o-L . 
Reprinted from “The Medical Press of Western New York." 
TOTAL EXTIRPATION OF THE LARYNX. 
BY ROSWELL PARK, M. D, [Reprinted from The Medical Press of Western New York, December*J$S=r.'] 
A CASE OF TOTAL EXTIRPATION OF THE LARYNX. * 
By Roswell Park, M D. v 
Prof, of Surgery, Med. Dept., Uniu. of Buffalo; Attending Surgeon to the Buffalo General Hospital. 
Gentlemen: The case I have to show you here is one of such in- 
terest that, while but very few of you had the opportunity of wit- 
nessing the operation, I cannot forego the chance of showing you 
its results so kindly permitted me by the patient, who is himself 
a physician and who was until very recently in active practice in an 
adjoining state. 
But that you may better understand his condition previous to 
operation I have begged my friend, Dr. F. W. Hinkel, under whose 
! care he had been, to give you a short account of the case as he had 
watched it. This he courteously furnishes as follows: 
“ Dr. J. H. Pierce was brought to my office for examination October 9, 1884, by 
Dr. H. R. Hopkins. His voice was shrill, discordant, and very stridulous. He 
gave his age as sixty-three years. He had the appearance of rugged health, but 
stated that while a youth he had been “ sent away to die of phthisis.” After his 
graduation in medicine he developed perfect general health, which he had since 
retained, in spite of much abuse in civil and military life, and by excessive smok- 
ing. Said he had used as many as twenty cigars a day. He dated his throat trouble 
from an attack of acute laryngitis after great exposure in the early years of our 
; civil war. Since then, has been annoyed by occasional attacks of hoarseness and 
sore throat, which gradually became more frequent, continuous and severe until,. 
* Part of a Clinical Lecture delivered at the General Hospital October 3, 1885. 2 
Park: A Case of Total Extirpation of the Larynx. 
in the last few months, his voice had fallen into its present condition. Lately 
there were occasional darting pains through the region of the larynx. He had a 
hacking cough—especially at night—with little expectoration and no pain. Occa- 
sionally he had attacks of dyspnoea, which he teimed “asthmatic attacks.” 
Otherwise his personal and family history were good. He had never had a laryn- 
goscopic examination. 
“ The oro-pharynx was found unusually small in proportion to size of patient, 
much inflamed and extremely irritable. The arches of the palate were swollen 
and red. The uvula was of a purplish-red color, much thickened and covered 
with corrugated mucous membrane, but not cedematous nor elongated. The 
laryngoscopic examination was made with difficulty, owing to excessive faucial 
irritability; It revealed deep congestion and puffiness of the mucous membrane 
in the supra-glottic portion of the larynx. The ventricular bands were swollen, 
deep red in color, and not clearly defined. The location of the vocal bands was 
filled with two reddish-grey, irregular, sessile growths, apparently filling the 
ventricles on either side and covering both vocal bands. By careful examination 
they could be seen to extend on each side over the lateral walls of the sub-glottic 
portion of the larynx, so that the bulk of the growth was sub-glottic. The glottis 
was much and irregularly encroached upon. A tooth-like process from the pos- 
terior third of the right growth, and a similar process from the anterior portion of 
the left growth, transformed the chink into an irregular Z-shaped opening. The 
sub-glottic larynx was irregularly contracted in its lateral dimensions, rendering it 
impossible to see beyond the growths. The further encroachment upon this small 
breathing space by the swelling incident to acute cor gestion readily explains the 
‘ asthma ’ from which he suffered at times. There was no ulceration present. 
The cushion of the epiglottis was swollen, but probing did not show marked 
tenderness over it or the growths. These latter I regarded as papillomata, but 
feared there was beginning epitheliomatous degeneration. Believing their com- 
plete removal per orern to be impossible, I made use of soothing alterative applica- 
tions, and warned the patient of the great possibility of malignant degeneration at 
his age, and of the possible future advisability of thyrotomy or even extirpation of 
the larynx. 
“After a few days he disappeared suddenly from my observation. He came 
under my care again for a few days on January 8, 1885. He had been under Dr. 
Elsberg’s care, in New York, in the interim. The condition and appearance of 
his throat were much the same as when first examined. On April 20 I saw him 
again. He stated there had been some operative procedures by Dr. Elsberg. 
Owing to the unfortunate death of that eminent laryngologist it has been impos- 
sible to obtain, with any exactness, his prognosis or treatment of the case. An 
examination showed but little change in the growths, and that for the worse, the 
glottis being smaller and the growths more redundant. The patient was suffering 
at the time from a severe pharyngitis. The uvula was much inflamed, and dyspnoea 
was quite marked. Under treatment this disappeared, and the patient with it. Park: A Case of Total Extirpation of the Larynx. 
3 
“ I again saw him on June 10. In the interval he had visited Philadelphia 
and was there seen by Drs. Seiler, J. Solis Cohen, and others. His condition was 
now changed much for the worse. There were darting pains through larynx and 
into left ear. Voice was gone completely. His breathing was noisy, difficult and 
hurried. Pulse rapid and weak. Sleep was disturbed, and had often to be taken 
sitting up, on account of sudden attacks of dyspnoea. He was losing his strength 
and spirits. The left ventricular band presented, on its anterior third, a smooth, 
rounded tumor, of deep red color and considerable density, shading into the sur- 
rounding congested mucous membrane. The growths over the vocal bands had 
increased somewhat in size, but were not ulcerated. There was exquisite sensi- 
tiveness over the cushion of the epiglottis and over the new formation in the ven- 
tricular band, when probed. The case being now plainly one of epithelioma, I 
seriously bioached to him thyrotomy, or extirpation of the larynx, as the only 
means of relief from the disease, and explained that tracheotomy might be ren- 
dered necessary by the slightest diminution of his air-space by inflammatory 
swelling. Some indiscretion on his part precipitated an acute congestion of his 
larynx, and on the morning of June 14 I found him in my office, laboring for 
breath, weak, excited and somewhat cyanosed, after a sleepless night spent in a 
struggle for life. Finding tracheotomy necessary at once, I hurried him home and 
called in Dr. Roswell Park, who met me that afternoon at the patient’s temporary 
residence.” 
The patient was in the condition described by Dr. Hinkel, when 
I first saw him. As he was in danger of.immediate suffocation 
there was no difference of opinion as to the immediate necessity 
for tracheotomy. This was consented to, and at once performed. 
So little breathing space was there that we even feared to give an 
anaesthetic; we therefore urged that it be borne without. A syringe 
full of cocoaine, four per cent, solution, was injected under the 
skin in the middle line of the neck, and the ether spray used as a 
local anaesthetic. With Dr. Hinkel’s kind assistance I then began 
to operate. But pain was by no means abolished, and on this ac- 
count the procedure was prolonged. Finally, after‘dissection was 
partly accomplished, and the deep parts so far exposed that, in case 
of necessity, the trachea could be roughly and quickly opened, the 
patient’s demand for chloroform was acceded to, and it was care- 
fully administered. 
No small difficulty was experienced in properly exposing the 
trachea, and the operation was, hence, annoyingly prolonged. Even 
after its exposure the proper introduction of the tracheal tube was 
rendered very difficult; and the introduction of wire sutures through Park: A Case of Total Extirpation of the Larynx. 
4 
skin edges and the margins of the tracheal opening, as I had con- 
templated, was impossible. Full anatomical explanation of these 
difficulties was furnished by the subsequent operation, which showed 
that the trachea not only lay at an unusual depth, but had under- 
gone a considerable calcification (senile) by which it had lost most 
of its elasticity. 
But the tracheal tube was finally introduced, and the patient 
breathed easier than he had for a longtime. Relief was immediate, 
and in two days he was up and about his room and had recovered 
from the physical exhaustion of his partial apncea. 
During the latter part of the first week there was a mild amount 
of nocturnal delirium, which we were then inclined to ascribe to 
the influence of opiates, but which, in the light of subsequent devel- 
opments, we had to consider traumatic in origin. 
The tracheotomy wound granulated so rapidly that in the absence 
of sutures the tube could not be kept in place, but was crowded up 
and out by the healing process. But the more or less inflamed and 
tortured larynx, even though filled up with growth’ as it was, had 
had a week’s rest, and after the removal of the tube he breathed 
with considerable ease. 
Now the question of “ what next ?” assumed no small propor- 
tions. It was a choice between sure death from extension of the 
trouble, or not improbable death from the results of a radical 
operation. For the latter, spoke the excellent physical condition 
and powers of endurance of the patient, and the facts that no 
cancerous cachexia was to be noted, and that there was no sign of 
any involvement of parts outside the laryngeal box. Against it, 
spoke only the known dangers of the operation. Our advice was in 
favor of operation, and this was also the advice of Dr. Carl Seiler, 
of Philadelphia, who saw him while on a trip to the West. The 
patient made his choice of radical operation, after a full presentation 
of its advantages and dangers. 
Accordingly, he took a private room in the Buffalo General Hos- 
pital, where he was prepared for operation. On June 28, 1885, 
complete extirpation of the larynx was performed. During it I had 
the valuable assistance of Dr. Phelps, who kindly took charge of 
the anaesthetic (chloroform with 1% of amyl nitrite), of Dr. Seiler Park: A Case of Total Extirpation of the Larynx. 
5 
and Dr. Hinkel, who assisted in the operative procedures, and of 
several of my colleagues of the hospital staff. The operation was 
made, in the presence of a number of medical gentlemen of the city, 
in the hospital amphitheater, where there is remarkably good light. 
It was necessary to make a long incision, in the middle line, 
which ran from a little in front of the body of the hyoid to one 
inch below the upper end of the sternum; this, as the head was 
drawn backwards over pillows, made it about six inches long. In it 
were included the remains of the previous tracheotomy incision. 
Careful dissection was then made down on either side of the larynx 
and trachea; the muscles attached to the sides of the larynx were 
peeled back with a sharp periosteum elevator. This separation of 
soft parts on either side was carried as high as the hyoid bone and 
as low as the second or third rings of the trachea. Vessels were 
caught in haemostatic forceps fast as they bled, and tied later with 
catgut; a few larger veins were tied twice and cut between ligatures; 
about twenty-five haemostatic forceps were employed, once or twice 
all being in lise at the same time. Up to this time patient had 
breathed his chloroformized air by the mouth. At this time, after 
the deep parts had been well exposed, and the lateral portions held 
aside with retractors, and after my fingers had pretty completely 
separated the trachea from the oesophagus, it was thought best to 
open the thyroid cartilage for exploratory purposes. This was no 
easy task, and sharp cutting bone forceps were necessary before it 
could be accomplished, so firmly was it calcified. By this explora- 
tion it was quickly noted that the growth was well confined within 
the laryngeal walls. So without further loss of time the trachea 
was divided; first longitudinally through its upper three rings, and 
then transversely between the first and second ring. A Trendelen- 
berg tampon tracheal canula was then inserted, but its rubber bal- 
loon proved faulty; consequently, I packed sponge around its main 
tube and used it as an ordinary tracheal tube, save that the tube 
and funnel for the anaesthetic connected with it were utilized dur- 
ing a part of the remaining time. 
The larynx and upper tracheal ring were now rapidly separated 
from the oesophagus, and after this separation was complete from 
below the thyro-hyoid membrane was divided and then the re- 6 
Park: A Case of Total Extirpation of the Larynx. 
mainder of the lateral walls of the lower pharynx, the constrictors 
were dissected off from their insertions into the larynx, and the 
whole removed in one piece. Hemorrhage was checked, and then 
the parts explored for evidences of any extra-laryngeal suspicious 
tissue. None was found here, but I decided to remove the uvula, 
which had been for some time very sensitive, and in which a little 
firm nodule was felt. The upper part of the epiglottis, with its 
glossal and lateral connections, was also left in situ. 
Particular attention was then given to every bleeding point, and 
hemorrhage, which had at no time been alarming or uncontrollable, 
was perfectly checked. A little blood had run down the trachea 
and was coughed up at intervals. The tracheal tube was then re- 
moved and a strong silk suture introduced on either side, through 
the skin and the upper tracheal ring which, it will be remembered, 
had been split vertically. These were the only sutures used, and 
were for the purpose, not of trying to pull the trachea up in the 
neck, but simply of holding it well to the front. A large single 
trachea tube of aluminum, made for the purpose, was then introduced 
and held by tapes around the neck. Over its upper surface fell the 
anterior-cut margin of the oesophagus. Iodoform was dusted spar- 
ingly throughout the wound and the whole cavity carefully packed 
with iodoform gauze, so arranged that a pathway to the oesophagus 
was left, this latter being lightly plugged with the same material. 
This ended the operation, which lasted just about one hour. Dr. 
Phelps* so carefully gave the anaesthetic that not once during its 
whole course did the patient’s pulse flagg. Once or twice his 
breathing was disturbed, but apparently only by the presence of blood 
in the bronchi, and which was speedily expectorated. Shock was 
very slight. He was put to bed with hot bottles, and the tempera- 
ture of the room ordered to be kept at 8o° F. Five hours after the 
operation, finding that he had not vomited at all, and as he wrote 
me he was feeling somewhat faint, I introduced a soft rubber 
oesophageal tube through the wound and through a funnel poured 
a half-pint of strong egg-nog into the stomach. His temperature 
was then 101.80, pulse 138 and respiration 40. 
•In this way he was fed every four to six hours, the nourishment 
being concentrated but fluid, at first mostly a mixture of Reed and Park: A Case of Total Extirpation of the Larynx. 
7 
Carnrick’s beef peptonoids in egg-nog. Quinine in good tonic 
doses was given, as also, later, fluid extract of coca and tincture of 
nux vomica; also hypnotics as needed, codeia being the only opiate 
employed and this sparingly. Not until the third day was the iodo- 
form gauze touched, and it was not entirely removed until the 
sixth. It .was replaced by fresh gauze or iodoform cotton. After 
the second day, when surgical fever had subsided, his temperature 
averaged 990, and was often normal. 
Convalescence was only broken by one incident, but this came 
near being disastrous. On the fifth and sixth days it was noticed 
that he seemed a little dazed, and his written messages were some- 
what incoherent; and I was reminded of his similar condition after 
his previous operation. Late in the evening of the sixth day, while 
apparently asleep, and being watched by one pupil of the training 
school for nurses, he suddenly jumped out of bed, threw up a 
window (second story) and made ready for a spring. The nurse 
seized him by his night-clothes and pulled him back. Then ensued 
a severe struggle, during which she was severely bruised, he endeav- 
oring to escape and she to hold him back; in a moment her calls for 
assistance were answered and he was put back in bed. But for her 
pluck he would have killed himself by his attempted leap. His 
acute mania was soon subdued. Next morning his temperature was 
only 990, and he showed no evidences of his wild night, save that 
his thoughts were incoherent. In two days he had practically 
recovered, though his mind was not quite clear for two weeks after- 
ward. This could not have been iodoform intoxication nor the 
effects of opium, because both had been used in minimum amounts; 
I therefore class it among those obscure cases of so-called “ traumatic 
mania,” about whose etiology we know pratically nothing. 
I soon began, however, to dress his wound with cotton steeped 
in a saturated solution of salicylic acid and potassium chlorate, and 
to the stimulating effect of the latter I ascribe the remarkably rapid 
granulating process by which the wound closed. 
Three weeks after the operation he rode a mile to his brother’s 
house, having had not the slightest septic symptom, nor any unto- 
ward lung complication; in fact, the mania was the only incident of 
his subsequent recovery. In three weeks and a half the oesophageal 8 
Park: A Case of Total Extirpation of the Larynx. 
feeding tube was introduced through the mouth instead of by the 
wound, which was no longer sufficiently open. In five weeks he 
was wearing the tracheal portion of his artificial larynx; in six weeks 
the pharyngeal portion of it, was breathing through his nose once 
more, and was able to whisper so that he could be heard across the 
room. In seven weeks he was able to swallow soft solids, when 
the obturator of the upper tube was introduced. In eight weeks he 
was able, by means of the vibrating reed inserted in the tubes, to 
talk almost as loudly as you or I, and to articulate with perfect dis- 
tinctness. And by a process of self-education combined with a 
certain self-reliance he has been able to learn to a certain extent 
to swallow ordinary food, and to drink, even without the obturator, 
he having acquired the knack of protecting the open upper end of 
the pharyngeal tube by the remainder of the epiglottis. 
This operation has not yet been performed, all told, a hundred 
times; and in this country, but two or three times previously to this 
case. As nearly as I can gather, never have the processes of repair 
occurred with greater rapidity than here; in fact, as I recall the 
formidable wound, it seems almost incredible that healing could have 
taken place as rapidly as it did. Now as you see the patient, only 
fourteen weeks after operation, you observe only an opening barely 
admitting a finger tip, and which has had its present size for eight 
weeks. Through this small opening are introduced the various por- 
tions of this most ingenious mechanism known as Gussenbauer’s 
artificial larynx, which it yet remains for me to demonstrate to you. 
The one which the patient is wearing is made of pure silver and 
was made for him by Mr. A. M. Edwards, of this city, an ingenious 
and skillful jeweler. It was fashioned after this other one, whose 
parts I now show you, which was made for me by the same artisan 
in Prague who has made all of Prof. Gussenbauer’s later instru- 
ments. 
It consists of a tracheal tube of large size (A) with rings at its 
lower end permitting a slight motion, corresponding to the natural 
flexibility of the trachea. Through its front plate and through an 
opening on its upper curvature passes a second or pharyngeal tube 
(B), made also flexible (or not, according to the case); with an 
opening on its lower curved surface, so placed that a stream of air Park: A Case of Total Extirpation of the. Larynx. 
9 
may play freely through both tubes, even though the external 
outlet be closed. The upper end of the pharyngeal tube lodges 
behind and below the epiglottis, if this have been left in situ, or 
behind and below the base of the tongue, as the case may be. 
Around it the oesophagus granulates and closes, so that after the 
healing process is complete the only passage from the pharynx into 
the larynx is by way of the metal tube. In order that fluids and 
solids may not pass through this, an obturator (C) is provided, 
which is passed through the external opening and up through the 
tube, so that its rounded upper end plugs the upper end of the 
pharyngeal opening, thus preventing passage of anything into the 
trachea. But since this would also shut off air, the obturator is 
attached below, not to a solid plug, but to a ring, as seen, which fits 
accurately into the external opening of the instrument, through IO 
Park: A Case of Total Extirpation of the Larynx. 
which, then, the patient breathes so long as this plug is worn. 
Except at meal times this simple stopper (£) is worn, so that at all 
other times he breathes naturally through the nose and mouth. 
After a time, by an instinctive education of the pharyngeal and 
buccal muscles, the upper end of the tube is protected during the 
process of deglutition, and patients wearing these instruments learn 
to swallow readily without the assistance of the obturator. Even 
thus soon, in this particular case, you see the patient uncon- 
sciously but easily swallows his saliva. 
Now the feature of greatest interest about this apparatus is the 
vocal part. Let this case forcibly remind you that the vocal cords 
do nothing in articulate speech but furnish the tone or sound, and 
that articulation is all carried on by parts above the larynx. With 
only the simple stopper in place, by aid of which the air current is 
directed toward the mouth, the patient will read to you in a loud or 
‘ stage ’ whisper which is distinctly audible all over this large room, 
and you realize how perfect his articulation is. Now you can under- 
stand how we may get a distinct speaking voice providing we can 
introduce some substitute for the vocal cords, something which, by 
vibrating in the air current, may produce a distinct tone. 
And in this simple mechanism (Z>) we have such substitute. 
Only a free metallic reed, like a melodeon reed, playing freely in a 
movable slotted bar, and fitted inside of a stopper like the other one. 
This movable bar carrying the reed has an external lever, by means 
of which the wearer is enabled, with a touch of his finger, to throw 
it into or out of the air current, and thus—as it were—to volunta- 
rily open or close his glottis. Placing this part of the instrument 
in situ, and throwing the reed into the air current, the metal strip 
vibrates as it does in the jew’s-harp, and the sound thus produced is 
converted, by the articulating parts above, into something more 
than the whisper you heard before,—into distinct speech. 
To be sure his ‘ voice ’ is now a monotone, but it is nevertheless 
a voice, and he is just as capable of carrying on a conversation as 
you or I. 
We may regard, then, the results of the operative and subsequent 
procedures in this case as perfectly successful, and as justifying such 
radical measures in selected cases. As you see the patient to-day Park: A Case of Total Extirpation of the Larynx. 
n 
[This figure, modified from one of Schuller’s, represents the instrument in situ. 
The artist’s notions of topographical anatomy have led to some distortion of the 
anatomical relations, but without interference with the main purpose of the illus- 
tration.] 12 
Park: A Case of Total Extirpation of the Larynx. 
he is the picture of health, without the slightest suspicion of return 
of the malignant disease. I might add here, parenthetically, that 
on careful microscopical examination the growth was found to be 
distinct epithelioma. But whether it returns in time or not, it is 
scarcely likely that either the patient or myself will regret the opera- 
tion which has already prolonged his life and saved him from the 
agony of suffocation. 
Let me only add that this apparatus does not represent the first 
efforts that were made, even by Gussenbauer who was the first to 
succeed, to devise a substitute for the larynx, or vocal box, but it 
shows the instrument in its most perfect form. And I know that the 
ingenuity and surgical ability thus displayed by that celebrated 
surgeon in the accomplishment of this purpose will command your 
sincere admiration.