Themistocles Gluck and the premises of modern total laryngectomy.

The aim of this historical vignette is to recall the importance of the German surgeon Themistocles Gluck in the development of total laryngectomy with primary closure of the pharyngeal orifice, a technique proposed a few years after Theodor Billroth's first total laryngectomy in 1873.

A historical overview of laryngeal carcinoma and the first total laryngectomies.

Laryngeal cancer was a well known entity since antiquity and its treatment evolved through several phases. The lack of knowledge in anatomy and pathology as well as the absence of anesthesia and proper instrumentation made the treatment almost impossible. Ancient physicians were performing laryngotomy or tracheotomy in an attempt to prevent the suffocation symptoms produced by tumoral masses. In 19th century the invention of laryngoscope and the advent of pathology and anesthesiology encouraged surgeons to operate on man. In 1873 Theodor Billroth (1829-1894) performed the first laryngectomy followed by several other colleagues among which Enrico Bottini (1837-1903) and Themistocles Gluck (1853-1942). Thanks to their contribution a new era came in laryngeal cancer treatment: the conservation laryngeal surgery.

The laryngeal disease of the German Emperor Friedrich III: treatment failure or fateful course.

BACKGROUND: Since the death of the Emperor Friedrich III in June 1888, there are still controversial discussions whether the Crown Prince could have been healed from his laryngeal cancer by a thyrotomy planned by his German physicians for May 21, 1887. METHODS: In order to find an answer to this historical question, the Emperor's biographies, the literature on laryngology published in the late nineteenth and early twentieth century, German manuals on laryngology and ENT, the BMJ and Lancet were thoroughly studied where in particular not only Mackenzie but also Virchow had published several articles on the disease of Friedrich III. RESULTS: Prof. Gerhardt had decided not to perform biopsies of the tumor. Furthermore, he did not perform iodine potassium treatment ex juvantibus as it was common practice at that time in order to confirm the diagnosis of carcinoma by excluding syphilitic gumma. So Mackenzie was perfectly right when insisting on performing excisional biopsy before surgery. It is tragedy that Virchow by making the diagnosis of pachydermia laryngis provided the justification for canceling the surgical intervention that had already been decided. It was also mistake that Prof. Gerhardt did not accompany the Crown Prince during his stay in England in summer 1887. The authority of the delegated medical officer Dr. Landgraf did not suffice to persuade Mackenzie to discuss again the matter of performing surgery together with Gerhardt and von Bergmann. The drawings made by Dr. Landgraf show an impressive tumor growth. The refusal of new consultations with Gerhardt and von Bergmann by Mackenzie can only be explained by the fact that Mackenzie was generally against such a surgical intervention. Regarding the question of the chances of such a surgery it can be said that thyrotomy and laryngectomy had been refused by the majority of laryngologists since the Congress of London in 1881 and the publication of P. v. Bruns in 1878. In Berlin, however, the improvement of surgical and anesthetic techniques by E. Hahn led to a positive opinion. F. Semon, who had strictly refused thyrotomy until 1886, supported the indication of thyrotomy of the Crown Prince since Hahn had successfully operated one of his patients in London. So the chance of healing a limited carcinoma of the vocal folds by thyrotomy was given. However, it may be questioned if partial resection had the desired outcome. The limited mobility of the left vocal fold that had been diagnosed already in May 1887 indicates that probably laryngectomy would have been necessary. The prognosis of this procedure, however, was extremely poor at that time. It is irony of history that T. Gluck who performed the separation of the airways from the digestive pathways in an animal model already in 1880 under von Langenbeck could not further develop his technique under von Bergmann. CONCLUSIONS: The Crown Prince acquired his disease at a time when the acceptance of surgical treatment of laryngeal carcinomas had reached its lowest point. Ten years later, the technique of thyrotomy was successfully established by Hahn, Butlin, and Semon so that Morell Mackenzie would probably have agreed to the intervention. Ten years later, due to Gluck and Sörensen, even the technique of laryngectomy had reached the performance that is still valid today so that the Emperor could have been treated successfully even with an advanced laryngeal carcinoma.

[Voice rehabilitation after total laryngectomy: A chronological review of medical history]. / Stimmrehabilitation nach totaler Laryngektomie: Ein chronologischer, medizinhistorischer Überblick.

BACKGROUND: Loss of voice is the consequence of laryngectomy most disturbing for the patient. As such, the notion of performing a laryngectomy has always been directly linked to the possibility of voice rehabilitation. The multitude of different technical and surgical approaches pays testimony to the problems associated with rehabilitation of speech and swallowing after laryngectomy. METHODS: Scientific online search engines and library facilities were used to search for recent publications and historical medical documents. Important works were identified and summarized. RESULTS: Four different categories of voice rehabilitation can be identified: external (electrical) devices, esophageal speech, and tracheoesophageal shunts either with or without fistula valves/voice prosthesis. During the past three decades, fistula valves/voice prostheses have become the state of the art, with some patients still using esophageal speech or external devices as a back-up method in case of prosthesis failure.

[Theodor Billroth: more than a century of artistic greatness]. / Theodor Billroth: más de un siglo de su grandeza artística.

Christian Albert Theodor Billroth, a German surgeon of great artistry and immense culture and promoter of abdominal surgery, who drove the length of the physiology of the surgical field through the use of experimental surgery, is considered the leading German medical figure of the second half of the 19th century in Europe. His works and techniques transcended through time and continue to be implemented (albeit with modifications). He founded a new school of surgery based in criticism, the influence of which affected the development of numerous European and American surgeons. He was also a born artist who excelled in the music field, with many interests in music criticism and public events.

Themistocles Gluck: biographic remarks emphasising his contributions to laryngectomy.

Themistocles Gluck was one of the most imaginative representatives of early modern surgery. During his life he developed landmark innovations in many different areas of surgery. His ideas were often far ahead of his time, a circumstance, which exposed him to severe criticism by his peers. In an era before surgical specialization, he contributed to several fields of surgery. He performed the first total joint replacement in Berlin, in 1890 with a hinged ivory prosthetic knee, and developed models for replacement of shoulder, elbow, and wrist. These efforts had remarkable short term success, but invariably failed in the long term because of infection. A long standing conflict with the powerful Ernst von Bergmann, seriously damaged Gluck's reputation, which he eventually regained, mostly because of his contributions to surgery of the head and neck; in particular, total laryngectomy. The results of laryngectomy in the decade after Billroth's first successful operation were dismal. Through Glucks refinements, developed in cooperation with his coworkers Johannes Soerensen, the results of laryngectomy improved slowly but inexorably, and mortality rates were reduced from 56 to 2%. In his lifetime, Gluck made significant contributions to head and neck surgery, some of which are still currently valid. This publication gives an outline of Gluck's remarkable biography.

[Evolution of laryngectomy based on a comparison of two cohorts a century apart: an illustration of the progress, difficulties and conflicts encountered in medicine]. / Histoire des laryngectomies illustrée par l'analyse de deux cohortes à un siècle de distance : un reflet du progrès, des difficultés et des conflits rencontrés en médecine.

Based on a comparison of two cohorts of patients with laryngeal cancer managed by laryngectomy one century apart, and an analysis of original textbooks from the end of the nineteenth century, we examine the development of laryngectomy, the difficulties encountered in this first therapeutic approach to laryngeal carcinoma, and the conflicts it generated. The overall death rate changed little over the course of a century, although the 5-year actuarial survival estimate improved from 22.6% in 1888 to 75.1% in 1988 (p < .0001). The causes of death also changed (p < .0001), with fewer deaths related to post-operative complications and/or local failure (82.7% in 1888, 9% in 1988). The rate of suicide deaths fell from 1.8% to 0.04%. In contrast, the percentage of deaths due to metachronous second primary tumors and/or intercurrent disease increased from 9% in 1888 to 76.7% in 1998. Analysis of actuarial survival rates demonstrated that 77.4% of patients died before the 60th post-operative month in 1888, while this percentage was only reached 275 months post-operatively a century later. Our research also underscores the importance of patient information and medical ethics.

Master of surgery in Archiv für Klinische Chirurgie.

INTRODUCTION: After the routine use of ether narcosis and surgical antisepsis, the evolution of surgery experienced fascinating and genuinely surgical technique-related advancements. Surgeons from Germany contributed strongly to the upturn of operative treatment in the second half of the nineteenth century. DISCUSSION: B. von Langenbeck inaugurated in 1852 an osteosynthese device in a patient with pseudoarthrosis. He is credited to be the very first in introducing the principle of fixateur externe. Th. Billroth performed in 1873 the first extirpation of the larynx in a patient with a malignant tumor. Postoperatively, the patient was cared with an artificial larynx. The first successful resection of the distal stomach inaugurated by Th. Billroth in 1881 was later called the Billroth II procedure. Rydygier from Kulm and Billroth from Wien are the first who successfully performed resection of the lower part of the stomach with anastomosis to the duodenum (Billroth I type of resection). In 1883, Th. Kocher from Bern reported 101 cases of thyroidectomy, the largest single-surgeon experience. L. Rehn from Frankfurt did in 1887 the first successful suturing of a beating heart to repair a large stab wound. A. Braun, Königsberg presented in 1892 his techniques of side-to-side anastomosis of the intestine to avoid a circular intestinal anastomosis. F. Sauerbruch from Breslau published in 1904 his thoracotomy chamber with space for two surgeons opening routine access to intrathoracic tissues protecting pulmonary ventilation during surgery. W. Kausch from Berlin reported in 1912 about three successful pancreatic head resections for peripapillary cancer. The first successful pancreatic head resection was performed in 1909 in a patient with a cancer of the papilla. The patient survived for a long term.

The history of horizontal glottectomy.

The history of horizontal glottectomy (HG) for the treatment of bilateral vocal cord lesions is not entirely clear. The present investigation analyzes the history of HG on the basis of cross-referenced database searches in general and professional medical literature databases. Books, original historical articles and medical history reviews were evaluated. The initial work was done by Moser in years from 1959 to 1965, and in 1961 he published the first paper on HG. Follow-up publications were reported in 1977 by Gramowski and in 1984 by Wilke. In 1970, Romanian laryngologists headed by Calarasu described a HG via excision of a rhomboid-shaped portion of the thyroid cartilage, but the authors had neither sufficient numbers of patients nor a sufficiently long follow-up for the procedure to gain widespread acceptance. In 1978, Calearo and Teatini described HG similar to Calarasu's method, but slightly more extended by the eventual inclusion of an arytenoid cartilage in the operative specimen. Theses authors have often been credited as the originators of the procedure, but actually were the first to publish in an English language journal. The procedure, while quite effective for treatment of bilateral and anterior commissure lesions, has never gained general acceptance in the United States, and in current practice, has been supplanted by endoscopic and non-surgical treatments.

History of voice rehabilitation following laryngectomy.

INTRODUCTION: The history of voice rehabilitation following laryngectomy is as long as the history of laryngectomy itself. The multitude of methods which have been employed to reduce the disability associated with the loss of the larynx, illustrate the difficulty of finding an optimal method of reestablishing verbal communication while preserving the ability to breathe and swallow. MATERIAL AND METHODS: The world literature was reviewed using various Internet and medical search engines and library facilities. Landmark articles were identified and summarized. RESULTS: A coherent history of voice rehabilitation following laryngectomy was constructed. DISCUSSION: The methods employed to reestablish voice after extirpation of the larynx may be grouped into the categories of: esophageal speech, surgical methods of creating competent tracheo-pharyngeal shunts to create lung powered voice with and without the use of prosthetic devices to prevent aspiration, "near-total" resection of the larynx with dynamic phonatory shunt, and the use of external pneumatic or electrical devices to create sound which is then transmitted through the oral cavity and pharynx. CONCLUSION: For the past two decades, simple shunt devices inserted either primarily, at the time of laryngectomy, or later as a secondary procedure, have mainly supplanted the other methods of voice rehabilitation, with the exception of an occasional patient who has acquired good esophageal speech, or for whom external devices may be the only practical method of voice production.

Historia de la laringectomía total / History of the total laryngectomy

Presenta la historia de la laringectomía total. En Uruguay, un cirugiano otorrinolaringólogo de origen italiano, Eugenio Streessino Cassanello (1853-1910), nascido en Túnez, Africa del Norte practicó en Montevideo la primera L.T. en la Latinoamérica (AU).

[One thousand laryngectomies performed at the Novi Sad University ENT Clinic--historical review and important data on treatment of laryngeal tumors].

INTRODUCTION: The first ENT Department in Novi Sad was established in 1926. In 1960 the ENT Clinic became a part of the Faculty of Medicine Novi Sad and treatment of malignant disease started in 1973 at the Laryngology Department. SURGICAL TREATMENT OF MALIGNANT LARYNGEAL TUMORS: Treatment of laryngeal cancers in Novi Sad started in 1960's. Until 1971, the treatment of choice was radiotherapy, and surgical treatment started in 1971, when the first laryngectomy was performed After the first surgery, 31 years have passed until we have reached the number of one thousand performed laryngectomies at ENT Clinic in Novi Sad. PERIOD: 1971-1988: During this period, 138 laryngectomies were performed at ENT Clinic. Total laryngectomies were done as salvage surgeries in 136 cases, and 2 patients underwent functional partial laryngectomies. Direct laryngomicroscopy was introduced by Zivko Majdevac in 1972. Oncology consilium was founded. PERIOD: 1990-2002: New protocol was adopted. Surgery became the primary treatment of laryngeal carcinoma, while radiotherapy remained a valid therapeutic alternative. All known surgical techniques were introduced, including Pearson's near-total laryngectomy. In this period 834 patients were operated, and 873 laryngectomies were performed, out of which 388 total laryngectomies. Year after year the number of patients increased and in 2002, 90 laryngectomies were performed. The number of functional reconstructive operations has increased to 67.8% in comparison to 32.2 % of total laryngectomies.

[More of five decades of supraglottic laryngectomy (Alonso's technique)]. / Más de cinco décadas de laringectomía horizontal supraglótica (técnica de Alonso).

In this paper we attempt to prove the relevance of the Spanish and Iberoamerican contribution, in the expansion and development of Alonso's technique for surgical treatment of supraglottic cancer, that began in Spain and South America in the fifties. We mention the most important authors and their ideas, and we explain their contribution to this surgical procedure which has been remained forgotten in the latest publications.

Más de cinco décadas de laringectomía horizontal supraglótica (Técnica de Alonso) / More of five decades of supraglottic laryngectomy [Alonso's Technique]

En este trabajo intentamos demostrar la importancia de la contribución española e iberoamericana en el desarrollo y difusión de la laringectomía horizontal supraglótica o técnica de Alonso, realizada en España y Suramérica desde la década de los '50. Citamos a los autores más importantes con la intención de recordar sus nombres y sus ideas con la finalidad de dar a conocer sus muy valiosas aportaciones casi nunca recordadas y menos referenciadas en las publicaciones modernas (AU)

In this paper we attempt to prove the relevance of the Spanish and Iberoamerican contribution, in the expansion and development of Alonso's technique for surgical treatment of supraglottic cancer, that began in Spain and South America in the fifties. We mention the most important authors and their ideas, and we explain their contribution to this surgical procedure which has been remained forgotten in the latest publications (AU)

Professor Nicolas Taptas (1871-1955): a pioneer of post-laryngectomy voice rehabilitation.

OBJECTIVE: To report on the career of Professor Nicolas Taptas of Constantinople (1871-1955) and his contribution to the development of an artificial larynx. STUDY DESIGN: Historical review. METHODS: The unpublished documents of Taptas's family archives and one of his papers, describing his own original technique for voice rehabilitation after total laryngectomies, were studied. RESULTS: In his texts, Taptas described the application of external laryngeal prostheses in one of his patients who underwent total laryngectomy. Taptas meticulously recorded his own first successful attempt in a woman with cancer of the larynx. He was one of the first scientists who, at the end of the 19th century, devised an external laryngeal prosthesis, which had the advantage of rehabilitating a sufficiently strong whispering voice; by using a prototype valve, he avoided problems of aspiration of liquids and food to the bronchi. CONCLUSION: Nicolas Taptas's contribution to the development of the artificial larynx was vital because he devised and applied one of the first external laryngeal artificial prostheses with satisfactory functional results.