LARYNGECTOMY 
IN A CASE OF 
CANCER OF THE LARYNX, 
-BY- 
GEORGE W. CRILE, M. D. 
Professor of Physiology and Lecturer on Minor Surgery in the Medical Department 
of the University of Wooster. 
Reprinted from “ The Cleveland Medical Gazette, ” 
December, 1892. 
PRESS OF 
Buel & llO Sheriff St., 
Cleveland, Ohio. REPORT OF A CASE OF CANCER OF THE LARYNX- 
LA RY NGECTOMY—RECOVERY FROM OPERATION- 
DEATH FROM RECURRENCE IN TWO AND ONE- 
HALF MONTHS/ 
BY GEORGE W. CRILE, M. D., CLEVELAND, 0., PROFESSOR OF PHVS- 
IOLOGY AND LECTURER ON MINOR SURGERY IN THE MEDICAL 
DEPARTMENT OF THE UNIVERSITY OF WOOSTER. 
A few weeks previous to the laryngectomy tracheotomy was made, 
Dr. Baker operating and I assisting. The patient was anaesthetized, 
chloroform being used at the time of the tracheotomy; respiration 
required the aid of the extraordinary respiratory muscles; the 
anaesthetic having abolished the action of these, suffocation was 
imminent. However, by bold and rapid incisions the trachea was 
quickly opened and the tube inserted.. There was considerable 
difficulty in accomplishing this, as the trachea was unusually deeply 
seated in the heck. Sutures were passed through the margins of the 
tracheal rings and anchored to the integument. By this manoeuver 
the tracheal opening could be well controlled. 
We had a number of tracheal tubes of various sizes and shapes, 
but not one was long enough to reach, and remain in the trachea. 
Special tubes were telegraphed for, one of which answered the pur- 
pose well. This tube the patient is still wearing with great com- 
fort. After the tracheotomy there was some improvement in his 
condition. The marked lividity of the preceding days passed 
away. Some bronchitis developed, a considerable cough and ex- 
pectoration was annoying for some time. In a few weeks he left 
the hospital for his home in Newburgh, feeling quite well, with the 
exception of some cough and difficulty in swallowing. The radical 
operation was proposed about this time, but as no very urgent 
symptoms were present, it was declined by the patient and his 
friends. Crick: Cancer of the Larynx. 
About two months later swallowing became so difficult that an 
operation was welcomed. July 5, he re-entered University Hos- 
pital for immediate operation, but a constant fever, harassing 
and unremitting, coughing, bronchial rales over both sides of the 
chest, were sufficient to cause delay. It was discovered about this 
time that when milk was taken part of it reappeared at the tracheal 
tube, a like phenomenon in the case of Frederick 111, caused diag- 
nosis of oesophageal fistula. After an unsuccessful week of treat- 
ment of the lung complication we concluded that the exciting 
cause was the detritus escaping into the lungs from the ulcerating 
laryngeal growth, and that the morbid growth, together with the 
food escaping into the trachea and bronchi, was the exciting cause 
of the cough, and consequently that further delay was useless. 
The indications for the operations rested upon the diagnosis of a 
malignant growth in the larynx and the consent of the patient after 
the probable results had been fully laid before him. 
The preliminary preparation consisted in enveloping the chest in 
an oiled silk jacket; the administration of digitalis and strophan- 
thus, together with Murdock’s food and eggnogs, the surgical 
preparation of the field of operation and the arrangement of an 
apparatus for administering the anaesthetic. Twenty minutes be- 
fore the operation morph, tbit atropia, was given hypodermically. 
Chloroform was administered by Dr. W. E. Lower so skillfully that 
not once did the patient emerge from the third stage of narcosis, 
neither was the narcosis at any time dangerously deep. 
A tin tube eight inches long reduced to the exact diameter of 
the tracheal tube and bent to its curve was substituted for the 
tracheal tube. To the distal end was attached the rubber tube and 
inhaler of a Trendlinberg tampon canula, taking the management of 
the inhalations at a safe distance from the field of operation. - Crtle : Cancer of the Larynx. 
3 
The operating table was well inclined, the head.of the patient 
placed on the lower end, held well up by an assistant. Owing to 
the shortness and thickness of the neck, a median incision from 
the hyoid bone to the lower border of the cricoid was made,and lateral 
incisions were carried along the upper margins of the hyoid bone. 
There being a marked depression at the entrance of the tracheal 
tube a seminuar incision was made about an inch above it, the 
skin deflected, the margins carried around the tube so as to form a 
barrier against the entrance of blood through the tracheal opening, 
at the same time giving free exposure to the inferior portion of the 
larynx. 
The larynx was exposed 'in the median line with the scalpel, 
which was not used again in the operation. By means of a modi- 
fied periostiome the soft parts were removed from each side, the 
larynx being held by a bullet forceps well fastened to the anterior 
surface of the cartilage. 
I next split open the larynx with a pair of bone pliers, the box 
having been found well ossified, and the interior inspected to de- 
termine to what extent the operation would be necessary. It was 
■at once evident that total extirpation was necessary. A stout hooked 
forceps having been fastened to the pomum adami, the soft parts of 
the sides of the thyroid were detached, then the soft parts of the 
sides and the entire posterior surface of the cricoid were detached 
likewise. 
Following this the trachea was severed with scissors while being 
supported on the periostiome. The haemorrhage was insignificant, 
a few snips with scissors severed the thyro-hyoid muscles, the 
thyro-epiglotidean ligament, and the remaining soft parts. 
The only haemorrhage of any moment was encountered when the 
larynx was split open, the morbid growth was lacerated, causing 
haemorrhage in the interior of the larynx. This was easily arrested by 
gauze tamponing. The wound was packed with antiseptic gauze, a 4 
Chile : Cancer of the Larynx. 
stomach tube passed into the oesophagus through the wound. The 
opening into the severed trachea was closed with a gauze tampon 
and the patient placed in bed. Not a ligature or suture was used. 
The time occupied in the operation was 47 minutes. The amount 
of blood lost was insignificant. 
* The patient bore the operation very well, there being no apparent 
shock. He slept quietly most of the day and the following night 
was equally restful. In the evening a little water was given through 
the (esophageal tube. The following day peptonized milk and Val- 
entine’s beef juice were given in a similar manner. 
In the evening the oesophageal tube was removed and 1 was happily 
surprised to find that he could swallow without much difficulty. 
Since then he has been able to swallow any kind of food with little 
if any difficulty. 
His pulse never reached 100, the wound repaired rapidly and 
during the past two weeks has been getting about his room. At 
present the wound is almost healed, there being a small space in 
the upper and the lower ends of the wound kept open for the ad- 
justment of the artificial larynx. He has been allowed a gen- 
erous diet of nutritious food, the wound has been dressed usually 
twice daily, and he has been given tonics. 
Since the operation his general condition has very much im- 
proved, his lungs have cleared up, and the suppurative, bronchitis, 
pain and dysphagia disappeared, the harassing cough tormenting 
him night and day and resisting every attempt at relief has not 
been heard since the operation, leaving no reasonable doubt as to 
its origin in the larynx. The broncho-pneumonia no doubt was 
due to the presence in the broncho-pulmonary tract of the products 
of the ulcerating growth in the larynx. 
Notwithstanding the great danger of pneumonia following opera- 
tions on the larynx and trachea, even in the absence of a light 
attack, the operation had a most favorable effect upon the lungs, in- 
asmuch as it removed the exciting cause. Having concluded this 
to be the cause, the operation was ventured on the otherwise very 
pangerous condition. Baker : Supplemental Report to Dr. Crile. 
1 developed the technique by frequent operations on dogs—the 
operation I found to be analagousin dogs—the comparative anatomy 
being very similar. From my experience in this case I can .ot too 
strongly recommend preliminary tracheotomy, the use of the tin 
tube in the administration of the anaesthetic, and the modified 
periostiome and forceps for the removal of the larynx, making the 
operation almost bloodless. 
A SUPPLEMENTAL REPORT OF DR. CRILE’S CASE OF 
LARYNGECTOMY. 
ALBERT R. BAKER, M. D., CLEVELAND, O. 
At the request of Dr. Crile, I make this supplementary report, 
as it is, so far as I have been able to learn, the only total extir- 
pation of the larynx ever made by a Cleveland surgeon. 1 only 
know of one other in the State, and that was reported some time 
since by Dr. Max Thorner, of Cincinnati. His patient died on 
the fifth day. 
Mr. Geo. Jockens, age fifty-six, German, brick-maker, consulted 
me early in March, 1892, for loss of voice, pain and difficulty in 
swallowing. He gave a history of having had occasional attacks of 
hoarseness and coughing for more than a year, but did not stop 
work until September, 1891, when he commenced having pain in 
the throat and side of head, voice became husky, and suffered from 
attacks of coughing and dyspnoea. General appearance good, 
well nourished, no cachexia, talked in a hoarse whisper. Laryn- 
goscopic examination, which was made with great difficulty, 
revealed a large growth involving almost the entire right side of the 
larynx, diagnosed laryngeal tumor, probably malignant in charac- 
ter. Large doses of iodide of potash were given for five or six 
weeks .without benefit. In the meantime a portion of the tumor 
was removed and its malignant character confirmed by a micro- 
scopic examination. 
Until the later part of April the left side of the larynx did not 6 
Baker : Supplemental Report to Dr. Crile. 
seem to be involved in the disease. The movements of the cord 
on that side were not much impaired, and respiration was not 
greatly interfered with except at intervals, most frequently at night. 
About the first of May there seemed to be a rapid increase in the 
size of the growth in the right side and the left side because in- 
flamed, and respiration greatly impeded. I urged the 
necessity of tracheotomy to prevent impending death from laryngeal 
obstruction. As the symptoms became more alarming, the patient 
finally consented and the operation was performed May 10th. 
Dr. Crile mentioned some of the difficulties met with in making the 
tracheotomy. Although I have had considerable experience in per- 
forming this operation, I must confess that I never fully realized the 
truthfulness of the statement of Dr. Gross in his classical work on 
“Foreign Bodies in the Air Passages,” who says, “I know hardly an 
operation in all surgery that I would not rather undertake 
under certain circumstances. The amputation of a limb, the 
extirpation of a glandular tumor, lithotomy and even the perineal 
section are trifling matters in comparison with tracheotomy in a 
short, thick-necked child.” This patient had a very thick neck, 
the upper ring of the trachea being on a level with the sternum, 
and situated more than two inches beneath the integument. It 
was almost impossible to reach the trachea without pulling it forci- 
bly upwards and forwards, and no ordinary tracheotomy tube could 
be retained, so we had to have one especially made about twice the 
usual length. The patient made rather a rapjd recovery and 
returned to his home in three weeks, and was more comfortable 
than for some months previous. He declined at this time to have 
a total extirpation of the larynx made, which was strongly urged. 
About the first of July it became impossible for him to swallow 
solid food ; an obstinate cough developed with considerable eleva- 
tion of temperature. On July sth he returned to University Hospi- 
tal for operation. 
After the operation the temperature immediately went down, pain 
disappeared, solid food as well as fluid could be taken with comfort. 
Only one who has seen the change of expression from that of the great- Barer : Supplemental Report to Dr. Crile. 
est distress, pain and suffering, depicted upon the countenance 
of a child suffering from membranous croup, relieved by a timely 
tracheotomy or intubation, can fully appreciate the relief expressed 
in the countenance of this patient after the removal of the larynx. 
He ate well, slept well, suffered no pain, regained his strength, and 
everything progressed favorably for about four weeks ; then he began 
to complain of pain in left side of neck, extending to ear and side 
of head, an enlargement, very painful to the touch, appeared in the 
left sub-maxillary region. It was hoped at first that this might 
prove inflammatory in nature, but before long our worst fears were 
realized and we were obliged to confess that it was a return of the 
malignant growth which pursued its usual course until death re- 
sulted, September 26th, two months and a half after the laryngec- 
tomy. 
The following report by Dr. Preble leaves no doubt as to the 
nature of the disease: 
October 27, 1892. 
Dear Doctor: The extirpated larynx examined at the request of 
yourself and Dr. Crile was found to be the seat of a rapidly-grow- 
ing epithelioma. I made a number of sections from various parts 
of the mass which lined the cartilages, using both the razor and 
microtome, and stained them with lithium-carmine. The sections 
were invariably those of a malignant epithelioma, and consisted of 
a fibrous stroma, studded with numerous nests of epithelial tissue. 
The epithelia were of colossal size, and preserved the semblance 
of a concentric arrangement within the nest ; but, in no instance, 
did I observe any trace of the horny metamorphosis which often 
occurs within the centre of the nest. This omission 1 believe to be 
due to the very active growth of the mass. 
Yours sincerely, 
Dr. A. R. Baker. Edward Preble. 
A few weeks after the operation a modified Fowler’s artificial 
larynx was inserted, which answered the purpose fairly well for a 
time, but owing to the rapid growth of recurring tumor, the 
pharyngeal portion of the artificial larynx caused considerable dis- 
comfort, and toward the last the patient preferred to use simply 
the tracheal tube. 
From ray observation of the case and from reading the literature 
on this subject, which is rapidly becoming voluminous, I believe 8 
Baker : Supplemental Report to Dr. Crile. 
that under certain conditions the operation is a justifiable one, and 
ought to be performed more frequently. 
Although the number of reported cases in which a permanent cure 
has been effected is comparatively small, enough have recovered to 
let us hope that better results will be attained in the future. In a 
private letter received from Dr. Roswell Park, he informs me 
that his case lived seven years after the operation. Several 
cases even more favorable than this have been reported. While 
a large percentage of the cases operated upon have died from 
the operation itself, I believe, that with our improved methods of 
operation, these may mostly be prevented. The technique, as de- 
veloped and performed by Dr. Crile in this case, makes it not such 
a formidable operation as one would suppose. Severer operations 
are being performed every day, and while the danger of recurrence 
cannot be prevented in this any more than in malignant diseases 
of other organs, early diagnosis and prompt removal will undoubt- 
edly be followed by a higher percentage of recoveries.