REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Larynx. Larynx. LARYNX. SARCOMA OF THE. Primary sarcoma of the larynx is a rare disease, and occurs oftener as the intrinsic than as the extrinsic variety. Butlin, in his ex- haustive and systematic treatise, to which the reader is re- ferred for fuller details, has collected only twenty-three cases of primary sarcoma of the larynx. The distinction established by Krishaber of intrinsic and extrinsic tumors, as applied to the larynx, also has significance in sarcomatous disease of this organ. Spindle- celled, round-celled, giant-celled, and mixed-celled, as wrell as the compound tumors, fibro- myxo- and lym- pho-sarcoma, are recorded as occurring primarily in the 429 Larynx. Larynx. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. HcemorrJiage occasionally happens during the ulcera- tive period, and may be copious. The flow of saliva is nearly always increased. Diagnosis.—Sarcoma may be mistaken for benign or other malignant growths, for syphilis and tuberculosis ; hence the differential diagnosis is often difficult. Sarcoma is generally single, consisting of irregular masses of a smooth or nodulated aspect, having a broad, hard base. Its surface is occasionally dendritic, and (lie adjacent mucous membrane may be either anaemic or of a deeper red than normal. There is nothing in the laryn- goscopic appearances of sarcoma which would warrant its differentiation from carcinoma, and the diagnosis must be established from other symptoms. The lymphatic glands are not involved in sarcoma, and Butlin regards this as an important clinical fact. When possible, a small fragment of the suspected sar- coma should be extracted by cutting-forceps and sub- jected to thorough histological examination, which en- ables us to differentiate sarcoma from other malignant growths, as well as from papillomata. Great caution should be exercised in its differentiation from syphilis—the previous history or the coincidence of other syphilitic manifestations will assist in the diagno- sis. There is no characteristic difference in the appear- ance of the sarcomatous ulcer as distinguished from that of syphilis ; the former is, however, generally solitary and confined to one side of the larynx. A mixed antisyphi- litic treatment may serve to clear up the diagnosis. The diagnosis of sarcoma from tuberculosis is not so difficult, the age of the patient, the presence of the phys- ical signs of pulmonary tuberculosis, and the ansemia of the laryngeal mucous membrane all assist in defining the nature of the malady under treatment. Prognosis.—Always fatal, by apnoea or asthenia, in cases in which there is no radical or surgical treatment. Much may, however, be done in the direction of pro- longing life and palliating symptoms, both by medical treatment and tracheotomy. That an early laryngec- tomy has been followed by good results in primary la- ryngeal sarcoma is undoubted, but the future will decide the exact merits of tlie.operation. In those cases in which the disease is extensive and of long duration, little can be expected in the direction of a radical cure by any op- eration ; but when the disease is intrinsic, unilateral, and there is but slight infiltration, recurrence is not apt to take place after complete extirpation of the sarcoma. The prospects of cure are, caeter is paribus, assuredly far brighter in laryngectomy for sarcoma than in laryngectomy for carcinoma. Bottini operated upon a male patient, twenty-four years of age, for sarcoma, on February 6, 1875, completely extir- pating the larynx. This patient held the position of mail- carrier between Miazzina and Trabaro, in Italy, in 1878, and was living eight years after the operation. One of Foulis’ cases lived seventeen and a half months after laryngec- tomy, Caselli’s case two years, F. Lange’s seven months, and Arpad Gerster’s one year. The duration of life after unilateral laryngectomy for primary sarcoma of the larynx is as follows : Gerster’s case lived one year, and died of pleurisy ; there was no recurrence. Kiister’s case is re- ported as cured, but definite information is inaccessible to the writer. Excellent statistical tables of partial and complete laryngectomies have been prepared by M. Mac- kenzie, Foulis, Blum, Burow, Hahn, Baratoux, and Cohen. The number of recorded laryngectomies (partial and complete) at this writing is about one hundred and twenty-five. Course and Termination.—Sarcoma, as a primary disease affecting the larynx, is generally slow in its course, and the malady is usually of from one to two years’ stand- ing when the patients seek medical aid. The termination, if there has been no surgical interference, is generally from suffocative apnoea, resulting from laryngeal stenosis; but, in the tracheotomatized subject, death most frequently results from exhaustion or pyaemia. Extensive peri- chondritis, secondary abscesses, and destruction of the cartilaginous structure of the larynx are liable to take place during the ulcerative period of the disease. larynx. The spindle- and round-celled growths are en- countered most commonly; the latter oftener than the former, according to the writer’s investigation. Sarcoma ordinarily attacks robust persons between the ages of twenty-five and fifty years, as is shown by the accompanying table prepared by Butlin : Patients. 7 years 1 24 to 30 years 3 31 to 40 years 6 41 to 50 years 5 Patients. 51 to 60 years 4 61 to 70 years 1 74 years 1 Uncertain 2 About eighty per cent, of those attacked are males. Profession and occupation exercise no marked influence in causing the disease, although exposure to cold, the abuse of alcohol and tobacco, as well as violent use of the vocal organ, may act as inviting causes. Some contend that hereditary influence, traumatism, and the degeneration of papillomata are causes of sarcoma, but the writer ventures to express his candid disbelief in the existence of sound clinical proof to sustain such opin- ions. In short, the origin of primary sarcoma within the larynx is quite as obscure as is its source in general. The vocal and ventricular bands of the left side are the favorite points of origin of these growths in intrinsic sar- coma ; the epiglottis in extrinsic sarcoma. These tumors rarely attain dimensions larger than an English walnut, usually are single and of smooth appearance, though at times nodulated or dendritic. Symptoms.—These are similar in most particulars to those of carcinoma of the larynx, although, as a rule, milder in degree and more gradual in development. Pho- nation, respiration, and deglutition are interfered with in a degree varying with the location of the primary lesion, its size, mode of attachment, and stage of progress. Hoarseness may exist for years prior to the develop- ment of the disease, but is a constant and important symp- tom. The voice is at first uneven, irregular, and finally shrill, but is rarely entirely and permanently extin- guished. The degree of dysphonia may bear no rela- tion to the dimensions of the intra-laryngeal tumor, great vocal changes resulting from the smallest swellings, even in the earliest stage of the disease. The infiltration of sarcoma soon interferes with the mobility of the intra- laryngeal muscles, and dysphonia results. It may be here stated that in benign neoplasms of equal size the move- ments of the vocal bands are not thus impaired. Embarrassed respiration, dependent upon tumefaction of laryngeal tissues and consequent stenosis, always oc- curs. At first respiration is slightly impeded, the patient noticing the impediment upon making slight muscular exertion, but ultimately the laryngeal dyspnoea threatens life and requires the opening of the trachea. The patient finds it often impossible to assume the recumbent post- ure, and loses sleep and strength. In rare instances the subjective symptoms are so slight that a sarcomatous growth may attain dimensions sufficient to cause death from suifocation before the patient applies for medical advice. A striking instance of this kind is reported by Dr. Louis Jurist, the patient, a gardener, sixty-five years of age, dying forty-eight hours after his first examination, and twenty-four hours after refusing to have a tracheo- tomy performed. Deglutition is interfered with in extrinsic sarcomata, particularly if the epiglottis is first invaded. It becomes necessary at times to sustain the patient by means of food introduced through an oesophageal tube, as swallowing is intolerable. Dysphagia may be absent or slight in in- trinsic sarcomata. Pain is by no means a constant accompaniment of sar- coma, although at times it is very severe. Pressure over the laryngeal region may elicit a tenderness. The pain radiates from the larynx to the ear, the fibres of the su- perior laryngeal nerve conducting the irritation through the auricular branch of the pneumogastric. The cough is primarily of a dry, barking, irritative nat- ure, but later it becomes loose. The expectoration be- comes fetid, occasionally containing fragments of detached growth and blood-clots. 430 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Iiarynx. Larynx. The destruction and disintegration of the soft tissues and cartilaginous framework of the organ may be so ex- tensive as to result in the formation of fistulous communi- cations between the air- and food-passages, as well as in the expectoration of necrosed cartilages. Treatment.—The treatment of primary sarcoma of the larynx is extremely unsatisfactory. It may be divided into palliative and radical measures. The palliative treatment includes, in addition to proper systemic medication, the topical treatment of the larynx through the natural passages and the early performance of tracheotomy. The systemic management of malignant disease is fully considered in another portion of this Handbook, and the necessary topical measures have been already discussed in the article on Larynx, Carcinoma of. Tracheotomy should he done early in the course of sar- coma—on the first symptoms of dyspnoea occurring, and before the strength of the patient is reduced from insuffi- cient oxygenation. Always, as in carcinoma, the trache- otomy should he made as far from the seat of disease as possible, and life may be thereby prolonged from one to four years. Radical treatment comprises intralaryngeal extirpation, thyrotomy, subhyoidean pharyngotomy, and partial or total extirpation of the larynx. Mackenzie, Navratil, and Tuerck report cases of pri- mary sarcoma of the larynx radically cured by intralaryn- geal operation ; but in the writer’s opinion there is great doubt about the propriety of relying upon such a proce- dure in growths possessing the infiltrating tendencies of sarcomata. Again, the tumor is not always either well defined or circumscribed. Butlin questions the accuracy of the above cures. lie further says, in most instances it is necessary to do more than remove the seat of attach- ment of the sarcoma, and that a tolerably wide area of the surrounding parts, even when these present a perfectly healthy aspect, must be removed. Thyrotomy has not been attended with favorable results, and the weight of opinion, including Bruns’, is decidedly opposed to its performance. It might he successful where the disease was limited to one vocal band, if a thyrotomy were performed, the band removed, and the surrounding tissues carefully cauterized (see article Tracheotomy). Subhyoidean pharyngotomy is only to he resorted to when the epiglottis is the seat of the sarcoma, and it there- fore has a limited scope of usefulness (see article Tracheo- tomy). Total Extirpation.—Upward of twelve total extirpa- tions have been performed for sarcoma of the larynx, and among them is Bottini’s famous case, already re- ferred to in this article. In the writer’s judgment, the future usefulness of this operation will be chiefly limited to the treatment of dis- ease of a sarcomatous nature, and then at an early stage of its existence. A small commencing sarcoma, circum- scribed, slightly infiltrated, and occurring in an otherwise vigorous patient, woidd certainly offer every chance of a radical cure if subjected to complete extirpation. In- creased experience and reliable statistics are urgently needed to settle the propriety, not to say the justifiability, of complete laryngectomy, and the near future bids fair to furnish the same. Cohen says : “ Taking for granted, as we are bound to do, that death was imminent in the above cases [those of Bottini, Caselli, and others] when the extirpation was re- sorted.to, we have a considerable prolongation of life in every instance, and a remarkable prolongation in two.” As far as our limited statistics go, therefore, the opera- tion of extirpation of the larynx, in hopeless cases of sar- coma, is worthy of the serious consideration of the sur- geon. Consult articles Larynx, Carcinoma of, and Laryngec- tomy for further information regarding this operation. Partial Extirpation.—A very small number of partial laryngectomies are recorded in medical literature, too few. to furnish a basis upon which to found any con- clusions of practical value. Hahn has claimed that par- tial excision for carcinoma was followed by as few re- currences as was total excision. But while this may he true of carcinoma, the characteristic tendency of sarcoma to infiltrate renders the operation of doubtful utility (consult article on Laryngectomy). Note.—For the literature of primary sarcoma of the larynx, apd illus- trations of the same, consult article ‘ ‘ Larynx, Carcinoma of.” Ethelbert Carroll Morgan. 431 Reference Handbook of THE Medtcal Sciences. PLATE XVII CARCINOMA AND SARCOMA OF THE LARYNX. H. BENCKE, LITH. N. Y.