A Case of Modified Laryngectomy for 
Epithelioma of the Larynx; Recovery. 
BY 
GEORGE R. FOWLER,' M.D., 
Surgeon to the M. E. Hospital, and St. Mary’s Hospital, Brooklyn, N. Y. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
October, 1889. American Journal of the Medical Sciences for October, 1889. 
Extracted from the 
A CASE OF MODIFIED LARYNGECTOMY FOR EPITHELIOMA 
OF THE LARYNX ; RECOVERY. 
George R. Fowler, M.D., 
SURGEON TO THE M. E. HOSPITAL, AND ST. MARY’S HOSPITAL, BROOKLYN, N. Y. 
On November 12, 1888, Mrs. C. D., aged fifty-eight, married, was 
admitted to my service at the M. E. Hospital, with the following history : 
For the past two or three years the patient has noticed a gradual and 
progressive hoarseness. Five months preceding admission, she first con- 
sulted me for the relief of this hoarseness, which very shortly thereafter 
amounted to complete aphonia. Laryngoscopic examination at this time 
revealed a neoplasm upon the anterior portion of the left vocal cord, 
and I referred her to my friend, Dr, T. R. French, of this city, for fur- 
ther examination and advice concerning- the necessity for an immediate 
operation for the removal of the growth. He confirmed my diagnosis 
of malignant disease of the larynx, and agreed with me in the desira- 
bility of attacking the growth and that the extra-laryngeal method of 
operation was the only one justifiable under the circumstances. 
She returned to her home in the country to make preparations for the 
operation, intending to return in the course of a fortnight. During the 
next few months I heard, through a friend, that a decided improvement 
had taken place in her voice, and that, encouraged by this fact, she 
hesitated before accepting my advice. I requested that she return to 
the city, in order that another examination be made, to which request 
she acceded, and in November she again visited Brooklyn, and allowed 
me to re-inspect her larynx. It was then found that the growth had 
considerably increased in size, the visible portion projecting well beyond 
the free margin of the vocal cord, and occupying most of its length. 
The improvement in the voice Avas evidently due to the fact that, 
Avhereas, when the aphonia was complete, the left vocal cord was so 
crippled by the growth that its function Avas practically abolished, later 
on, as the groAvth increased in size, the right vocal cord could be brought 
into contact Avith the former, and thus phonation was reestablished. 
Dr. French again examined her at this time, and succeeded in pho- 
tographing the parts as they appeared, both in ordinary respiration and 
in phonation (Figs. 1 and 2). It Avas decided to give her the benefit of 
an extirpation of the larynx by the modified procedure suggested by 
Prof. J. Solis-Cohen, of Philadelphia, but Avhich, up to this time, had 
never been performed upon the living subject.1 Accordingly, on Novem- 
1 New York Medical Journal, vol. xlv. pp. 682, 683, 1887. Transactions -AmericaiH 
Laryngological Association, 1887, New York, 1888, ix. 38-10. 2 
FOWLER, MODIFIED LARYNGECTOMY. 
ber 13tb, the day following her admission to the hospital, a low trache- 
otomy was performed, preliminarily; in order to accommodate an extra 
large sized tracheotomy canula, an oval piece was removed from the front 
wall of the trachea. A few superficial sutures were applied, in order 
to close the wound below the tube. The parts were dressed with an 
artificial cuticle of collodion and sub-iodide of bismuth. 
Fig. 1. 
Fig. 2. 
Showing parts during ordinary respi- 
ration. (Hemi-tone, after a photograph 
by Dr. T. R. French.) 
Showing parts during phonation. (Hemi- 
tone, after a photograph by Dr. T. R. 
French.) 
On November 17th, four days following the tracheotomy, it being 
found that complete toleration of the presence of the tracheal canula 
had been established, the operation of modified laryngectomy was per- 
formed in the presence of Prof. J. Solis-Cohen, Drs. T. R. French, B. 
F. Westbrook and Bryson Delavan, together with the hospital staff. 
The anaesthetic used was nitrous oxide, administered by Dr. George W. 
Brush, of this city. The method of administering the anaesthetic was 
by means of a coupling made to fit the opening of the tracheal canula, 
and attached by a piece of flexible tubing to the ordinary inhalation 
apparatus of the dentists. Inasmuch as the operation differed in one 
or two particulars from the procedure suggested by Prof. Solis-Cohen, I 
have thought it best to describe the different steps of the operation in 
this the first application of the new method. The operation as per- 
formed by myself is as follows : 
An incision was made from the upper border of the hyoid bone to 
the first ring of the trachea. This was afterward extended to the tra- 
cheotomy wound. The structures overlying the thyroid were separated 
from about one-half to three-quarters of an inch on either side of the 
angle of junction of the two wings of this cartilage; the isthmus of the 
thyroid body was divided with the thermo-cautery. The crico-thyroid 
muscles were divided near their attachments to the thyroid cartilage, 
the soft parts were retracted to either side, when, all hemorrhage being 
arrested, the cricoid cartilage was separated from the first ring of the 
trachea by a transverse incision. The stump of the trachea was drawn 
forcibly forward and rapidly packed with gauze by an assistant, while 
the cross incision was being made. A silk ligature was passed through 
the first ring of the trachea and tied in a loop, in such a manner that 
the stump of the trachea could be drawn well forward. By means of 
narrow-bladed angular forceps each wing of the thyroid was split down 
to the crico-thyroid membrane at a point about one-quarter of an inch 
on either side of the angle of junction of the two wings. The interior 
structures of the larynx were now cleared from the inner surface of the 3 
FOWLER, MODIFIED LARYNGECTOMY. 
thyroid cartilage; the mucous membrane of the right side peeled off 
easily, but that on the left side proved to be hard and somewhat un- 
yielding, although it finally separated completely from the underlying 
thyroid. It was then readily ascertained that the growth occupied this 
portion of the interior of the larynx, being moulded to the shape of, but 
not involving the interior surface of the corresponding wing of the thy- 
roid. Both wings of the cartilage being cleared, the soft parts behind 
and to the sides of the cricoid, including the articulation of the latter 
with the inferior cornuse of the thyroid and its connection with the 
oesophagus, were separated; the attachments of the inferior constrictor 
muscles of the pharynx to the posterior portion of the thyroid cartilage 
were not interfered with. The arytenoid cartilages were included in the 
parts thus dissected. Upon reaching the line of the attachment of the 
oesophagus to the cricoid posteriorly, the former was opened in the 
median line, and through the opening thus formed the index finger of 
the operator’s left hand was passed into the pharynx up to the base of 
the tongue and hooked over the epiglottis. The latter, together with the 
entire respiratory contingent, was now forcibly drawn downward, so as 
to identify the attachments of the thyro-hyoid membrane. The latter 
was now incised, and the epiglottis detached from the aryteno-epiglotti- 
dean folds, when a few touches of the knife served to release the whole 
mass from its remaining attachments. 
It was found that the entire diseased mass had come away completely. 
After ligating a few bleeding points, the stump of the trachea was re- 
packed with dry gauze, and an oesophageal tube was passed about eight 
inches down the oesophagus, and the parts above and below the section 
of the gullet, as well as the neighborhood of the feeding tube, as it passed 
into the latter, were well packed with oxide of zinc gauze; the latter 
reached well up into the pharynx above the base of the tongue. A 
large safety-pin was passed crosswise through the oesophageal tube to 
prevent the latter from slipping into the stomach. 
The patient left the table, fully conscious, within a minute after the 
completion of the dressings and without the slightest symptom of shock, 
although the anaesthesia by nitrous oxide had been maintained steadily 
and without the least difficulty for an hour and forty minutes by Dr. 
Brush. Indeed, had she been allowed to, she would have walked to her 
room from the operating theatre. 
On the following day the dressings were removed and a small Barnes’ 
rubber bag was introduced into the stump of the trachea, distended, 
and gauze packed down upon it. The wound was repacked and the 
gauze packing was not allowed to rise in the pharynx above the level of 
the wound. It was soon found, however, that the simple gauze dressing 
Avas equally efficient, and tolerated better than the rubber bag, and the 
latter Avas abandoned for the former. The thyroid wings had been 
somewhat separated, during the operation, from the muscular structures 
passing upon either side of their outer walls; their diAuded edges were 
brought as near in coaptation as possible. 
On the second day after the operation, the oesophageal tube was re- 
moved, to be again introduced, for purposes of alimentation, at the 
time of the dressing; but even this caused considerable pain, and finally 
the tube Avas left in position eight hours, during which time several 
feedings Avere accomplished, the tube being then removed, and the parts 
remaining undisturbed for four hours. FOWLER, MODIFIED LARYNGECTOMY. 
On the eighth day the tracheal tube was removed from the trache- 
otomy wound and inserted into the stump of the trachea. About one- 
eighth of an inch of the edge of each thyroid wing was now found to 
be somewhat discolored and showed a tendency to curl toward the 
median line and away from the lateral riband muscles of the laryngeal 
region. They were accordingly trimmed off with a pair of curved 
scissors. The entire cavity left by the removal of the larynx contracted 
with marvellous rapidity, and its walls were found to be covered by 
healthy granulations. The upper end of the oesophagus had become 
very oedematous, and this, when the tracheal tube was removed, served 
the purpose of an epiglottis in preventing secretions from the pharynx, 
which found their way down behind the base of the tongue and into the 
upper portion of the wound, from entering the larynx. Up to this time 
the patient’s diet had consisted of from four to six ounces of peptonized 
milk, every two hours, and two ounces of whiskey every four hours, 
with a teaspoonful of beef-juice. On the tenth day following the opera- 
tion, the patient was allowed to attempt to swallow general fluid diet, 
such as egg-nog, beef tea, and cocoa. 
Fig. 3. 
A modified Gussenbauer’s artificial larynx. A, tracheal canula; B, pharyngeal or 
“ chimney ” tube; C, obdurator, in position as in eating; I), button for securing ring 
attached by a wire to obdurator; E, button for securely holding the chimney tube 
attached to the tracheal portion of the apparatus. At A 1 is shown the lower extremity 
of the tracheal tube cut off somewhat at an angle. 
On the seventeenth day the contraction of the muscular parts upon 
either side of the remains of the thyroid cartilages had brought the edges 
of the latter so closely in contact as to render it impossible to pack 
gauze in that portion of the cavity represented by the parts lying 
between the wings of the thyroid. The tracheotomy wound had been 
entirely closed for several days, and the oedema of the oesophagus disap- 
peared. The irritation of a drop of secretion into the stump of the 
oesophagus caused efforts at swallowing, which act seemed to be perfectly 
normal. There was a painless contraction of the pharyngeal muscles, 
which, when it occurred, forced the secretions of the mouth through the 
wound and out upon the neck. 
On the twenty-fourth day after the operation the oesophageal tube was 
removed from the wound, and thereafter at each time of feeding it was 5 
FOWLER, MODIFIED LARYNGECTOMY. 
passed through the mouth. The packing of the wound was discontinued 
and a compress of gauze placed in position oyer the latter, in order to 
absorb the secretions from the mouth, which were still discharged 
through the wound. On the forty-first day a modification of the artifi- 
cial larynx of Gussenbauer was placed in position. 
This modification consists, first, of substituting aluminium for hard 
rubber or silver as the material from which the apparatus is made ; 
second, in dispensing with the cumbersome projecting ring collar— 
which, besides being in the way of the patient’s dress collar, is exceed- 
ingly awkward to detach and replace by the patient—and replacing it 
with the flat plate and retaining button of the ordinary silver trache- 
otomy canula (Fig. 3). With the aid of a little pocket mirror, the 
patient readily adjusts the different parts of the artificial larynx herself. 
The patient can now make herself heard in speaking better than be- 
fore the operation. On New Year’s day, forty-four days after the opera- 
tion, the patient partook of a hearty meal, principally solid food. On 
January 29th complete cicatrization having taken place, the patient was 
discharged cured. On May 25th the patient presented herself at my 
office prior to her departure for her home in the country. She is able 
to speak in a loud whisper, although no artificial vocal cords or reeds 
have as yet been supplied to the artificial larynx which she wears. At 
the date of writing (August, 1889), there is no evidence of a return of 
the disease, and the patient expresses herself as being perfectly comfort- 
able and in good health. 
Attention has already been called by Prof. Solis-Cohen to the great 
infrequency with which the thyroid cartilages become invaded with car- 
cinoma or other diseases for which complete or partial laryngectomy is 
performed. This fact Jed him to consider both the desirability as well 
as practicability of modifying the operation in such a manner as to retain 
this portion of the larynx, while removing those portions already 
invaded, or liable to invasion, by disease. As a result of this study he 
advanced the opinion that, not only is it possible to lessen the dangers 
of the operative procedure itself, as well as the difficulties of the sub- 
sequent treatment by leaving a portion of the thyroid cartilages in situ, 
but that, theoretically at least, where the preservation of the attach- 
ments of the inferior constrictor muscles of the pharynx to these struc- 
tures are considered, the functional result may be improved by the 
operation which he proposed. 
So far as the knowledge of the writer goes, the case herewith reported 
is the first hi which this proposition, L e., the retention of the thyroid 
cartilages, has been carried out. The result fully justifies the views 
held by Prof. Cohen concerning the operation itself and the improved 
functional result. The. comparatively small gap left by the incision and 
removal of the diseased parts, and consequently lessened traumatism 
inflicted, the readiness with which the parts filled up by the reparative 
process and the firm support afforded for the artificial larynx, together 
with the great advantages gained by preserving comparatively unimpaired 6 
FOWLER, MODIFIED LARYNGECTOMY. 
at least one of the pairs of the muscles of deglutition, will, it is be- 
lieved, lead to the adoption of this method of operation, to the exclu- 
sion of all others, in cases in which laryngectomy is at all applicable. 
The growth in this case, upon examination by the hospital patholo- 
gist, Dr. Eugene Hodenpyle, proved to be a typical epithelioma. 
So far as I know, this is the first attempt that has been made to make an 
artificial larynx from aluminium. The exceeding lightness of this metal, 
as compared with either of the materials heretofore employed (silver or 
vulcanized rubber) commends it at once to the practical surgeon. Again, 
the decomposition of the silver by the secretions of the parts, and the 
consequent formation of soluble argentum compounds, which, as has 
been claimed, are not without deleterious effects when absorbed into the 
system, are not to be lost sight of. 
At F (Fig. 3) is shown the end of the tracheal canula cut off 
somewhat of an angle; the effect of this is to increase slightly the 
capacity of the opening at the point at which the air enters the canula, 
as well as to prevent the anterior edge of this opening from impinging 
against the wall of the trachea. THE AMERICAN JOURNAL 
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