LARYNGECTOMY UNDER EUCAINE A well-built man of forty-six years of age was re ferred by the laryngologist of the hospital, Dr. Joseph Gibb, to the wards for the removal of a carcinoma of the larynx. There was no family history of tumors or phthisis, nor had he had syphilis. He had been a moderate drinker and smoker. His present trouble began one and a half years previously, with hoarseness, cough, and slight tenderness in the larynx. Six months ago he experienced difficulty in respiration and his breath became offensive. During the last month the attacks of dyspncea became more frequent, so that finally the patient was unable to get any sleep whatever, and death seemed imminent from suffocation. He had not lost much flesh. The laryngoscope showed an ulcer ating carcinoma of the larynx. There was apparently no glan dular involvement. The case seemed eminently suitable for opera tion, which, however, promised to be difficult on account of the short, thick, full neck. The thyroid cartilage was not at all promi nent, but level with the adjacent surface. The parts to be oper ated on were thoroughly cleansed on the day before the operation, and covered with gauze wet with bichloride solution. Previous to the operation the neck was again cleansed. The assistant and nurse who handed sponges wore rubber gloves, as did also the operator, until after the trachea had been divided and removal of the larynx proper had begun.
The operation was commenced by injecting with a sterilized syringe, previously boiled, I per cent. eucaine B. solution into the skin from just above the hyoid bone to the top of the sternum. A straight incision was made through this anaesthetized area. By gradual dissection, aided by the injection of a few drops of eucaine solution laterally into the parts, the sternohyoid and sternothyroid muscles were separated and turned aside, the deep fascia and isthmus of the thyroid gland cut and the trachea ex posed. Bleeding vessels were carefully clamped, as little tissue as possible being included in the grasp of the forceps. The sternohyoid and thyroid were detached above to allow of greater retraction. The trachea was cleared down to the suprasternal notch, the recurrent laryngeal nerves being pushed backward. Only five or six tracheal rings could be exposed instead of the nine or ten usually found above the sternum. Operating was proceeded with slowly and very carefully and gently, so as to avoid giving unnecessary pain ; quick, rough handling would have caused laryngeal spasm. He was permitted to rest at com paratively short intervals, as he would ask to be allowed to get his breath. The stenosis was marked, and he could only breathe at all by considerable effort. The trachea having finally been fully exposed anteriorly and at the sides, an incision was made across it just below the cricoid cartilage. As bleeding followed the cut, in order to prevent the blood from getting into the trachea, a few drops of eucaine were injected, and the division of the front and sides completed with a few strokes of a Paque lin's cautery-knife. Eucaine was again injected into the mucous membrane of the posterior wall, and after scoring it with the cautery, was divided with the knife. It was then carefully de tached from the esophagus behind and brought forward, a piece of gauze being placed behind the upper portion of the divided trachea to prevent access of blood or infection from the larynx above. It had been the intention to administer chloroform as soon as the trachea had been opened, but the operation had progressed so satisfactorily under local anaesthesia that it was continued. Eucaine was injected alongside the thyroid cartilage, and the remaining attachments of the sternohyoid and omohyoid, sternothyroid, thyrohyoid, and part of the inferior constrictor muscles, and the rest of the soft structures separated to the pos terior border. The rubber gloves being now removed, the hands were again disinfected by the permanganate method. The lower portion of the larynx was lifted up and the upper portion of the esophagus separated from its posterior surface well up on the arytenoid cartilages. The remaining attachments were divided along the left posterior border of the larynx, the latter being drawn to the patient's right. On cutting the structures towards the upper portion the patient flinched, probably when the superior laryngeal nerve was divided. Bleeding from the superior thyroid artery and its branches was quite free, necessitating the applica tion of haemostats. The thyrohyoid membrane and base of the epiglottis were divided and the detachment proceeded with down the right side and the complete larynx removed. The hmmostats were taken off and a few vessels ligated with catgut. The sides of the upper portion of the esophagus were approximated with a couple of catgut sutures. The trachea was stitched in the lower angle of the wound with silk sutures, the skin being slightly drawn in. The wound above the trachea to the hyoid bone fell nicely together, and two silkworm-gut sutures kept the parts well in apposition. The line of the wound and surface adjoining were painted with Whitehead's paint (an ethereal solution of iodo form and benzoin). On the completion of the operation the patient was comfortable, breathing quietly, with a pulse of 1o4, and not the slightest evidences of shock. He was placed in a room the temperature of which never fell below 8o° F., the air being kept moist by boiling water. Gauze was placed over the tracheal opening to prevent the entrance of dust. In all seventy five minims of a 1 per cent. solution of eucaine B. were used. The day of the operation was cold, and it was snowing.
Subsequent Course. He passed a somewhat restless night, being disturbed by coughing. On the second day his temperature rose to 103° and his pulse to 120, and considerable stringy mucus came from the trachea. An alkaline steam-spray was used at intervals. On the third day the temperature was and pulse 12o; respirations, 24 to 3o. He coughed considerably, and some of the silk stitches had cut through and were removed. He could speak in a whisper, and was able to swallow some milk and brandy, a few drops appearing at the wound. At times he was dyspnceic, apparently from mucus in the trachea. He passed a very restless night, and on the fourth day his temperature was 1o3° and pulse 112; respiration, 24. His pulse was feeble; he had profuse sweats and discharged large amounts of mucus from the trachea. On the fifth day he suddenly became wildly delirious and jumped out of bed. On being returned, he made no more attempts to move, and gradually became unconscious. His pulse rose to 136, his temperature from 102.5° to 1o9°, his lungs filled up and he died. His urine at the time of operation was io28 specific gravity, acid, with a faint trace of albumen but no casts ; hyaline casts had, however, been found three days previously. He passed twenty-one ounces the second day, eigh teen the third day, and sixteen the fourth.
Post-mortem Examination. This showed an intense con gestion of the tracheal and bronchial mucous membrane as well as of the kidneys, liver, and spleen. The wound from the trachea up was united by primary union. The trachea was separated from the skin about half a centimetre, and behind its upper edge were a few drops of pus. Streptococcus growths were obtained from the various organs, and Dr. Robertson, the pathologist, gave streptococcus infection as the cause of death.
Inasmuch as the technique of the operation of laryngec torny is still unsettled, it may be profitable to consider what light this case may throw on some undecided points. Keen (ANNALS OF SURGERY, July, 1899) gives as the chief causes of mortality, weakness due to the disease previous to operation, shock, haemorrhage, and aspiration pneumonia ; this latter being the greatest danger. Butlin (" Operative Surgery of Malignant Disease," page 193) gives in addition collapse and paralysis of the heart as a frequent cause of death (seventeen out of eighty-four cases), and states there is no sure means of guarding against it. In the present case the patient was not materially weakened by the disease. Haemorrhage and shock were avoided by careful hxmostasis. In the attempt to avoid infection and pneumonia are involved the questions of anes thesia and treatment of the trachea. Inasmuch as pneumonia is liable to result from the entrance of blood into the air passages, and as this is favored by the use of general anes thetics, it was decided to at least begin the operation with local anaesthesia, and resort to chloroform later, if necessary. As the operation progressed, it was found possible to complete it without general anaesthesia. The main objection to local anesthesia is that it prolongs the operation considerably. The patient only showed signs of pain when the superior laryngeal nerves were cut. When asked afterwards if the operation had been very painful, he said no. He was, however, a courageous man, and may have belittled any distress which he may have felt, but at all events he did not interfere with the operative procedures. What few drops of blood flowed into the trachea were immediately expelled, so that infection did not arise from this cause. As the trachea was brought forward when divided, there was no necessity to use the Trendelenburg position, and the operation was done with the patient in a reclining position, the shoulders being elevated. Congestion and bleeding would have been more marked with the head lowered.
The most important undecided point is as to the desirability of a previous tracheotomy. While in many cases tracheotomy would be easy of performance and quick in healing, in others, particularly for existing carcinomatous disease, it may in itself prove fatal, or leave the parts in a quite unfavorable condition for a subsequent removal of the larynx. In 1895, Delavan, in Dennis's " System of Surgery," Vol. iii, stated that " nearly all authors agree that a preliminary tracheotomy is necessary, in contradistinction to the views held by the earliest operators." Notwithstanding this, we find Briddon (ANNALS OF SURGERY, Vol. xxi, page 59) operating without it, and stitching the trachea in the wound, a fatal result following from pneumonia, although no blood had found its way into the respiratory tract. Also, William W. Seymour (ANNALS OF SURGERY, 1897, Vol. xxvi, page 637) divided the trachea and brought it into the wound. Butlin (second edition, 19oo, page 193) says, " Tracheotomy is performed either at the time of the extirpa tion or some time previously, according to the condition of the patient and the views of the operator." Francis W. Murray (ANNALS OF SURGERY, Vol. xxv, 1897, page 600), in an article on " Preliminary Tracheotomy in Operations on the Air-Passages," states that " when a patient is strong and in good general condition, I can see no objection to performing the preliminary and the major operation at the same sitting." Mr. Watson Cheyne also advocated the tracheotomy at the time of the major operation.
Finally, W. W. Keen, in his address before the American Surgical Association (ANNALS OF SURGERY, July, 1899), in reporting a states that he did a tracheotomy at the time of operation, but that he was strongly of opinion that it would be better to omit tracheotomy entirely. Thus it will be seen that surgical opinion was almost uniformly against the ad visability of doing a preliminary tracheotomy. Since operating on the I have read Dr. D. Bryson Delavan's article in the British Medical Journal of November 27, 1897. His views are worthy of quotation. He favors a preliminary tracheotomy because the use of a tube is irritative, and a few days will allow this irritation to subside ; the local condition ameliorates; time is saved in performing the operation, and shock and haemor rhage are less, and the administration of the anaesthetic is easier. He continues, " Lastly, a point of great practical im portance has lately come to my notice in connection with the method of laryngectomy practised by Dr. J. Solis-Cohen. In that operation the larynx is entirely removed, and the severed end of the trachea is turned forward and fastened to the external incision in the neck. In a case of this kind orally reported to me several months ago there had been no early tracheotomy, and, in consequence, there was no cicatricial ad hesion of the parts ; and when the edges of the trachea were stitched to the cervical wound, there was free movement of the former with every effort of respiration, and the sutures failed to keep the parts properly together. Thus union could not take place, the operation was a failure, and the patient died." Dr. Delavan's precise words are given because they state exactly what occurred in the present case. The patient would not lie down, claiming he was more comfortable in a reclining posi tion supported by pillows. Whenever he coughed, which was frequently, the trachea jumped up and down, pulling violently on its attachment to the skin, so that by the third day some of the stitches had cut through and were removed. That this was the main cause of the unfavorable issue, I have not the slightest doubt. Had a preliminary tracheotomy been per formed, the trachea would have been fixed in place, and there would have been no ulcerating wound constantly kept irri tated by the tugging of the trachea on the skin. That infection was introduced at the operation is not probable in view of the care taken to guard against it. The wound from the divided trachea up to the hyoid bone healed by primary union. Just on the surface posterior to the upper edge of the divided trachea were a few drops of pus ; there were none between the posterior surface of the trachea and esophagus. There was no pocket of pus anywhere. The edge of the wound around the trachea was inflamed, and it must have been here that the infection started in spite of the efforts made to pre vent it.
An interesting feature of the case was the fact that soon after the operation he could talk in a low whisper sufficiently clearly to make himself easily understood. No cesophageal tube was left in the wound, as this would have caused a fis tulous opening and prevented healing. It was probably un necessary, as he could swallow fairly well on the third day.
I was unwilling to attempt the use of a general anaesthetic for the tracheal operation, because I have had suffocative symp toms supervene in other cases, and Seymour, in his had to hurriedly open the trachea and resort to artificial respiration to save his patient.
To sum up. It is feasible to remove the larynx under eucaine anwsthesia. If the two operations are done simul taneously, and a favorable course is pursued, the result will be brilliant, the patient being " out of bed on the fourth day." It is my belief that Delavan is right, and that preliminary tracheotomy ought to be done. We should not sacrifice safety for brilliancy. That the leaving of an cesophageal tube pro jecting from the wound is probably unnecessary, the patient swallowing on the third day. The wound need not be tam poned, but can be closed from the upper edge of the trachea to the hyoid bone. These patients can make their wishes un derstood by speaking in a short time after the complete removal of the larynx. In this case it was found comparatively easy to remove the larynx from below upward, going up one side, then across at the hyoid bone, and down the other.