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Conditions more immediately associated with the operation itself then come under consideration, as septic conditions, paralysis of the heart, and hæmorrhage. Profuse hæmorrhage and insufficient packing around the tracheotomy tube lead through aspiration of blood to a fatal issue, either suddenly, with appearances of suffocation, or a short time after the operation, with signs of a rapidly advancing bronchitis and pneumonia. Secondary hæmorrhage is of more frequent occurrence, as the result of erosion of blood vessels or the detachment of ligatures, often due to unavoidable suppuration in the wound, and the hæmorrhage so caused leads to asphyxia, especially if assistance is not at hand; or later to pneumonia. The difficulty, almost the impossibility, of preserving ascepticity during the operation and after treatment, explains sufficiently the proportionate frequency of septic processes as causes of death.

Amongst the causes of death after extirpation of the larynx, heart failure has taken a considerable place in the literature on the subject, and many authors have attempted an explanation. The clinical picture is well known. Immediately after the operation, or within the next day or two, the heart begins to beat forcibly with a very frequent and weak pulse, and after a certain time exhaustion of the heart becomes evident; the heart failure.

Some authors hold that this is accounted for by a possibly abnormal course of the depressor fibres of the vagus through the larynx, along the course of the superior laryngeal nerve, and that their section during the operation results in a cessation of the retarding influence of the vagus on the heart, while the accelerator influence predominates. On this assumption the clinical picture of death from heart failure appeared to be completely explained. The strict proof, however, remains wanting

A different explanation has been given by Grossmann. According to him, it is due to irritation of the superior laryngeal nerve, the irritation spreading to the vagus, with corresponding results. If, on looking through the histories of cases of death from heart failure after the operation

for laryngeal cancer, the impression is obtained at first that there is a specific post-cperative vagus phenomenon, with closer study of the post mortem records, however, another opinion is arrived at.

Koschier studied the post mortem records of cases, in the Institute of Pathology at Vienna, that had died after the operation of extirpation of the larynx for cancer, since the first performed by Billroth. In all cases in which the symptoms before death were such as might be attributed to interference with the vagus nerve, there were changes in the heart found post mortem that allowed a natural explanation of the cardiac paralysis apart from this theory.

In some of the cases there was degeneration of the heart muscle with arterio-sclerosis, while in others there was more or less advanced fatty degeneration of the heart muscle. In one there was complete adhesion of the heart to the pericardium. In those cases in which death occurred a few days after the operation there were changes in the lungs of the nature of lobular pneumonia and bronchitis. These changes in the heart are sufficient in themselves to explain the sudden onset of heart failure, when one thinks of the harm done to the organism by the long duration of the operation, and anästhesia. In the cases which were complicated with pneumonia or bronchitis the heart failure is still more intelligible on account of the increased strain thrown on the already weak heart by the pulmonary congestion. More important, because incomparably more frequent, as a cause of death after extirpation of the larynx, is “aspiration ” pneumonia. It occurs either through aspiration of blood during the operation or the aspiration of food or secretion from the wound during the after treatment. Against the former danger a sufficient protection is formed by the use of a good Trendelenburg tampon cannula, or the later modification of the same by Hahn, and if necessary one operates with the patient's head hanging down.

It is more difficult to protect the patient from aspiration of secretion from the wound during the after treatment. The wound left after the operation is a large one, and consequently

there is a copious secretion from the granulating surfaces, which possibly flows into the trachea and is followed by bronchitis and then pneumonia with a fatal result. Pneumonia is also set up by the entrance of saliva, or food, into the trachea through the abnormal opening that exists between it and the pharynx. To guard against this occurrence it is necessary to carefully fill up the cavity of the wound next the trachea, and this object he has sought to attain by the introduction of suitable packing Strips of iodoform gauze, the usual medium, have proved insufficient, as it is difficult to fix the packing so well that it will not be moved out of place when the patient swallows, and so come to lie with one end of the gauze in the throat, setting up coughing and vomiting, or to pass by the side of the tracheotomy tube into the trachea, causing signs of suffocation. The packing also gets loose in a few days, and on the fourth or fifth day one is forced to change it before the surfaces of the wound are covered by granulation tissue. It is obvious that the second packing will not lie so well in position as the first, and in consequence the danger of "aspiration” pneumonia is greater even than before. The artificial nourishment of the patient has therefore to be carefully attended to, and some surgeons at the end of the operation pass a flexible catheter through the nose or through the opening in the neck into the oesophagus, by means of which the patient is fed for a time. Surgeons have been on the look-out for a method that would separate the wound and pharynx from the trachea, and have tried to effect this by a plastic operation, sewing together, after partial extirpation, the remaining part of the posterior wall of the larynx, and the hyothyroid membrane.

A truly decisive result was attained through the experimental studies of Gluck and Zeller on the origin of septic pneumonia after the operation on the larynx. They came to the conclusion that resection of the trachea is an infallible means of preventing such a pneumonia, and on the basis of these experiments Gluck proposed freeing the trachea from its surroundings, and so making it mobile, then resecting it and stitching the distal cut end to a button-hole in the skin, thus

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interposing an impermeable barrier between the wound and the lungs which renders the inspiration of foreign bodies impossible. By the adoption of this method the results of the operation were so improved that Gluck was able to reduce the mortality to 4.5 per cent. Gluck's modification is applicable to those cases in which the laryngeal carcinoma is so widely spread that total extirpation of the larynx is required.

If, however, one considers that, thanks to the spread of laryngology, we are more frequently in a position to recognise early carcinomata of the larynx, or at least such as are still confined to one side, where unilateral resection of the larynx is sufficient, then it is evident that Gluck's modification can proportionately seldom be employed. Even in cases of total extirpation of the larynx, both the patient and the surgeon are loath to give up a direct communication for purposes of phonation between the air passages and the mouth, and the idea of being obliged to use an artificial larynx is regarded with disfavour. The unpleasantness associated with the wearing of such an apparatus, even when practicable, is well known, and patients prefer to give up loud phonation rather than go about with one. Surgeons again always have in mind the phonetically faultless results in cases of extirpation of the larynx by the earlier methods, thanks to the use of a Schornstein cannula, by which the patient could phonate perfectly while holding the end closed with the finger. A classic example of this is the case of Franzos, operated on by Stoerk and Gersuny with so successful a result.

The method employed by Föderls must be pointed out, by which he attempted to shut off the large cavity of the wound from the trachea, and at the same time to retain a permanent communication between the trachea and the mouth. He removed the whole thyroid cartilage, the arytenoids, and the upper part of the posterior lamina of the cricoid cartilage, in the case of a carcinoma that had spread over the entire larynx. He then drew the trachea upwards after freeing it from its surroundings, and sutured the anterior part of the cricoid to the body of the hyoid. This procedure was carried out in one case by him, and the result was excellent; but it is

scarcely possible in all cases on account of the displacement of the trachea that is necessary, and, as a matter of fact, in Germany, as in Vienna. a few similar attempts of other surgeons did not attain the desired results, because the stitches between the trachea and the hyoid separated. The method has a further disadvantage, in that the patient is not able to swallow easily, especially fluids, as the opening of the air passages is not sufficiently covered during deglutition. With solid food this imperfect closure is of no special consequence, and after a few months patients learn to swallow almost faultlessly, even if they have difficulty at first, but the difficulty of swallowing liquids remains to some extent.

While the method of Gluck in total extirpation reduces the danger of “aspiration” pneumonia to a minimum, we are still obliged to make as absolute a separation of the trachea as possible from the wound cavity by the use of packing, as in the majority of cases cancer of the larynx is unilateral. To improve upon the disadvantages of the method of dealing with the wound already discussed, Koschier uses another method, the results of which have given him entire satisfaction. After finishing the laryngeal extirpation, he lines the cavity of the wound with a broad double strip of iodoform gauze, under the guidance of the fingers, and takes special care that the space within the remaining part of the cricoid, or the space at the commencement of the trachea if the cricoid had to be removed, be sufficiently filled up. The upper part of the wound opposite the pharynx is treated in like manner, and into the sac thus formed a narrow strip of iodoform gauze is introduced in such a way that first the lower and then the upper part of the wound is filled accurately. The packing must be done very carefully, and as long a strip as possible carried into the sac. If during the operation a horizontal incision necessary at the level of

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upper border of the thyroid cartilage, then the edges of the wound will remain open and have to be united exactly by sutures. The air is then allowed to come out of the Trendelenburg cannula, which is then removed and replaced by an ordinary perforated Stoerk’s tracheotomy tube. A light bandage

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