved, owing to the more general use of the laryngoscope and the introduction of recent methods of examination. Thus, by direct laryngoscopy it is possible to investigate children as easily as adults. Microscopical examination of fragments removed with laryngeal forceps is of great value in confirming the clinical diagnosis; the sections can be made by freezing, or in paraffin, the latter method requiring, with recent improvements, not more than twenty-four hours. Semon, who has done more than any other man to improve the early diagnosis of malignant disease of the larynx, is strongly in favour of such examinations. It must be remembered, however, that the result is sometimes inconclusive, for it is difficult to be certain that the actual growth has been removed. In cases that are thought to be malignant, it is better to open the thyreoid[6] cartilage than to rely upon endolaryngeal operation, as there is a danger of stimulating the growth to greater activity, especially by repeated interference. When the thyreoid cartilage has been opened, the whole disease can be explored thoroughly and a fragment selected from which to make a frozen section. In the majority of cases a definite diagnosis can thus be arrived at, and even when it is necessary to examine several fragments the amount of time lost is small.

[6] [The spelling of this word has been adopted in conformity with the Basle Anatomical Nomenclature.--Ed.]

As regards the value of skiagraphy, Walsham and myself have found that photographs can be made of tumours of the larynx which in some instances determine accurately the position and extent of the disease.

[Ill.u.s.tration: FIG. 254. SKIAGRAM SHOWING A TUMOUR OF THE LARYNX. A, Tumour; B, Body of hyoid; C, Greater cornu of hyoid; D, Epiglottis; E, Posterior plate of cricoid; F, Vocal cord; G, Trachea; H, sophagus.]

Fig. 254 is a photograph showing a cancer of the upper opening of the larynx, lying above the vocal cords, the position of which was proved to be accurate by later operation upon the patient. It is, however, doubtful whether the method will eventually a.s.sist in the differential diagnosis between innocent and malignant growths.

(ii) _Tuberculosis._ Endolaryngeal operations are successfully performed for chronic conditions such as ulceration or tumour, and, rarely, in acute forms such as abscess, necrosis, and the like. Removal of a portion of the epiglottis occasionally gives great relief to a patient who is suffering from dysphagia.

(iii) _Strictures_ resulting from trauma, from the ulcerations of syphilis, diphtheria, and other inflammatory diseases, or caused by congenital webs.

(iv) _Foreign bodies_ impacted in the larynx.

(v) _dema_ of the mucous membrane due to trauma or inflammation, local abscess, necrosis, and other allied conditions, in which obstruction is likely to supervene.

The operation may be performed either by indirect or by direct laryngoscopy.

OPERATION BY INDIRECT LARYNGOSCOPY

It being essential that the patient should be tolerant, this method is chiefly applicable in the case of adults. The operation may require a course of instruction, but this presents no difficulty if given with discretion. The employment of cocaine, novocaine, and adrenalin is of the greatest importance to both surgeon and patient. Cocaine, which is generally to be preferred, may be used in strong solutions--10 or even 20%--if applied to the mucosa by a small swab of wool; but, if used as a spray, weaker solutions are employed (4%). With neurotic patients cocaine must be applied cautiously, as a sense of suffocation is sometimes produced. It is necessary first to treat the soft palate, the uvula, base of the tongue, pharynx, and epiglottis; secondly, with the help of a laryngeal mirror, the interior of the larynx must be cocainized; this can be accomplished by expelling a few drops of the solution from a laryngeal syringe or by means of a swab attached to a suitable wool-carrier. Fifteen to twenty minutes must be allowed to gain the full effect of anaesthesia. The patient must be instructed on no account to swallow the saliva. The secret of successful intralaryngeal operations lies in the thorough application of these principles, and in not attempting the operation until the patient is able to tolerate the presence of an instrument within the larynx. The surgeon must be experienced in the use of laryngeal instruments, and must be provided with a complete equipment, including forceps (Mackenzie's, Whistler's, Grant's, &c.), which must be of different lengths to suit the patient, snares, galvano-cautery, curettes, probes, and other instruments for the application of drugs. Proper illumination is also very important.

When removing an intralaryngeal growth, the surgeon sits facing the patient. The mouth is opened to the fullest extent, and the tongue drawn well forward and held by the patient's right hand. The mirror is introduced in such a way that the tumour is distinctly seen. If the epiglottis overhangs, it can be drawn forward with the forceps; or, in rare instances, a special instrument (Fig. 255) can be used for transfixing its upper margin with a thread, the latter being grasped by a pair of pressure forceps, which, being allowed to hang, will automatically raise the obstruction.

The forceps, having been warmed, are taken in the right hand when the tumour is on the right side of the larynx and in the left hand when the tumour is on the left, thus allowing a clearer view than when the same hand is employed irrespective of the position of the disease. It is introduced as follows: firstly, the handle is directed towards the patient's left ear until the point of the forceps has pa.s.sed beyond the back of the tongue and lies behind the epiglottis; secondly, the instrument is quickly rotated so that the handle lies below the chin; thirdly, the hand is raised so that the point is directed forwards; fourthly, the whole instrument is quietly lowered and the beak of the forceps directed towards the growth. This manipulation is made more difficult by the laryngeal image being reversed in an antero-posterior direction.

[Ill.u.s.tration: FIG. 255. HORSFORD'S INSTRUMENT FOR TRANSFIXING THE EPIGLOTTIS.]

When the point is seen to rest upon the growth, the instrument is opened, and the tumour grasped and avulsed: with careful manipulation there is little danger of wounding the normal mucosa, and haemorrhage is insignificant. When dealing with multiple growths the patient must understand that it may be necessary to repeat the operation, either immediately or after an interval. Given suitable instruments, sufficient experience, and a tolerant patient, it is possible to remove, with the help of cocaine, the majority of simple tumours. Operations upon cysts, the scarification of mucous membrane with a guarded knife, the curettement of tuberculous ulcers, and cauterization of the larynx, are all conducted upon similar lines. Foreign bodies can generally be removed with forceps; thus, F. A. Rose[7] reported a case in which part of the breastbone of a chicken, measuring 1 inch in length and over 3/4 of an inch in width, was removed after having been impacted in the larynx for nearly forty-eight hours. In rare instances such an operation is not successful; _e.g._ with a foreign body firmly impacted, multiple papillomata, or an intolerant patient, general anaesthesia may be required, and removal may have to be effected through a tube-spatula or by external incision.

[7] _Proc. Roy. Soc. Med. London_, vol. i, No. 2, Laryn. Sect., p. 5.

=After-treatment.= Intralaryngeal wounds generally heal well, but every effort should be made to prevent infection of the parts, to allay any inflammation that may arise, and to avoid catarrh and swelling of the mucosa. It is advisable to order complete vocal rest until the redness has subsided, and the patient should refrain from coughing; the sucking of ice, or the inhalation of benzoin or other medicated steam, has a sedative action upon the parts. If the larynx becomes septic or filled with irritating discharge, the use of sprays or powders is indicated; in such a case the patient may be given a parolein spray, with menthol, eucalyptus, or other antiseptic, for constant use; or a powder such as orthoform, the latter being sucked into the larynx through a warmed gla.s.s tube (Leduc's insufflator), or applied by the surgeon. In the later stages the patient may be treated by the local application of caustic fluids, or by galvano-cautery, as occasion requires. The success of such operations depends largely upon the skill of the surgeon; if attention be given to the after-treatment the results are very good, and the voice is generally recovered. As Semon has shown conclusively, there is no practical danger of the occurrence of malignant degeneration through the influence of instrumentation.

OPERATION BY DIRECT LARYNGOSCOPY

=(Killian's Method)=

=Indications.= (i) _Multiple papillomata._ These tumours occur most commonly during the early years of life, and operations for their removal present great difficulties, first, in their removal, and, secondly, owing to their inveterate tendency to recurrence whatever operation is performed; moreover, in some instances operation seems to stimulate the growths to greater activity. The case reported by Stoker is a well-known instance. He was consulted by a man thirty years of age who had suffered from papilloma for twenty-three years, during which period one surgeon had performed 100, and a second 120 operations.

(ii) _Benign tumours_ other than papillomata, which are not amenable to operation by indirect laryngoscopy.

(iii) _Foreign bodies._ Direct laryngoscopy is advised for patients who are intolerant (_e.g._ young children), or when the object is firmly impacted, or when other methods of treatment have failed. Thus in one of my cases a man presented himself with a long pin impacted transversely above the vocal cords; it was found impossible to remove it by indirect laryngoscopy without serious injury to the parts. An anaesthetic was therefore given and a large tube-spatula pa.s.sed into the larynx: with strong forceps the pin was bent upwards and removed with ease.

(iv) _Granulations_, _ulcers_, _necrosis_, and other _inflammatory conditions_ such as are caused by diphtheria, tubercle, syphilis, and many other diseases.

(v) _For diagnostic purposes._ There can be little doubt that direct laryngoscopy has a great future before it as a means of determining the nature of doubtful laryngeal conditions. If the upper parts of the larynx be swollen, if there be any stenosis such as follows ulceration, or if the patient be intolerant, the air-pa.s.sages cannot be thoroughly examined with the laryngoscope alone. With the newer method many of these difficulties have disappeared, and it is now possible for the surgeon to diagnose with certainty many conditions which would otherwise have remained doubtful.

_The apparatus required_ consists of:

(_a_) The _tube-spatulae_. The tube originally suggested by Killian was made of straight metal and circular in section, the distal end being cut obliquely with the projecting portion fashioned like a spatula. A strong handle, at right angles to the tube, was used for manipulation.

Different sizes were required for children and adults. Various modifications of these tubes are now in use, notably those of Mosher and Bruenings: the instrument recommended by the latter is easier to manipulate and gives a better view than the earlier forms described.

[Ill.u.s.tration: FIG. 256. MULTIPLE PAPILLOMATA OF THE LARYNX. (_From Specimen No. 1647 in the Museum of St. Bartholomew's Hospital._)]

(_b_) The _lamp_ for illumination. Different forms of head-lamp (Killian's, Kirstein's) and hand-lamp (Caspar's) have been devised for illumination from the outside, and Chevalier Jackson has invented a lamp which is sufficiently small to pa.s.s to the distal end of the tube, where it lies in a compartment of its own lest it should be broken and fall into the trachea. Recently these electroscopes have been improved upon by Bruenings, in whose instrument (Fig. 257) the lamp is more powerful and is attached to the handle in such a manner that it can be easily swung into position when required. A condensing lens has also been added and the light can be focused to any desired distance. If preferred, an ordinary forehead-mirror reflecting the light from a powerful Nernst lamp (100 c.p.) can be employed.

(_c_) The _instruments_ for operation. Various forms of forceps for removal of tumours have been devised by Killian, von Eicken, Bruenings, Patterson, and others. In any form that is employed it is necessary, in order to allow of clear vision, that the handle should be set at an angle with the shaft. For foreign bodies, hooks of different shapes are also useful. Other requirements include a gag for opening the mouth, a tongue depressor, tongue forceps, suitable cotton-wool carriers, the requisites for tracheotomy, and a darkened room.

[Ill.u.s.tration: FIG. 257. TUBE-SPATULae USED FOR LARYNGOSCOPY. A, Killian's. B, Bruenings'. A, Handle; B, Collar to allow rotation; C, Fixation spring; D, Switch; E, Socket for lamp; F, Focus; G, Lamp; H, Lens; I, Aperture for eye; K, Reflector.]

=Operation.= The operation can be performed with local or general anaesthesia. With patients who are intolerant chloroform is more reliable, and is preferable to other drugs, which tend to excite secretion. Chloroform should always be employed for children. It should be given slowly and in the smallest possible quant.i.ty, the head of the patient being kept lower than the body to allow blood and mucus to drain away from the trachea. To make the parts more tolerant, cocaine can also be applied to the vocal cords, or a dose of morphine (codeine is advised in children) can be given half an hour before the operation. The importance of a skilled anaesthetist cannot be too strongly emphasized.

With chloroform, the patient should lie upon the back or right side, with the head projecting beyond the end of the table, so that the neck can be extended as required. With cocaine the upright position is often preferred, and the patient should sit on a low stool facing the surgeon.

When the patient is rec.u.mbent, the surgeon should sit or kneel behind the head (Fig. 258). He should observe the strictest antiseptic precautions, and should introduce no instrument which has not been properly sterilized; further, the tubes should be previously warmed to prevent 'fogging', and oiled with sterilized liquid paraffin before introduction. There should be two a.s.sistants, one (the chloroformist) to support the head and watch the respiration and pulse, the other to help with instruments.

In order to examine the larynx, the mouth is opened by a gag, and the tube-spatula is pa.s.sed to the upper border of the epiglottis; when this has been inspected the spatula is pushed behind it, and the upper portion of the cricoid plate is examined; the tongue is then pulled forward and the tube tilted so that the larynx can be seen. The examination should be methodical, and should include the vocal cords, ventricular bands, and openings of the ventricles. The whole manipulation can be performed with great delicacy, and is entirely guided by the eye, so that there is little fear of injury even in young children.

In this and the further technique the chief difficulties are caused by: (_a_) _The prominence of the upper teeth._ This may seriously interfere with the easy pa.s.sage of a straight tube, even when the neck is fully extended. The difficulty can be overcome by turning the head laterally, so that the tube pa.s.ses through the opposite angle of the mouth. (_b_) _The mucus_, which collects in the tube and obstructs the vision. This must be overcome by using a secretion aspirator, by frequent sponging, or, as suggested by Ingals, by giving a previous dose of atropin[e].

(_c_) _Intolerance of the parts_, which can be counteracted by the judicious use of cocaine (10%). It may be noted that this combination of chloroform and cocaine is not dangerous, even in young children, so long as the cocaine is prevented from running into the pharynx.

[Ill.u.s.tration: FIG. 258. REMOVAL OF MULTIPLE PAPILLOMATA BY DIRECT LARYNGOSCOPY]

The condition of the larynx having been thoroughly examined, the operation can proceed. The method of removing multiple papillomata will first be described. In some cases it will be found that better exposure of the tumours is obtained if the end of the tube is placed above the epiglottis rather than in the larynx itself. The position of the growths having been determined, a suitable forceps is selected and introduced through the tube. The papillomata are seized and avulsed separately, without injury to the normal tissues. To arrest the bleeding it may be necessary to apply cocaine and adrenalin mixture, and to raise the foot of the table so that the blood drains away from the field of operation.

As far as possible, all the growths should be removed; it may be difficult to attack those which are situated in the anterior commissure or subglottic region, but this difficulty may be overcome by the use of specially devised instruments; thus, von Eicken has invented a tube which is long enough to pa.s.s through the larynx and into the trachea, the portion lying in the larynx being provided with a lateral window which can be turned in any direction, so that a growth can be made to project into the tube, where it can be easily removed.

At any moment during this operation the surgeon may be called upon to perform tracheotomy.

=After-treatment.= This must be carried out upon the same lines as those already suggested; everything must be done to relieve congestion and irritation. Killian advises internal administration of a.r.s.enic for a period of several months, and, if this fails, pota.s.sium iodide in large doses. It should be remembered that in some instances syphilis seems to play an important part in the causation of these conditions. Ingersole suggests that X-rays prevent recurrence, and may even cause shrinkage of existing growths.

Recurrence occurs in most cases in some degree, and requires further operation; this may be carried out after an interval of a week or longer, according to the case. At these secondary operations it may not be necessary to use the forceps; local applications such as absolute alcohol, salicylic acid in absolute alcohol (2-10%), solutions of silver nitrate or chromic acid, and many other drugs, have been advised by different surgeons. Wylie is strongly in favour of the galvano-cautery, and is of opinion that the technique is more reliable and the liability of local infectivity diminished. If the latter method be employed, very little should be done at one sitting, otherwise great inflammatory reaction may be set up, entailing tracheotomy. A tracheotomy tube may be required for a short time while such treatment is being carried out; some surgeons, with whom the author does not agree, always perform preliminary tracheotomy, and claim that the papillomata are less likely to recur if complete rest is thus given to the larynx.

=Results.= In discussing the value of the above method it is necessary to refer to the results obtained by other operations, such as--

(i) _Tracheotomy_ (see p. 522). This operation has been advocated as a method of curing papillomata. It has been noted that by giving rest to the larynx the congestion is relieved, the papillomata decrease in size, and in some cases completely disappear. Mackenzie[8] published seven cases which he had had under observation for a minimum of two years, with four recoveries, the canula having been worn for periods varying from six to fifteen months. He also mentioned thirteen other cases in which good results had been obtained by other surgeons, and was of opinion that the method was most successful with 'virgin' cases. There are, however, many objections to this form of treatment. For instance, it is often necessary to retain the tube for a prolonged period, two years or longer, and even then the result is doubtful; moreover, the prolonged use of a canula is disastrous to the larynx, not only in r.e.t.a.r.ding development, but also in the production of stenosis; there is also a danger of bronchitis, of broncho-pneumonia, and possibly of tuberculosis. In regard to the last, G. A. Wright,[9] in reporting a case in which tubercle supervened, argues that 'presumably there is more risk of this happening to the wearer of a tracheotomy tube than when breathing in a normal way through the mouth or nose'. Further, the line of treatment is difficult to enforce on account of the aversion shared by most parents to the performance of tracheotomy.

[8] _Brit. Med. Journ._, 1901, vol. ii, p. 883.

[9] Ashby and Wright, _Dis. of Child._, 4th ed., p. 350.

(ii) _Laryngo-fissure_ (see p. 487). Under this head are included thyrotomy, or complete division of the thyreoid cartilage; partial thyrotomy, where a small portion of the upper or lower part of the thyreoid cartilage is left intact (an operation which does not give a good exposure of the larynx); infrathyreoid laryngotomy, which is only applicable to adults; cricotomy, with division of the cricoid cartilage and crico-thyreoid membrane; and subhyoid pharyngotomy. Of the above, thyrotomy is the most satisfactory operation, because it gives the best exposure of the parts and facilitates removal of the growths; recurrence, however, is frequent, permanent injury to the voice is common, and stenosis may result.

The results of these operations, especially during childhood, are by no means satisfactory. In the statistics carried up to 1896, collected by Rosenberg and von Bruns,[10] laryngotomy was performed 143 times on 109 children; 11 were operated upon twice, 3 children three times, and 1 child seventeen times. 52 of the children were under four years of age; 20 died, princ.i.p.ally from suffocation with recurrent papillomata; 43 showed recurrences after repeated operation; 40 were cured (_i.e._ 36%), and of these 10 showed disturbance of voice.

[10] Bergmann, E. von, _Sys. Pract. Surg._, vol. ii, p. 231.