CARCINOMA OF THE LARYNX.1

THE SU

BY D. BRYSON DELAVAN, M.D., New York.

HE surgical treatment of cancer of the larynx can no longer be considered a new subject.

Since the early attempts of Watson, in 1866, many methods have been devised and many operators have undertaken by the radical removal of the disease to save the lives of its unfortunate victims. Some of the surgeons who have undertaken the work have been men of exceptional professional eminence. Many have not. The results of the operative work have sometimes been exceedingly brilliant. More often they have shown a degree of failure at once surprising and disheartening. While many improvements in existing methods are unquestionably possible, the time has arrived when, with the material at our command, we may critically review the situation and fairly weigh the value of the surgical treatment of laryngeal cancer.

In the attempted treatment of laryngeal cancer by surgical intervention, four general methods have been proposed:

1. Removal of the disease by intralaryngeal

measures.

2. Division of the thyroid cartilage followed by excision of the diseased soft parts and, if necessary, by a limited removal of the larynx itself. (thyrotomy; partial laryngectomy).

3. Removal of the entire larynx (laryngec

tomy) with as much of the surrounding tissues and connecting lymph nodes as necessary.

4. Tracheotomy, to relieve dyspnoea in advanced disease.

With the first and last of these we need not concern ourselves. Intralaryngeal treatment stands absolutely condemned and has long ago been abandoned by all intelligent men. Tracheotomy is used merely to palliate a symptom. It has never been even supposed to be curative.

It interests us, therefore, to deal in this discussion only with those operations intended to effect the radical removal of the disease-thyrotomy, partial laryngectomy and complete laryngectomy. And here let me say that the time is ripe for the announcement of a contention which I believe has never been made before, namely, that, in view of the present condition of affairs in this department, and in the light of the opinions held by the leading authorities of the world, there are to-day no serious differences of opinion as to the main principles which should govern the surgical treatment of cancer of the larynx.

While here, as everywhere else, much discussion has been raised upon various points con

1Read before The New York State Medical Association, at the Twenty-second Annual Meeting, New York, October 16-19, 1905.

nected with the subject, I venture to say that most of the labor expended has been thrown away. If we were to insist that all theoretical speculation be set aside and that the subject be considered strictly from the light of actually demonstrated facts, there would be little room for controversy.

How true this is may be seen from a glance at some of the chief points at issue. Thus, the diagnosis of laryngeal cancer by visual examination has always been, and still remains a matter of great difficulty. Where doubt exists, the differential diagnosis should be made by every possible means, including examination for tuberculosis and a short course of potassium iodide. Diagnosis through the aid of the microscope is most desirable, if the histological conditions are such that a correct diagnosis can be made by this means. Repeated attempts to remove the growth, however, whether for purposes of diagnosis or for treatment, are to be strongly condemned.

In the face of a few supposed cures the weight of evidence here, as elsewhere, is overwhelmingly against irritation of a suspected epithelial growth.

The most radical advocates of latitude in this particular have been obliged to yield their ground and to admit that, when tissue is removed from the larynx in a suspected case, it should be with. the distinct understanding that if the case prove malignant, operation be immediately submitted

to.

Again it is contended by some that degeneration of a benign laryngeal growth into a malignant one never takes place. Practically this is a hairsplitting proposition, for if early diagnosis of the growth is impossible, and irritation of it sure to result in harm, what difference does it make in the final result whether an apparently innocent growth was really malignant from the start or whether it became so at a later stage of its progress?

The most important question apparently now at issue is as to the choice between partial removal of the larynx and complete laryngectomy.

In every department of surgery it is being urged that cancer should be early diagnosed and early operated upon in order to obtain the best results. As has long and eloquently been insisted by Mr. Butlin, this is especially true in the case of the larynx. Late operation could never be done from choice, but in the hope of prolonging life. The question, however, as to the necessity for complete removal of the larynx in early cases, when the disease is confined to the interior of the organ, is a burning one. It may be asked: "Is carcinoma at any stage of its progress confined to the interior of the larynx?" We contend that it is and that numerous examples of a similar nature may be found in other parts of the body, as, for instance, the auricle of the ear. Any experienced dermatologist will admit the curability of certain superficial cancers, and in the early stage many laryngeal cancers are pretty certainly superficial.

Eliminating these considerations, however, as

possibly theoretical, one grand argument presents itself in favor of limited operation in suitable cases and that is the overwhelming weight of statistics. Thus, in laryngectomy, recent general statistics assume that 15 to 16 per cent. of patients operated upon have remained well over a period of three

years.

In thyrotomy, with removal of the diseased soft parts the permanent cures in general are estimated at about 44 per cent., while of twenty patients operated upon by Mr. Butlin about 70 per cent. lived for more than three years. Making allowance for several fallacies which may arise in estimating the reliability of these figures, it still remains that the partial operations suitably applied, have demonstrated that they may rightfully claim our respectful considération. We would say, save the patient if you can by means of the less serious operation. If not, save him even at the expense of radical and complete removal of all offending tissues, but save him.

If the treatment of every given case were to be studied in the light of what has already been proved and announced by those of best experience, and if it were to be managed in strict accordance with what have now become well-established rules, it is safe to say that fewer patients would be sacrificed to shock, to sepsis and to pneumonia.

In my experience with operators many beginners have seemed unwilling to accept valuable information, even neglecting to study the easily obtainable classics of the subject; in witness whereof they have unnecessarily used a tracheal cannula after operation, they have placed the patient upright in bed, or they have provided inexperienced nurses, commonly with fatal result.

Laryngeal operations of this class are at the best difficult operations. They are not at all of the same class with ordinary surgical procedures. They never have been and perhaps never will be within the reach of the average operator. First attempts in any direction are never apt to be as successful as later ones, and the history of laryngectomy clearly shows that operators have improved with experience. Until something better shall have been proposed, surgical means seem to remain our only reliance.

Let such operations be done, therefore, but only by men of experience and under rules and conditions most likely to save the patient and to bring to him a maximum of comfort, usefulness and length of days. The question of metastasis is the most important one brought out in this discussion. As I have said above, whatever theoretical arguments may be adduced in favor of extensive resections of the larynx and the communicating lymph nodes the contrast of the actual surgical results of cases so operated upon with those wisely dealt with upon the principle of early partial operation will give overwhelming testimony in favor of the latter course. The statistics are before us. Let them speak for themselves.

DISCUSSION.

Dr. Emil Mayer, of New York City, said the subject of cancer of the larynx and its early recognition was to the laryngologist what the early diagnosis of typhoid fever was to the general practitioner or early operation in appendicitis was to the surgeon. In other words, the most important question was the early diagnosis.

Quite recently, Dr. Mayer said, he saw in consultation a patient who suffered from laryngeal stenosis, apparently a post-typhoidal condition. Daily stretching of the parts was resorted to, but as that failed to give relief, a tracheotomy was done. Subsequently, a laryngotomy was deemed advisable, and upon opening the larynx a growth was found which upon microscopical examination. proved to be malignant. That patient was still alive.

Dr. Robert C. Myles, of New York City, said he did not know of any department of medicine in which there was greater confusion than in that relating to carcinoma of the larynx. Laryngologists were too willing to ensconce themselves behind the lack of early diagnosis, and when an operation was finally undertaken, in the later stages, it usually not only shortened the life of the patient but also greatly increased his suffering. Aside from the difficulty of the operation itself, it required the greatest care and skill to safely tide these patients through the post-operative stage. Early diagnosis and early operation were the important factors. As regarded the choice of methods, Dr. Myles said he preferred the external operation.

N°

MEDIASTINAL TUMORS.1

BY WILLIAM FRANCIS CAMPBELL, M.D.,

Brooklyn.

O satisfactory appreciation of these tumors can be had without a clear understanding of their location and the important structures with which they are in intimate contact. It is the pressure effects upon these structures that give us the group of symptoms characteristic of mediastinal growths.

In no cavity of the body do we find structures more intimately associated with the vital processes or where effects of pressure could be more destructive than these associated with this class of tumors; hence, we shall first consider these tumors from a regional standpoint.

Anatomical Considerations.-The thoracic cavity may be divided into three irregular compartments. Two of these compartments are occupied respectively by the right and left lungs with their pleural investments. The remaining compartment is the mediastinal space and lodges the remaining thoracic viscera.

Read before The New York State Medical Association, at the Twenty-second Annual Meeting, New York, October 16-19, 1905.

It will thus be observed that the boundaries of this space are laterally the mesial pleura of the lungs; in front, the sternum; behind the vertebral column; below the diaphragm and above the superior opening of the thorax corresponding to a plane passing through the top of the sternum, the first rib and the first dorsal vertebra.

The middle of this mediastinal space is occupied by the heart and its pericardial investure. While the subdivision of this space is purely arbitrary, yet for purposes of description it is convenient and rational to consider the pericardium as occupying the middle of this space or middle mediastinum. The part above the pericardium is the superior mediastinum. In front of the pericardium is the anterior mediastinum, and that behind the posterior mediastinum.

Except the middle mediastinum the structures of most importance are found in the superior and posterior mediastinum. They are the trachea, the esophagus, the great vessels connected with the heart, the pneumogastric nerves with the left recurrent, the phenic and cardiac nerves, the thymus gland or its remains, bronchial lymphatic glands and the thoracic duct.

The anterior mediastinum merely contains some lymphatic glands and alveolar tissue.

Lymphatics of the Mediastinum.

In a discussion of the neoplasms of any region the lymphatics play an important part. The glands of the mediastinum are very numerous and very important, and according to Delamere may be divided into an anterior group (those in the anterior mediastinum), a middle group (the peri-tracheobronchial glands), and a posterior group (those in the posterior mediastinum).

Those in the anterior mediastinum lie in front of the pericardium behind the sternum. They receive lymphatics from the anteromedian portion of the diaphragm and from the lower internal mammary glands.

The peritracheal and bronchial glands are placed between the divisions of the bronchi and about the bifurcation of the trachea. These glands are frequently enlarged because of the frequent infections to which they are exposed.

The posterior mediastinal glands are scattered about the esophagus.

A gland of considerable importance in its bearing upon tumor formation is the thymus, a vascular gland situated in the superior mediastinum. Like the thyroid and suprarenals, it secretes a substance which passes directly into the circulation, the nature of which we do not know.

It differs, however, from other glands in the fact that it is a transitory organ pertaining essentially to fetal and embryonic life. It begins to atrophy at the age of two, and at the twentyfifth to the thirtieth year we find but a vestige of it. The remains are represented by a fatty mass of tissue with some particles of thymus tissue persisting, and in this is developed undoubtedly certain of the mediastinal tumors.

Origin of Mediastinal Tumors.

A mediastinal tumor is one which has its origin in structures situated within the mediastinal space. We therefore exclude tumors arising from adjacent structures and trespassing upon this space.

The remnants of the thymus, the bronchial glands, the fat and connective tissue, the pericardium, are frequent sites of neoplastic degeneration.

Letulle (arch. gen. de Med. 1890 7 ser.) after reporting eight cases sums up his conclusions as follows: "The upper part of the anterior mediastinum [the superior mediastinum in our classification] is the favorite seat for primitive cancers of the mediastinum; with the exception of ganglionic tumors the primitive cancers develop at the expense of the thymus or of its atrophic debris.

"The embryonic region of the thymus explains perfectly the different varieties of primitive can

cers.

Among the benign tumors are found hypertrophic thymus, endothoracic goiter, lipomata, fibromata, dermoid cysts, terratomata, and lymphadenomata; sarcomata and carcinomata represent the malignant varieties.

As to the frequency of these respective varieties Hare in a study of 520 cases concludes that cancer is more frequently found in the mediastinal space than any other morbid process. In frequency he rates them as follows: Cancer first, abscess second, sarcoma third, lymphoma fourth, dermoid cyst fifth, hydatid sixth, and fibroma seventh. While a study of the cases reported to date does not entirely conform to this order of frequency, we may state in a general way:

1st. That there are few benign tumors compared with malignant ones.

occur

2d. Neoplasms of the mediastinum. more frequently in the male than in the female at a ratio of three to one.

3d. They usually occur between the ages of twenty and thirty, rarely at an advanced age.

4th. By far the larger number of new growths in the mediastinum are sarcomatous or carcinomatous.

5th. That sarcoma is twice as frequent as carcinoma.

6th. The confirmation of Loomis' statement that almost all sarcomata are primary; when secondary they usually follow sarcoma of the pleura.

The new growth invades the space occupied by the thoracic viscera, gradually encroaches upon their domain, literally crowding them to the wall-the bony unyielding wall of the thorax. Thus symptoms are all referable to disturbances of respiration, circulation or innervation.

More especially we may enumerate:

1st. Dyspnea due to pressure upon the trachea, bronchi, lungs.

2d.

Cough, expectoration and hemoptysis— from same cause.

3d. Cyanosis and embarrassment of circulation from pressure on heart.

4th. Differences in the radial pulse, one side being enfeebled by pressure upon the innominate artery (Nelston & Walshe).

5th. Dilation of the veins of the chest due to constriction of the large venous trunks and development of a collateral circulation.

6th. Circumscribed edema from venous obstruction.

7th. Pulsation in the tumor from transmitted heart impulse.

Pressure upon the nerves gives us an interesting variety of phenomena:

1st. Pain; this is not so severe as the discomfort arising from embarrassment of respiration and circulation. It is frequently referred to the region of the diaphragm-due to pressure upon the phrenic.

2d. Hoarseness or loss of voice, pressure upon the left recurrent laryngeal, giving paralysis of vocal cords.

3d. Hiccough, compression of phrenic. 4th. Retarded pulse early, palpitation late, due to compression of the vagus.

5th. Dysphagia due to paralysis of the vagus or actual compression of the esophagus.

6th. Asymmetry of pupils-pressure upon sympathetic.

7th. Exophthalmos-caused in the same way. In addition we may, as a late symptom, find an actual bulging of the chest wall. Sometimes it is possible to palpate the tumor behind the upper margin of the sternum.

Malignant tumors may even penetrate the chest wall and present on the surface as an external growth.

Emaciation and cachexia follow in the wake as malnutrition and absorption of the toxins progress.

Apropos of the slowness of benign growths and how even the vital structures in the mediastinum may adapt themselves to extreme conditions provided the period of adjustment be sufficiently long, we find a case reported in which autopsy revealed a tumor of the mediastinum the size of a child's head which produced no symptoms during life.

It is the malignant growths which present an acute symptomatology and terminate rapidly and fatally. In repeated instances sudden death has occurred before a diagnosis was made.

Let me at this point cite a case which in view of the foregoing symptomatology presents a clinical picture of unusual interest.

In April, 1905, there was referred to me for operation a farmer twenty-one years old, with a diagnosis of goiter. He gave the following history: Always enjoyed good health, no previous illness till two months ago when the first symptoms he noticed was hoarseness, loss of voice power; this continued till one month later, when a swelling appeared in the region of the thyroid. His breathing became troublesome, he could not sleep lying down, his appetite was very poor and it hurt him to swallow. This was the statement of the case from the patient's standpoint, presenting a sequence of symptoms as follows: Loss of voice, swelling just above sternal notch, embarrassment of respiration, and difficult deglutition. A study of these symptoms elicited from the patient is exceedingly interesting, for they are symptoms all associated with goiter. The point of interest is not the symptoms unrelated, but the sequence of the symptoms. Observe that the very first symptom was loss of voice; this led me to doubt the previous diagnosis, for in goiter loss of voice is a late symptom, not an early one; in goiter the appearance of the tumor is first and loss of voice secondary. loss of voice secondary. Here the loss of voice was first and the appearance of the tumor sec ondary. ondary. Convinced therefore that the explanation of these symptoms would be found elsewhere than in the thyroid, a more extended examination gave the following findings: The patient presented a good muscular frame, skin pale, breathing labored, voice hoarse, lips slightly cyanotic, right pupil dilated, left normal, both react to light, sclera pale. Mouth, pharynx and spine negative. Projecting above the suprasternal notch is a tumor half the size of a lemon, lying between the two sterno-mastoid muscles and in front of the thyroid cartilage, pushing the larynx and hyoid bone upward and backward, evidently not attached to the larynx or involving the thyroid gland. It is moderately firm on pressure, non-pulsating, gives no thrill or murmur, and no tracheal tug on elevation of the larynx.

The cervical and submaxillary glands on the right side are not enlarged, but the glands in the left lower cervical region are enlarged to the size of a small almond.

The tumor is dull on percussion; this dulness is continuous with marked dulness over the first piece of the sternum and is continuous with heart dulness, but this appears to be more marked in the upper half of the cardiac area.

There is no pulsation, thrill or murmur over the first piece of the sternum.

The left border of the heart percusses one-half inch to the right of the nipple line.

The sounds at the apex are moderately distinct; no murmurs are heard at this point.

There is marked dulness in the right of the sternum in the second space for two inches; this continues down as far as the fifth space, where it becomes continuous with liver dulness.

Over the upper half of the heart the sounds are very faint and no murmurs are heard. Both radial pulses are synchronous, but the left is a little smaller than the right; over both lungs the breathing is feeble; inspiration is shallow and quick. Loud bronchial sounds are transmitted through the lungs.

Paroxysms of coughing occur every few minutes and with each effort one or two ounces of mucopurulent material is ejected.

I do not wish to weary you with the details of this case, but the clinical picture is so perfect that its detailed consideration is not without profit.

I desired to X-ray the thorax and sent the patient to the hospital for this purpose and for further observation. On the second night after entering the hospital he was sitting as usual by the open window. This was his most comfortable method of resting. He arose to get something; after walking several steps he fell and expired.

Autopsy showed a tumor of the mediastinum involving the pericardium and extending into the sac. It extended backward and upward into the neck and was about the size of the head of a seven months fetus.

Pathologist reported it a lymphosarcoma. The diagnosis of these tumors is always difficult; they are seldom diagnosed definitely.

In the Roentgen rays we have an excellent means of verifying our percussion outlines. We can sometimes palpate the tumor behind the sternal notch, as in the case reported. Enlarged lymph glands in the neck and axilla are of great diagnostic importance. Rapidity of growth and cachexia enables us to differentiate between malignant and benign tumors.

It will not be difficult to differentiate aneurism when we consider that aneurism never causes as many or as severe symptoms of pressure as a mediastinal tumor.

It is unnecessary to weary you with a discussion of treatment of these tumors, as we have seen benign tumors may attain a large size without producing any symptoms. They are sometimes diagnosed sufficiently early for successful removal. The surgeon has invaded the mediastinal space and recovery has followed operative interference, but when we consider that malignant tumors of the mediastinum are hopeless, that when they have attained a size sufficient to produce symptoms, they have already invaded chains of lymphatics that elude the surgeon's knife, the treatment must as yet remain a problem which each must solve for himself.

THE PROTECTION OF THE NEW YORK MILK SUPPLY.1

S

BY WALTER BENSEL, M.D.,

New York.

TATISTICS of New York City show that

children under five years of age constitute about one-third, and infants under one year about one-sixth of all deaths, and that a large proportion of these infant deaths is due to intestinal diseases.

When we consider that cows' milk in some form is used during a considerable part of almost every child's life, and that, owing to the ignorance or carelessness of the larger number of milk-producers, milk is notoriously filthy, we at once realize the importance of the enforcement of most stringent regulations concerning its production, transportation and sale.

During the past thirty years New York City has engaged in an active warfare against impure milk. Until 1902 this warfare was waged entirely with the wholesale and retail dealers in the city, no attention being paid to the sources of supply. In May, 1902, two of the Department of Health milk inspectors were appointed State inspectors by the State Commission of Health, and an investigation of the sources of supply was begun.

The City of New York is supplied with about one million five hundred thousand quarts of milk daily, of which about two hundred thousand quarts are produced from dairies within the city limits. Handling this enormous quantity of milk are some 450 creameries and about 9,000 dairies. To inspect these creameries and dairies the Department of Health employs two inspectors, more being unavailable through a lack of appropriation. Nevertheless, an enormous amount of work has been done. A large proportion of the creameries has been visited once or twice and most of the bad conditions therein have been corrected, but the dairies remain as yet practically untouched.

According to the Sanitary Code milk is adulterated when it contains more than 88 per cent. of water, when it contains less than 12 per cent. of milk solids, when it contains less than 3 per cent. of solids, when it contains less than 3 per cent. of fats, when it is drawn from animals within fifteen days before or five days after parturition, when it is drawn from animals fed on distillery waste, or any substance in a state of fermentation or putrefaction or any unwholesome food, when it is drawn from cows kept in a crowded or unhealthy condition, when any part of its cream has been removed, when any foreign substance whatever is added to it, and finally when it is at a higher temperature than 50 degrees Fahrenheit.

Within the confines of New York City thirteen. inspectors are continually at work hunting for milk which contains too much water, too little solids, any foreign substance, more particularly a preservative, or which has too high a tempera

1Read before The New York State Medical Association, at the Twenty-second Annual Meeting, New York, October 16-19, 1905.