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SURGERY 
.« MONTHLY REV1SW OF SURGICAL SCIENCE AKD PJU.CTICS 
L S. PILCHER. A M, M D» 
FREDERICK^TREVES. PR.CS, 
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Oreat Britain: Cassell and Company. London: 
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Slagle Co9U». Two Shilling* 
JULY, 1893 
UNILATERAL LARYNGECTOMY; A CASE OF EXCISION 
OF THE RIGHT HALF OF THE LARYNX FOR 
CARCINOMA; RECOVERY; NO RECUR- 
RENCE AT THE END OF A YEAR. 
By GEORGE H. MONKS, M.D., 
SURGEON TO THE CARNEY HOSPITAL; SURGEON TO OUT-PATIENTS AT THE 
BOSTON CITY HOSPITAL, AND ASSISTANT IN CLINICAL AND 
OPERATIVE SURGERY AT THE HAR- 
VARD MEDICAL SCHOOL. Fig. i.—Showing lines of external incision. UNILATERAL LARYNGECTOMY : A CASE OF EXCI- 
SION OF THE RIGHT HALF OF THE LARYNX 
FOR CARCINOMA; RECOVERY; NO 
RECURRENCE AT THE END 
OF A YEAR.1 
GEORGE H. MONKS, M.D 
SURGEON TO THE CARNEY HOSPITAL; SURGEON TO OUT-PATIENTS AT THE 
BOSTON CITY HOSPITAL, AND ASSISTANT IN CLINICAL AND 
OPERATIVE SURGERY AT THE HAR- 
VARD MEDICAL SCHOOL. 
ON May 17, 1892, at the Carney Hospital, I excised the right 
half of the larynx in a man thirty-nine years of age. The 
operation was done for the removal of an epithelioma 
involving the right vocal cord. 
The after-treatment, so important in cases of this kind, was 
carried out with the most conscientious attention to details by the 
House Surgeon, Dr. F. J. Giblin, and the Sisters at the hospital. 
The recovery from the operation was speedy and uninterrupted, 
and the patient left the hospital twenty-five days after the opera- 
tion with an ordinary silver tracheotomy tube tied in the wound. 
Soon after this he resumed his occupation (that of a photographer), 
and, ever since, has been able to earn his former wages. 
Shortly before he left the hospital the patient was able to 
talk intelligibly in a hoarse whisper, and since then his voice has 
gradually improved in strength and tone. After removal of the 
tube he pulls together the edges of the wound in his neck, or 
covers it over with a pad or with his finger tips ; and the current 
of air is thus driven through what remains of his larynx into his 
mouth, and his phonation, though hoarse, is excellent. Lately I 
have had made for him a tracheotomy tube with a fenestra in its 
upper part, and, with this in position, he can talk satisfactorily 
1 This patient was shown at the Congress of the American Surgical Association, 
in Boston, June, 1892, and, somewhat later, at that of the American Laryngological 
Association. The case was reported in full, and the patient again shown at the meet- 
ing of the Surgical Section of the Suffolk District Medical Society, February I, 1893. 2 
GEORGE H. MONKS. 
when the outer opening of the tube is plugged. He generally 
uses a cork for stopping this aperture. It is now about one 
year since the operation, and there is no sign of recurrence, and 
the patient enjoys excellent health. 
A Detailed Account of the Case. 
Some time previous to the operation this patient had been 
under the care of Drs. J. W. Farlow and W. F. Knowles in the 
out-patient department at the hospital. 
The man had had marked and persistent hoarseness for 
about a year. When the case was first seen by Drs. Farlow and 
Knowles, the right vocal cord was somewhat thickened and red- 
dened, and its movement during respiration and phonation was 
extremely limited. 
For a long time the case was carefully watched, and various 
methods of treatment, both local and general, were faithfully tried. 
In spite of this the voice remained husky, and the immobility of 
the right vocal cord became even more pronounced. 
In all other respects the man seemed to be well and strong. 
He never had marked pain in his throat or difficulty in swallow- 
ing. No cachexia was present. The family history revealed no 
trace of cancer. 
About this time I was asked to see the case in consultation, 
with reference to a surgical operation, looking to the partial or 
complete removal of the larynx. 
The case seemed to be a favorable one for operation. The 
growth was apparently confined to one side of the larynx, and 
no enlargement could be detected in the cervical glands. The 
neck was long and thin, and the larynx very prominent—-just such 
a neck, in fact, as one would prefer in case a laryngectomy were 
to be performed. In view of all the circumstances it was decided 
that an operation was justifiable—in fact, that the right half of the 
larynx, and all the soft parts within it, should be removed. 
A careful explanation was made to the patient, who was a 
remarkably intelligent man, as to the probable course of the dis- 
ease if left to itself, and as to the prospects in case an operation 
should be done. UNILATERAL LARYNGECTOMY. 
3 
After a few days’ deliberation he returned to the hospital to 
say that he had decided to undergo the operation and to put 
himself in our hands. 
A private room at the hospital was prepared for him. It 
was thoroughly cleaned and aired, and the bed was placed 
near the middle of it. The upper end of the bed was covered 
with a light canopy to keep off the drafts, and a steam jet was so 
arranged that the air under the canopy should be sufficiently 
warm and moist. The temperature of the room itself, when all 
was in readiness for the patient, was about 75 ° F., and until the 
patient was practically out of danger after the operation it was 
never allowed to go lower than this, or above 8o°. Arrangements 
were also made for a special watch through the day and night. 
The patient was given an ounce of castor oil on the night 
before the operation, and an enema in the morning. The entire 
'neck and vicinity were sterilized and enveloped in an antiseptic 
dressing. At the operation I was assisted by Dr. Knowles and 
Dr. H. W. Cushing. When the patient was thoroughly ether- 
ized, several pillows were placed under his shoulders so as to allow 
the head to fall back and fully expose the front of the neck. (See 
Fig. 1.) 
Two straight incisions were made ; the one (vertical) in the 
median line of the neck from the hyoid bone to about an inch 
and a half below the cricoid cartilage, the other (horizontal), on 
the right side of the neck, about the level of the lower border of 
the thyroid cartilage. This second incision joined the first at 
right angles. Part of the sterno-hyoid muscle was divided in 
the transverse incision. 
The thyroid and cricoid cartilages on the right side were 
laid bare, the soft parts having been carefully dissected away 
from them. 
The adjacent (the right) half of the back of the cricoid was 
then separated from the anterior wall of the oesophagus, so that 
after the operation was finished the oesophageal wall might be 
left intact as high up as possible, and the liability to regurgitation 
of food diminished. 
After the bleeding was arrested the trachea was opened at 
he lowest part of the wound, just below the cricoid cartilage, 4 
GEORGE H. MONKS. 
and a large-sized silver tracheotomy tube inserted. The whole 
larynx was then split in front, in the median line, and the two 
halves held apart, while gauze was packed into the lowest part 
of the cavity firmly upon the tracheotomy tube. The cavity of 
the larynx having thus been shut off from the trachea the entire 
right half of the larynx was removed, the incisions beginning 
from below. 
First, the right half of the trachea was divided just below 
the cricoid cartilage; then the knife was placed within the larynx, 
and the posterior part of the cricoid cartilage split vertically in 
the median line from the front. 
The thyroid cartilage was then carefully separated from its 
attachments to the soft parts behind, and, after this, the thyro- 
hyoid membrane was divided. Lastly, the superior cornu of the 
thyroid cartilage was pulled down and cut out. In all this dis- 
section the edge of the knife was kept as close as possible to the 
cartilages. 
Thus, the entire right half of the larynx was removed, 
including one-half of the thyroid and cricoid cartilages, the crico- 
thyroid membrane, the right arytenoid cartilage, the right vocal 
cord, and the other soft parts belonging to the right side of the 
larynx. Care was taken, when separating the thyroid cartilage 
at its anterior superior angle, to preserve as much as possible of 
the base of the epiglottis. 
An examination of the specimen after removal showed that 
the growth had not been fully removed, and that a part of it, 
which had extended across the median line in front to the other 
side, had been left at the anterior end of the left vocal cord. This 
portion was removed by the scissors, which were made to cut 
well into the sound tissues about the growth. 
The bleeding during the operation was not excessive, but 
troublesome on account of the difficulty in preventing the blood 
from running down the trachea after the gauze about the trache- 
otomy tube had been saturated. Elevating the foot of the table 
kept the blood from the trachea, but, as this expedient greatly 
increased the haemorrhage, it had to be abandoned. 
The wound left, after the parts above mentioned had been UNILA TERAL LAR YNGECTOMY. 
5 
removed, was large and irregular, and at its upper part communi- 
cated freely with the pharynx and oesophagus. A large-sized 
soft rubber stomach tube was passed from the wound through 
this opening well down into the oesophagus. Iodoform gauze 
was packed into the wound about this tube, and the skin edges 
above it were then approximated by silk sutures. 
The patient stood the operation very well, and he was taken 
to his room with two tubes in his neck, the one leading to the 
oesophagus and the other to the trachea. 
The resected portion of the larynx was sent to Dr. E. M. 
Greene, the pathologist of the hospital, and a few days later the 
following report was returned : “ The specimen . . . showed 
a considerable increase in the size of the vocal cord. No ulcera- 
tion was observed. Microscopical sections showed the normal 
tissue of the cord to be almost entirely replaced by a new growth 
made up of irregular masses and nests of large epithelial cells. 
Here and there broken-down muscular fibres were seen, sur- 
rounded by the growth. Diagnosis: Epithelioma.” 
The patient recovered quickly from the ether, and com- 
plained of no pain or distress, except when he made the motion 
of swallowing. 
During convalescence the chief difficulty experienced was 
in preventing the discharges at the wound from trickling down 
the trachea and causing irritation and cough. There was also 
some trouble in carrying out proper alimentation. 
For the first few hours after the operation there was a good 
deal of coughing, and mucus mixed with blood was expector- 
ated in large quantities. Finally, the foot of the bed was raised, 
and this procedure was found to be so efficient in keeping 
the bulk of the discharges out of the oesophagus that the bed 
was kept in this position, day and night, for about a week. 
On the day after the operation the rubber stomach tube was 
removed, and for a day a large-sized soft rubber catheter was 
put in its place. After this, whenever it was necessary to feed 
the patient, the catheter was introduced through the wound into 
the oesophagus, and liquid food administered through it. The 
patient was fed, every three hours or so, with egg-nog, whiskey 6 
GEORGE H MONKS. 
and milk. He did not like beef-tea. At first there was some 
regurgitation through the cesophageal wound, but this was 
largely prevented by pressing a plug of gauze against the wound 
during the act of swallowing. 
On the day after the operation the silver tube was removed 
from the trachea, and a glass tube, with an inflated rubber jacket 
about it, put in its place. This contrivance, which I devised after 
the plan of Trendelenberg’s canula, answered the purpose 
admirably, and was used until the troublesome mucous secretion 
and the accompanying cough had largely subsided. Had I 
thought of making such a tube before I should certainly have 
used it during the operation, and possibly throughout, in prefer- 
ence to the ordinary tracheotomy tube. This tube can be made 
very rapidly, and with little or no expense, somewhat as follows: 
A piece of glass tubing about four inches long, and having 
a calibre of about a third of an inch, is bent at an oblique angle 
near its middle in such manner as not to interfere with the calibre 
of the tube. A long rubber finger, such as can be procured in 
any rubber store, is nicked in two places—at the tip of the finger 
and at a point one side near the open end. The glass tube 
is then pushed through these two holes and the rubber tied 
firmly about it. A little glass tube is inserted at the open end 
of the finger, and this end is tied closely upon it. A rubber 
tube is attached to the small glass tube, and a small spring clip 
put on. 
The rubber jacket can then be inflated, when in position, 
by an air-bulb, after which the spring clip is set and the bulb 
detached. (See Fig. 2.) 
On the fourth day after the operation the temperature was 
ioo°, the highest point during the whole course of the case. 
This temperature was speedily brought down by an enema, which 
was followed by a copious dejection. The glass tracheal tube 
was removed for good on the fifth day. The same day some ale 
was given to the patient through the oesophageal catheter. This 
seemed to stimulate him in a most satisfactory manner. A spray 
of benzoinol and guiacol, administered from time to time, afforded 
great relief. Fig. 4.—The present condition of the operation field. 
Fig. 3.—The canula resting in the tracheal opening. UNILA TERAL EAR YNGECTOMY 
7 
On the ninth day fine bits of beefsteak were chewed and 
swallowed with evident relish, but the tube was still necessary 
when fluids were taken. On the tenth day the patient sat up for 
a while in a chair, and about this time it was noticed that he could 
talk in a rough whisper by closing the opening in his neck. 
Later, the opening showed a tendency to close, and it was 
thought best to keep an ordinary tube in the tracheal wound. 
Soon after the patient left the hospital he acquired the power 
of swallowing liquids without the use of the catheter, and with- 
out regurgitation through the wound, so long as slight pressure 
was kept up at the opening into the oesophagus. (See Figs. 3 and 4.) 
Fig. 2.—Glass trachea tube with rubber jackets inflated. 
Figures 3 and 4 are from photographs of the patient taken 
about a year after operation. The contraction of the parts dur- 
ing cicatrization forced the tracheal tube from the opening, which 
was originally made for it in the trachea, up into the larger 
wound which was left because of the removal of part of the larynx. 
This accounts for the fact that in these cuts the opening for the 
tube appears to be somewhat to the right of the median line. 
Though the tube now occupies a higher position than before, it 8 
GEORGE H. MONKS. 
does not touch the left vocal |cord, a circumstance which would 
seriously interfere with phonation when the tube was in place. 
Figure 4 shows the tube about to be introduced. The tip 
is within the wound, and the broad shield rests upon the collar 
of the patient. The fenestra on the upper curvature of the tube 
is plainly shown, and a cork has been placed in the outer open- 
ing. The patient wears this tube day and night, only removing 
it for the purpose of cleaning it. It is held in place by a tape 
about the neck. 
This patient breathes easily, talks intelligibly, sleeps and eats 
well. He does as much work, and for the same remuneration, 
as was the case before he lost half of his larynx. He seems to 
be thoroughly satisfied with the results of the operation. 
Remarks. 
This case seems to me worthy of being recorded if for no 
other reason than that it shows that removal of half the larynx, 
in favorable cases, is not inconsistent with the subsequent comfort 
and usefulness of the patient, without any great loss of natural 
voice and without recurrence for a long period of time.